ACHE BOG Information for Laurence Weinreich

Module One- Healthcare

What are the latest trends in healthcare? Latest trends in healthcare, insurance
across state lines, the implementation of the ACA, physicians becoming employees
of hospitals

Are you familiar with the common healthcare acronyms? I have been in
healthcare since 1984. I am very familiar with the acronyms used in our business.

Knowledge of healthcare and medical terminology I am very familiar

with the terminology used in healthcare. I am actively employed in this field and
have been since 1984.

Knowledge of healthcare trends I am familiar, but not always as up to date

on trends as I would like to be.

Knowledge of managed care models, structures, and environment

(e.g., group, staff, IPA, PPO) I have had to build a radiology department in the
past year. A great deal of my time was spent on pricing and insurance for Imaging
exams. I have become familiar with most of the ins and outs of the insurance
structures and models. I was also part of the team who helped to bring our hospital
in-network with Blue-Cross.

Knowledge of the ambulatory care sector (e.g., acute care,

ambulatory care, post-acute, public health, long-term) Outpatients have
been a big sector of my business. I was even involved with the swing bed program
at the CAH which employed me in 2013.

Knowledge of the interdependency, integration, and competition

among healthcare sectors [provide your self-rating for this bullet, along
with evidence to support your level of competence]

Knowledge of ancillary services (e.g., lab, radiology, therapies) My

whole career has been spent in the ancillary area.

Knowledge of physicians roles: I have worked with radiologists, ortho,

Neuro, Cardio, general surg and ER physicians most of my career, but I am also now
working with hospitalists.

Knowledge of implications of community standards of care: I know

there is more in this area that I can learn.

Knowledge of evidence-based management practice: I have been on

three different quality committees for three different hospitals.

Knowledge of staff perspective in organizational settings (e.g., frame

of reference by discipline and role; orientation)
Chair of EAG committee

Department Director for over 2 years

Manager of radiology for over 10 years
Supervisor for over 5 years

Knowledge of healthcare economics: I am still a newbie in this area. I can

use further experience and learning.

Knowledge of the interrelationships among access, quality, cost,

resources allocation, accountability and community
I have run budgets and been held accountable for productivity and cost reduction.

Knowledge of nurse and allied health professionals scope of practice -

I know nursing basics from being a Corpsman in the Navy Reserve for 17 years
I was a Special Procedures technologist and practiced nursing scope of practiced in
the early 90s
I assisted the nurse manager with the PICC line team and GI lab in one hospital

Knowledge of support services (e.g., plant operations, materials

management, supply chain management, hospitality services)
I have been supply officer in multiple hospitals including military hospitals.
I chaired the EAG in two hospitals
I have been hospital safety officer in one hospital, I ran EVS in one hospital

Knowledge of patient perspective (e.g., cultural differences,

expectations)
I am well versed in Studer principles since 2008.
I helped certify our radiology department for Spanish speaking patients by providing
bilingual forms for patients.
I round on in-patients and make follow up calls to outpatients

Personal Development Plan:

Knowledge of implications of community standards of care I will visit with
my CNO and gain her insights in this area.
Knowledge of healthcare economics- This is an area where my CFO and CEO
can help me to understand the trends and ins and outs of this area.
----------------------------------------------------------------------------------------------------------------------Journal Entry Business and Management Knowledge

Business Knowledge
Do you know what to look for in a contract?
Yes, I have dealt with contracts for many years in radiology. I have put together
deals for radiology equipment and service contracts as well as room construction
and contracts for radiology students to work in our department.

Are you familiar with marking principles and tools?

Yes, I have used marketing around our city to increase our patient load and to
facilitate business from new physician partners.
Knowledge of strategic planning principlesI am well aware of the planning principles of value proposition, strong core
merchandising, strategic plan, and metrics to monitor.
Knowledge of basic contractsI am very familiar with contracts and the pitfalls which may occur from the language
within the document.
Knowledge of marketing principles and toolsI have worked with my marketing teams at three hospitals to increase public
awareness of services offered at those facilities, and I have spoken at events to
assist our marketing team in selling our hospital services to various groups.
Knowledge of techniques for business plan development, implementation
and assessmentI have worked with my boss on business plan development, but I have not been solo
in charge of a business plan.
Knowledge of principles of public affairs and community relationsI have spoken at and planed events to increase awareness of our radiology
department, specifically our mammo services during breast awareness month.
Knowledge of the functions of organizational policies and proceduresI have been a chair person of policy and procedure committee. I have written as
well as edited policies and procedures at three hospitals.
Knowledge of socioeconomic environment in which the organizations
functions-

I have worked in a hospital where we had to provided services to disadvantaged

persons. I have also had to consider tailoring my services to the area in which my
hospital resided and target those specific demographics.

Management
Do you have knowledge of contingency planning?
I have serviced as Hospital Safety officer and on the emergency council at two
hospitals. I have been involved with an organization by the name of STRAC (South
Texas Regional Advisory Council) who controls all disaster planning for South Texas
and controls movement of all EMS in this area.
Are you familiar with team building techniques?
I am very familiar with team building techniques from both the military and on the
civilian side.
Knowledge of implementation planningI have used these skills when buying new equipment and being in charge of building
out a place for that equipment to reside. I have also been responsible for the
renovation of both a radiology department and individual room which needed
updating and repair before new radiology equipment could be installed.
Knowledge of contingency planningI have serviced as Hospital Safety officer at one hospital and on the emergency
council at two hospitals. I have been involved with an organization by the name of
STRAC (South Texas Regional Advisory Council) who controls all disaster planning for
South Texas and controls movement of all EMS in this area. I also served on the
committee who helped to plan for Y2K.
Knowledge of organizational systems theory and structuring control, chain
of command, interrelationships of organizational unitsI have been around and used chain of command both in the military and in the
civilian world. I have worked on various committees where I have used my skills to
build interrelationships between both departments and other hospitals.
Knowledge of management functionsI have managed for well over 17 years now and am familiar with management
functions.
Knowledge of leadership theory and situational applications-

I have studied leadership theory in the military in leadership school and at Siena
Heights as well as using those theories in everyday work environment.
Knowledge of team building techniquesI have used team building techniques both in theory and in real life situations both
in and out of the military.
Knowledge of mediation, negotiation and dispute resolving techniquesI have worked with my HR department at three different hospitals in solving
employee issues and resolving disputes with other departments concerning
problems between my employees and other departments employees.

Knowledge of potential impacts and consequences of decision making in

situations both internal and externalI have been on both the good and bad side of planning. Which has showed me what
the potential consequences of decision making consist of.
Knowledge of how an organizations culture impacts its effectivenessI have seen firsthand how culture affects effectiveness, both with respect to culture
as a custom from an organization and from a society point of view.
Ability to analyze and evaluate information to support a decision or
recommendationI am well versed in this area both where personnel are concerned and when
purchasing equipment.
Ability to distinguish relevant from irrelevant informationThis is a decision making process which I use daily.
Ability to integrate information from various sources to make decisions or
recommendationsAgain this is a decision making process I use on a daily basis, such as comparing
two different Cat Scans and deciding which would benefit my department, budget,
and patients the best.
I feel that I am very strong in both of these areas, Business knowledge and
Management knowledge. I have both studied these areas and have used this
knowledge for real running a radiology department. These two areas are the bread
and butter of what I do on a daily basis. I do not see any areas for a SMART plan at
this time.
-----------------------------------------------------------------------------------------------------------------Governance and Organizational Structure

This area deals with the development and analysis of the organizational structure
and with delineating responsibility, authority and accountability at all levels of the
organization. Functions include the development and implementation of policies and
procedures for the governance process.
What are the responsibilities of the board of directors? The board of
directors are appointed or in some cases, voted into power to act on behalf of the
shareholders. The board runs the day to day affairs of the business and finance. The
board of directors' main job is to ensure the company's prosperity. The board of
directors also must deal with challenges and issues relating to corporate
governance, corporate social responsibility and corporate ethics.
What is the structure of the medical staff? The medical staff is a voluntary
position, and the chief medical staff position is rotated throughout the credentialed
physicians of each hospital. There is usually different departments such as surgery,
ED, radiology, and orthopedics. These physicians practice within the hospital and
send their patients to that hospital.

Knowledge of governance theory: I am well versed with the processes and

relations which control and direct corporations.
Knowledge of governance structure: The shareholders, CEO and board of
directors help define the upper echelons of the corporate structure of any company.
I am well versed in this system of governance. I have also assisted in the opening of
a new hospital and radiology department. This has allowed me to be involved in the
formation of the governance structure of a hospital.
Knowledge of medical staff structure and its relationship to governing
body and facility operation: I am well versed in this area. I have been a
director/manager for many years and have assisted in the credentialing/ privileging
process many times.
Knowledge of public policy matters and legislative and advocacy process: I
have been in management for over 15 years. I am very well versed in the legislative
and advocacy process. I have also helped to open a hospital and was on the
committee which helped to form our policy. I have also been involved in enforcing
public policy on my department and as safety officer, I had to enforce public policy
on our hospital.
-----------------------------------------------------------------------------------------------------Laws and Regulations
This area covers identifying and interreting the impact of government regulations
and law on the organization; identifying the need for and working with others to
develop new regulations and laws; investigating, monitoring, documenting and
enforcing existing statutes; and maintaining communication and cooperation with
both public and private organization.

Are you familiar with the various laws affecting healthcare? I am familiar
with the ACA and HIPAA, HITECH. I am also familiar with laws which affect CAHs
such as the Swingbed program.
Do you have knowledge of third party payment regulations? I am familiar
with third party payments made by private, not for profit foundations
Knowledge of human resources laws and regulations: I am very
knowledgeable of HR laws and regulations. I am one of the editors for the newest
edition of the AHRAs CRA exam text book which covers HR. The book goes to print
in June 2016.
Knowledge of confidentiality principles and laws: I have sat on committees
concerning HIPAA and have been the records administrator for imaging records at 3
different hospitals.
Knowledge of corporate compliance laws and regulations: I have sat on the
ethics committee board at 2 hospitals.
Knowledge of Medicare/Medicaid/Third Party payment regulations: I have
performed reconciliation of payment for imaging exams at 3 different hospitals.
Knowledge of inspection and accrediting standards, regulations, and
organizations: I led 3 imaging/radiology departments through passing JACHO and
CMS inspections. I have also been radiation safety officer at two of those hospitals
and started a radiology department from scratch applying for our accrediting and
inspection from various governmental agencies. I have also spearheaded two
departments towards ACR accreditation.
Knowledge of patient rights laws and regulations: I am very familiar with
patient rights and laws affecting their stay in healthcare facilities.
---------------------------------------------------------------------------------------------------------------------Human ResourcesThis area deals with assessing the need for and the supply of professional staff and
other personnel. Functions include recruitment, selection, training, compensation
and evaluation of such personnel and how to examine ways of evaluating
productivity and monitory accountability for results.
Knowledge of performance management systems: I am highly proficient in the
area of performance management systems
Knowledge of recruitment techniques: I am highly proficient in recruitment
techniques.
Knowledge of selection techniques: I am highly proficient in the selection
techniques used to find candidates for open job positions.

Knowledge of labor relations strategies and tactics: I am highly proficient in

labor relations
Knowledge of staffing methodologies and productivity management: I am
highly proficient in this area. I have used productivity daily at three different
hospitals over the past 17 years.
Knowledge of employee satisfaction measurement and improvement
techniques: I am highly proficient and round on my employees daily.
Knowledge of motivational techniques: I am highly proficient in using
motivational techniques on my employees. For 5 weeks before my hospital closed
we were not paid, I did not lose one employee. I kept my people working and ready.
Knowledge of compensation and benefits and practices: I am highly
proficient in speaking on this subject at hospital orientation day.
Knowledge of worker safety, security and employee health issues: I am
highly proficient in this area. I was the hospital safety officer for my last hospital.
Knowledge of conflict resolution and grievance procedure: I am highly
proficient in this area and I have had to settle differences with many employees
over the years.
Professionalism and Ethics- This area focuses on the development, monitoring
and maintenance of procedures to ensure the needs of professional staff are met.
Ethics includes identifying, monitoring and disseminating codes of professional
conduct; understanding the implications of ethical decisions; providing procedures
to monitor standards of behavior within the organization; and determining,
maintaining and monitoring accountability procedures.

Knowledge of professional codes of ethical behavior: I am highly proficient in

the knowledge of ethical behavior.
Knowledge of patients rights and responsibilities: I am highly proficient in
the knowledge of patient rights and responsibilities.
Knowledge of ethics committees roles, structure, and functions: I am
highly proficient and have served on ethics boards at one hospital.
Knowledge of cultural and spiritual diversity for patients and staff as they
relate to healthcare needs: I am highly proficient in this area.
Knowledge of conflict of interest situations as defined by organizational
bylaws, policies, and procedures: I am highly proficient in this area.
Knowledge of professional norms and behaviors: I am highly proficient in this
area.
Knowledge of the consequences of unethical actions: I am highly proficient in
this area.

Knowledge of ethical implications of human-subject research: I am highly

proficient in this area.
--------------------------------------------------------------------------------------------------------------------FinanceThis is my Achilles heel. I have had exposure to the financial aspects of radiology
departments, but most of the time I have been given a budget and told to stay
between two lines. I have not had to create a budget for my department.
This area covers the planning, development, establishment, analysis and
assessment of financial management process for an organizations capital, budget,
accounting and related reporting systems.
Are you aware of operating budget principles (i.e., zero-based, fixed)? I
have used fixed budgets. The others I have only studied.
Are you familiar with healthcare reimbursement and ramifications? I am
familiar with reimbursements and ramifications.
Knowledge of basic accounting principles (e.g., accounts receivable, cash
flow, chart of accounts, GAAP) I have studied some basic accounting principles,
but I have not put those in action.
Knowledge of financial management and financial analysis principles (e.g.,
balance sheets, income and cash flow statements, ratio analysis)- I have
studied these principles, but have not used them.
Knowledge of operating budget principles (e.g., fixed vs flexible, zerobased, variance analysis) I have used the fixed budget, but not the others. I have
studied the other principles.
Knowledge of capital budgeting principles - I have prepared capital budgets
many times in the past.
Knowledge of reimbursement methodologies and ramifications- I am
familiar with reimbursements and ramifications
Knowledge of fundamental productivity measures (e.g., hours per patient
day, cost per patient day, units of service per man hour) I have used
productivity measures in my jobs as director/manager.
Knowledge of financial controls and auditing principles I have studied, but
not used financial controls and auditing.
SMART Plan:

Knowledge of capital funding sources- I have studied capital funding, but

have not had to use it in my job.


Knowledge of revenue generation- I have studied revenue generation,
but have not had to use it.

Knowledge of asset management, including facilities equipment,

etc.- I have used asset management on a daily basis in my job as director/
manager.

Financial management and financial principles- (s)- I will work with my

CNO/CFO during the hospital reopening on financial matters to gain experience. I
will have the basics down by Sept 30 and start using this skill by 30 Dec 16.

Operating budget principles-(s)- I will work with my CNO/CFO during the

hospital reopening on planning my department budget from scratch to gain
experience. I will have the basics down by July 30 and start using this skill by 30 Oct
16.

Reimbursement methodologies and ramifications-(s)- I will work with

my CNO/CFO during the hospital reopening on how our hospital captures
reimbursement to gain experience. I will have the basics down by Oct 30 and start
using this skill by 30 Dec 16.

Financial controls and auditing principles-(s)- I will work with my

CNO/CFO during the hospital reopening on finance controls and auditing to gain
experience. I will have the basics down by June 30 and start using this skill by 30
Aug 16.

Capital funding sources-(s)- I will work with my CNO/CFO during the

hospital reopening on capital funding sources to gain experience. I will have the
basics down by July 30 and start using this skill by 30 Dec 16.

Revenue generation-(s)- I will work with my CNO/CFO during the hospital

reopening on how the hospital captures revenue and the cycle of revenue to gain
experience. I will have the basics down by Sept 30 and start using this skill by 30
Dec 16.
------------------------------------------------------------------------------------------------------------------------------Healthcare Technology and Information Management
This area covers management information and clinical information systems such
as finding computer-based support for management, assessing how current
technologies and major innovations are changing the way healthcare executives
manage, using information systems for short-and long-range planning, using
clinical information systems and acquiring information systems.
Are you aware of technology security requirements? I am not aware

Are you familiar with the role and function of information technology in
operations? I am familiar
Knowledge of the role and function of information technology in
operations- I know my little part in radiology, but not the overall aspect of the
entire hospital.
Knowledge of technology trends and clinical applications- I know my little
world, but not the other departments.
Knowledge of technology security requirements (e.g., re: HIPAA, local
governmental and organizational policies)- I am very well versed with HIPAA
and use it on a daily basis. I am also familiar with my organizational policies. I am
not, however familiar with all the local government regulations.
Knowledge of health information (e.g., data equipment, inter-operability
standards, decision support)- I am not familiar with this area.
Knowledge of information systems continuity (e.g., disaster planning,
recovery, backup, sabotage, natural disasters)- I am familiar with disaster
planning and recovery. But this is not my field.
Knowledge of information systems planning and implementation (e.g.,
service architecture, technology lifecycles, obsolescence)- I am well versed
with my PACS and RIS, but not so much with technology lifecycles and
obsolescence.
1. Knowledge of the role and function of information technology in
operations- (s)- Consult with my IT director on the basics, have a working
knowledge by 15 Aug 2016.
2. Knowledge of technology trends and clinical applications-(s)- Consult with
my IT director and have a working basic knowledge by 15 June 2016.
3. Knowledge of technology security requirements -(s)- Consult with my IT
director and CIO to have the basics by 15 Sept and useful knowledge by 15 Oct
2016.
4. Knowledge of health information- (s)- Consult with my IT director and
complete basic knowledge by 15 June 2016.
5. Knowledge of information systems continuity-(s)- Consult with my IT
director and have a working knowledge by 15 July 2016.
6. Knowledge of information systems planning and implementation -(s)Consult with my IT director while we are preparing to reopen the hospital and have
a working knowledge by 15 Aug 2016.
---------------------------------------------------------------------------------------------------------------------------Quality and Performance Improvement-

Quality and Performance Improvement

This area concentrates on the development, implementation and evaluation of
organizational accountability, including quality improvement theories and
frameworks programs, quality assessment and assurance philosophies, policies,
programs and procedures.
Are you familiar with benchmarking techniques? Yes
Do you have knowledge of risk management principles and programs? Yes
Knowledge of benchmarking techniques? I am very highly qualified in
benchmarking. I have used benchmarking in both comparing my radiology
department to others within my system and comparing my hospital to others in the
same area.
Knowledge of medical staff peer review I have used radiologist peer review
systems in my departments, but I am not well versed with the other physician
specialties.
Knowledge of risk management principles and programs (e.g., insurance
education, safety, injury management, patient complaint, patient and staff
security) I am well versed in this area. I have sat on risk management
committees and served as hospital safety officer.
Knowledge of performance and process improvement I am very well
qualified in this area. I have sat on performance and quality improvement
committees.
Knowledge of customer satisfaction principles and tools I have been
trained and use the Studer principles. I could, however obtain knowledge of other
principles, such as Six Sigma.
Knowledge of clinical methodologies (e.g., clinical pathways, evidencebased medicine, population health, pay for performance)- I have had
experience in this area, but could improve.

Knowledge of utilization review- I have had training in this area.

Knowledge of national quality initiatives including patient safety- I

have used these in my committees and hospital safety officer duties. I have also
used and been trained in this area for passing CMS and JACHO inspections.

Knowledge of medical staff peer review (s)- I will work with my nurse
training officer to gain experience. I will have the basics down by Sept 30 and start
using this skill by 30 Dec 16.

Knowledge of customer satisfaction principles and tools (s)- I will

work with my CNO/ Nurse training officer on Six Sigma to gain experience. I will
have the basics down by March 2017 and start using this skill by July 30 2017.


Knowledge of clinical methodologies -(s)- I will work with my CNO/CFO/
Nurse training officer during the hospital reopening to gain experience. I will have
the basics down by Oct 30 and start using this skill by 30 Dec 16.