Healthcare Leadership Competencies Assessment
   LAST 4 OF SSN      
I hereby certify that ALL information I have provided to FILL IN THE BLANK on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.    
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

Rating Stars (Click) RELATIONSHIP MANAGEMENT 1 2 3 4  
Organizational structure and relationship   
Build collaborative relationships   
Develop and maintain medical staff relationships   
Provide internal customer service   
Practice and value shared decision making  
Rating Stars (Click) COMMUNICATION SKILLS 1 2 3 4  
Sensitive to what is correct behavior when communicating with diverse cultures, internal, and external   
Communicate organizational mission, vision, objectives, and priorities   
Prepare and deliver business communications, including meeting agendas, presentations, business reports, and project communications plans   
Present results of data analysis to decision makers   
Provide and receive constructive feedback  
Rating Stars (Click) FACILITATION AND NEGOTIATION 1 2 3 4  
Mediation, negotiation, and dispute resolution techniques   
Team building techniques   
Create, participate in, and lead teams   
Facilitate group dynamics, process, meetings, and discussions  
Rating Stars (Click) LEADERSHIP 1 2 3 4  
Leadership styles/techniques  
Potential impacts and consequences of decision making  
Establish a compelling organizational vision and goals   
Hold self and others accountable for organizational goal attainment   
Promote and manage change   
Promote continuous organization learning/improvement  
Managed care models, structures, and environment   
Levels of healthcare along the continuum of care   
Evidence-based management practice   
The interrelationships among access, quality, cost, resource allocation, accountability, and community   
The patient experience (e.g., cultural differences, expectations)   
Healthcare technological research and advancements   
Organization and delivery of healthcare   
Regulatory and administrative environment in which the organization functions  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)  
Rating Stars (Click) BUSINESS SKILLS AND KNOWLEDGE 1 2 3 4  
Ability to analyze and evaluate information to support a decision or recommendation   
Collect and analyze data from internal and external sources relevant to each situation   
Techniques for business plan development, implementation, and assessment   
The functions of organizational policies and procedures   
Promote and apply problem-solving philosophies   
Demonstrate critical thinking and analysis   
Systems thinking   
Facilities planning  
CERTIFICATIONS     Expiry Date :   
ACHE Fellow Status  
Nurse Executive  
Nurse Executive, Advanced  
Other (type):  
Other (type):