FACHE credential Application

Transcription

1 FACHE credential Application Completing this application is the first step toward earning the FACHE credential. Please read and complete each section fully and accurately in clear, legible handwriting or type. If you have any questions, please call ACHE s Customer Service Center at (312) Monday through Friday, from 8 a.m. to 5 p.m. Central time or contact@ache.org. If you are sending in a hard copy application, it is required you mail in a check for security purposes. To pay via credit card, apply online at ache.org/fache. Personal Information PREFIX FIRST MIDDLE LAST SUFFIX ACHE MEMBER ID NUMBER (IF KNOWN) Uniformed services personnel and USPHS commissioned officers, please enter rank. Please indicate any other prefixes as applicable and include all doctoral degrees. Education List all academic degrees earned. I confirm that I am a current member of ACHE and have at least three (3) years of membership tenure. UNDERGRADUATE SCHOOL AND LOCATION ATTENDED (FROM TO: LIST MONTH/YEAR) DEGREE OR DIPLOMA (ABBREV.) MAJOR SUBJECT GRADUATE SCHOOL AND LOCATION ATTENDED (FROM TO: LIST MONTH/YEAR) DEGREE OR DIPLOMA (ABBREV.) MAJOR SUBJECT OTHER ADVANCED DEGREE (Optional) SCHOOL AND LOCATION ATTENDED (FROM TO: LIST MONTH/YEAR) DEGREE OR DIPLOMA (ABBREV.) MAJOR SUBJECT Current Position Civilian Uniformed Services Check here if this is a Veterans Affairs organization. /RANK START DATE (MM/DD/YY) /BRANCH ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE COUNTRY BUSINESS PHONE BUSINESS FAX BUSINESS ADDRESS Job Description, Organizational Chart and Resume A copy of your current job description, organizational chart showing your position and resume must be included with your application. Healthcare Management Experience At the time you submit your Fellow application you must currently hold an executive-level healthcare management position, and you will need at least five years of executive healthcare management experience. An executive-level healthcare management position is one in which the applicant is employed by a healthcare organization or by an organization whose purpose is to influence the growth, development or operations of a healthcare organization. To be eligible for advancement an applicant s position must be at a department director/department head level, which includes control of departmental budgeting, planning and staffing and accountability to senior management for department performance. Eligible positions include C-suite executives, vice presidents and directors/department heads. Additional titles may be accepted if job responsibilities reflect departmental control as described above. Applicants whose management authority is at a project and/or program level do not qualify. Examples of this level of authority might include: analyst, coordinator, program manager, project manager and specialist. Administrative fellowships, residencies and internships do not qualify. Need help determining your qualified years of executive healthcare management experience? View our matrix on the next page.

2 ACHE Healthcare Management Experience (HME) Decision Matrix Purpose: This tool is intended for use by candidates to assist in determining qualified years of HME to use toward advancement to Fellow with ACHE. Instructions: Work your way down the left-hand side of the table and find the highest level of organizational management you believe your position falls under. Then, indicate your years of experience (in years and months) managing each of the functional areas. Add the years of experience up and mark it in the Total Years of Experience column. Note that you do not have to have a timeframe in each function if you do not have experience with one or more of the functions, simply enter zero (0). Name: Organization: Position: Level of Management Planning Organizing Staffing Controlling Directing Decision Making Financial Management Total Years of Experience Manages self HME is not applicable at this level of management Manages unit or team Manages department Manages multiple departments Manages organization Manages system or multiple organizations Total HME: X years, X months Definitions Healthcare Management: Healthcare management is the profession that provides leadership and direction to organizations that deliver personal health services, and to divisions, departments, units, or services within those organizations. Planning: This function refers to setting direction and determining what needs to be accomplished. It means setting priorities and determining performance targets. Organizing: This function refers to the overall design of the organization or the specific division, unit, or service for which the individual is responsible. It means designating reporting relationships and intentional patterns of interaction. Determining positions, teamwork assignments, and distribution of authority and responsibility are components of this function. Staffing: This function refers to acquiring and retaining human resources. It also refers to developing and maintaining the workforce through various strategies and tactics. Controlling: This function refers to monitoring staff activities and performance, and taking the appropriate actions for corrective action to increase performance. Directing: This function refers to initiating action in the organization through effective leadership and motivation of, and communication with, subordinates. Decision making: This function refers to making effective decisions based on consideration of benefits and the drawbacks of alternatives. Financial Management: This function refers to the efficient and effective management of money (funds) in such a manner as to accomplish the objectives of the organization. Resource: Understanding Healthcare Management (Longest, Rakich, & Darr, 2000)

3 References Submitting reference forms Submit two references: One in the form of a structured interview with a current Fellow; one written reference from a senior-level executive (VP or higher) in your organization OR a second Fellow. Identifying references Use the online Member Directory on ache.org to locate Fellows in your area or across the world. Your references do not need to be located near you. Contact your Regent or Chapter officials and ask for assistance with identifying Fellows to serve as references (go to ache.org/regent to find the Regent for your area). Contact ACHE s Customer Service Center at (312) Monday through Friday, from 8 a.m. to 5 p.m. Central time or via at contact@ache.org. In the spaces provided below, please list your two references and identify which one is the structured interview. We will keep this information on file to help you track the status of each completed form. REFERENCE STRUCTURED INTERVIEW Continuing Education Demonstrate 36 hours of healthcare-related continuing education within the last three years 12 hours of which must be ACHE Face-to-Face hours. Organization Program Title Date Attended Faculty or Participant Credit hours Participation in Healthcare and Community/Civic Activities Please include examples of your participation over the past three years. No specific number of hours is required; however, you must list at least two healthcare and two community/civic activities. Service Type Community/Civic Description Service Start Date Service End Date (if applicable) Community/Civic Healthcare Healthcare Accompanying Materials ENCLOSED Current job description Current organizational chart Resume ENCLOSED Copy of most recent diploma or final conferred transcript 36 Hours of healthcare-related continuing education (including 12 ACHE Face-to-Face hours) Volunteer activities Mail completed application with payment to: American College of Healthcare Executives 3439 Eagle Way, Chicago, IL APFEL0116

4 Statement of Release and Agreement By submitting this application to advance to Fellow of ACHE, I pledge to abide by ACHE s Bylaws, Code of Ethics, Regulations and other rules (available on ache.org). I release ACHE and its agents from liability with respect to any evaluation of my fitness for membership or continued membership in ACHE. SIGNATURE Application Fee* DATE Check in the amount of $250 is enclosed (payable to the American College of Healthcare Executives) Receipt of your application will be acknowledged within three weeks. Please mail this application, the $250 non-refundable application fee by check and accompanying materials to the address below. Keep a copy of your application for your files. Upon approval, your application will remain valid for two years. If you have questions, contact ACHE s Customer Service Center at (312) or contact@ache.org. *Note: Check payment is required with hard copy applications. To pay with credit card, please apply online at ache.org/fache. What influenced you to advance to Fellow?: COLLEAGUE OR CO-WORKER EMPLOYER UNIVERSITY OR COLLEGE PROGRAM PROFESSOR OR INSTRUCTOR ATTENDED AN ACHE EDUCATIONAL PROGRAM INTERNET BROWSING OTHER Referred by a member? Be sure that member gets recognized provide his or her details below: /BRANCH CITY AND STATE/PROVINCE

5 Fellow or Senior-Level Executive Reference Form Confidential Fellow of the American College of Healthcare Executives The Distinction of Board Certification Side A: Completed by Candidate Fellow Candidate: Complete the information on this side and then forward this form to your reference for his or her completion of the reverse side. Remember, this reference can be from either an ACHE Fellow or a senior leader in your organization. Reference: Please complete the reverse side of this form and fax ( ) or mail it to ACHE as soon as possible. You may also complete and submit your reference form at ache.org/fache. Date Reference Information ADDRESS CITY STATE ZIP Candidate Information ADDRESS CITY STATE ZIP Page 1 of 2

6 Fellow or Senior-Level Executive Reference Form Side B: Completed by Reference Reference: Please fax, mail or complete this form online at ache.org/fache. Confidential Inquiry on Applicant to Become a Fellow of the American College of Healthcare Executive You have been listed as a reference by the candidate whose name appears on the reverse side. We would appreciate your completing and returning this form to ACHE as soon as possible. Your reply will be held in strict confidence. ACHE is interested in learning of the candidate s professional reputation for competence, judgment, integrity and ethics. Candidates also must have executive healthcare management experience in order to advance to Fellow status. Please review the definition at ache.org/fache. Thank you. Do you recommend this candidate for Fellow status in the American College of Healthcare Executives? Yes No Questions This reference may be completed by an ACHE Fellow or a senior-level executive (vice president or higher in the candidate s organization). 1.) Please describe how you know the candidate 2.) What are the candidate s responsibilities in the organization? 3.) The candidate must have five years of executive healthcare management experience to be eligible for Fellow status (see executive healthcare management definition at ache.org/fache). Does the candidate meet this definition? Yes or No Please provide your rationale 4.) Do you recommend this candidate for Fellow in ACHE? Yes or No PRINTED SIGNATURE DATE Send to: American College of Healthcare Executives (Confidential) 1 N. Franklin St., Ste Chicago, IL Phone: (312) Fax: (312) Page 2 of 2 6

7 Structured Interview Fellow Reference Form Confidential Fellow of the American College of Healthcare Executives The Distinction of Board Certification Side A: Completed by Candidate Fellow Candidate: A structured interview is a face-to-face meeting or telephone call between the Fellow candidate and the reference. During the interview, the reference should ask questions about your competence, judgment, ethics and integrity. Complete the information on this side of the form and then forward it to your reference to complete the reverse side. You are responsible for contacting the reference to arrange the interview. To prepare for the structured interview with your Fellow reference, please review the questions on the reverse side of this form. Reference: Please complete the reverse side of this form and fax ( ) or mail it to ACHE as soon as possible. You may also complete and submit your reference form at ache.org/fache. Date Reference Information ADDRESS CITY STATE ZIP Candidate Information ADDRESS CITY STATE ZIP Page 1 of 2

8 Structured Interview Fellow Reference Form Confidential Side B: Completed by Reference Confidential Inquiry on Applicant to Become a Fellow of the American College of Healthcare Executives You have been listed as a reference by the candidate indicated on the reverse side. As a Fellow reference, the candidate will contact you to schedule an interview. We strongly recommend that this interview be conducted face to face; however, a telephone interview is acceptable if a face-to-face meeting is not possible. Your reply will be held in the strictest confidence. ACHE is interested in learning the candidate s professional reputation for competence, judgment, integrity and ethics. Candidates also must have executive healthcare management experience in order to advance to Fellow status. Please review the definition at ache.org/fache. Thank you. Structured Interview Questions As a reference, please ask the candidate the following questions in your interview. Then provide your comments regarding the candidate in the space below. 1. Describe your healthcare administration career path to present. What are your career goals? 2. Why do you want to achieve Fellow status, and how do you plan to use your credential? 3. How do you plan to promote your board certification in healthcare management? 4. What role has mentoring played in the development of your career? Do you plan to mentor healthcare leaders in their careers? How? 5. How has the ACHE Code of Ethics guided your behavior? Why is this code important? 6. What does professionalism mean to you? Why do you think individuals join ACHE (list at least three reasons)? 7. As communities become more diverse, so must the healthcare organizations that serve them. In what ways does your organization support a racially/ethnically diverse and equal work force? 8. What can you do personally to foster diversity and equality? 9. Describe ACHE s governance structure. Include the following: Council of Regents: Who may serve as a Regent? How are they elected? What is the role of the Regent and the Council of Regents? Board of Governors: Who may serve as a Governor? How are they elected? Describe the role of a Governor and the Board of Governors. 10. Please describe your healthcare management experience. Comments SIGNATURE DATE IF KNOWN, PLEASE INCLUDE YOUR ACHE MEMBER ID NUMBER Send to: American College of Healthcare Executives (Confidential) 1 N. Franklin St., Ste Chicago, IL Phone: (312) Page 2 of 2 Fax: (312)