AONE Nurse Executive Competencies: Population …...Value-based purchasing will decrease health care costs through efficiencies across the integrated delivery networks. The pressure

COMMUNICATION

KNOWLEDGE

LEADERSHIP

PROFESSIONALISM

BUSINESS SKILLS

Nurse Executive Competencies:

Population Health

2 NURSE EXECUTIVE COMPETENCIES: POPULATION HEALTH

Suggested APA Citation: AONE, AONL. (2015). AONL Nurse Manager Competencies. Chicago, IL: AONE, AONL.

Accessed at: www.aonl.org

Accessible at: www.aonl.org/competencies

Contact: [email protected] or (312) 422-2800

© 2015 American Organization of Nurse Executives (AONE), American Organization for Nursing Leadership (AONL). All materials contained in this publication are available to anyone for download on www.aonl.org, for personal, non-commercial use only. No part of this publication may be reproduced and distributed in any form without permission of AONL, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce this material, please email [email protected].

©2015 AONE, AONL


Health care systems increasingly are

identifying strategies and interventions

to improve the health of their patients

and the communities they serve. Acute,

ambulatory and post-acute care organizations

are realizing the promotion of health and

wellness outside their settings creates

improved outcomes. This shift in care delivery

focuses on partnerships across the health

care settings and addressing specific health

needs of particular populations. Population

health management (PHM) programs seeks

to improve the health outcomes of entire

populations through the effective utilization

of patient data and analyzing that data into

actionable efforts that lead to improved

clinical and financial outcomes. Tantamount

to the development, execution, and

refinement of PHM programs is leadership

from the nurse executive. As an advocate

for community health needs and patient

populations, the nurse executive serves as

an agent of change in this strategic effort.

OVERVIEW

Reliability and validity for the AONE, AONL Nurse Executive competencies is established by periodic job analysis/role delineation

studies. These competencies are based on A National Practice Analysis Study of the Nurse Executive (2014).

ASSUMPTIONS

� Health care systems will consolidate andbecome a predominant model of integratedcare delivery.

� The health care enterprise will be patientcentric.

� Enterprise-focused executive nursingleadership is essential to the success ofintegrated delivery networks.

� Nursing practice must be aligned to the futurestate of integrated delivery.

� Academic practice partnerships are critical tocurrent and future workforce development.

� “Hospital” will not be centric to care delivery;the health care continuum will be the focus.

� Interprofessional collaboration is critical tofuture state.

� Legislation, policy and regulation should beguiding principles aligned with effective caredelivery systems.

� The shift to population health managementwill continue.

� Value-based purchasing will decrease healthcare costs through efficiencies across theintegrated delivery networks.

� The pressure for standardization based onsound evidence based practice will continue.

� Health care system transformation will continueto evolve.

� Population Health Management is thefoundation for value-based reimbursement.

� Competencies for nurse executives to leadPopulation Health Management initiatives arerequisite educational preparation in current andfuture health care delivery environments.

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A. EFFECTIVE COMMUNICATION

� Produce and present cogent andpersuasive communication materialsto address population health issuesappropriate to diverse audiences with theoutcome of engaging people, communitiesand organizations.

� Effectively resolve and manage conflict withdirect reports and colleagues.

� Possess excellent negotiation skills relatedto contracts and programs.

� Competently navigate of social media toensure effective communication across awide audience.

B. RELATIONSHIP MANAGEMENT

� Build trusting, collaborative relationshipswith stakeholders that demonstrateinterprofessional partnerships across thecontinuum of care, practice settings and thecommunity. Include the integration of virtualtechnologies where appropriate.

� Facilitate direct and honest interactions in acredible and supportive manner.

� Demonstrate integrity, including follow-through on promises and concerns.

� Provide service recovery to dissatisfiedstakeholders.

� Demonstrate empathy and concern forindividuals and groups while ensuring thatorganizational goals and objectives are met.

� Assert views in non-threatening, non-judgmental ways.

� Build relationships with communities,organizations and health care providers toprovide smooth transitions throughout thecontinuum of care and within populationserved.

� Acknowledge and celebrate successes andaccomplishments of the team.

C. INFLUENCING BEHAVIORS

� Collaborate with stakeholders to create andcommunicate a shared vision related topopulation health.

� Collaborate with stakeholders to develop,communicate and monitor behaviorexpectations.

� Demonstrate confidence and boldness inaddressing sensitive or emotional issues.

� Provide feedback and mentoring to newleaders, including coaching.

D. DIVERSITY

� Create an environment which recognizesand values differences in staff, healthcare providers, patients, families and thecommunity at large.

� Assess current environment and establishindicators of progress toward culturalcompetency.

� Define diversity as understood bystakeholders, patients, families andcommunities.

� Incorporate population data to identifycultural clusters within communities andengage patients and families in assessingneeds, defining and implementing solutions,and evaluating outcomes.

� Define cultural competency and permeateprinciples and expectations throughout theorganization.

� Address inappropriate behaviors andattitudes toward diverse groups.

� Develop processes to incorporate culturalhealth beliefs and alternative treatmentoptions into care delivery.

� Promote diversity (and divergent thinking)as a mechanism that will drive innovativeidea sharing and problem solving withinpopulation health management.

COMMUNICATION AND RELATIONSHIP BUILDING1

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E. SHARED DECISION-MAKING

� Promote the development of integratedstructures for shared decision-making.

� Utilize the strategic plan to engage internaland external resources in a structuredpartnership.

� Ensure representation of patient andcommunities populations affected bydecision-making.

F. COMMUNITY INVOLVEMENT

� Apply systems thinking to providing care forcommunities and populations.

� Represent the organization in thecommunity as a nurse leader.

G. PROVIDER RELATIONSHIPS

� Build relationships and thereby, credibility,with provider groups as a championfor health care consumers, qualityoutcomes, population health and nursingprofessionalism.

� Address inappropriate behavior towardshealth care consumers and their significantothers/families and staff.

� Represent nursing at provider executivecommittee and other provider staffcommittees.

� Collaborate with provider staff leadersin determining needed population health services.

� Collaborate with providers to developpopulation health protocols, policies andprocedures.

� Collaborate with providers to determinehealth care consumer needs.

� Utilize provider/staff mechanisms to addressprovider clinical performance issues.

� Facilitate dispute resolution and teambuilding involving providers and nurses orother disciplines.

H. ACADEMIC RELATIONSHIPS

� Determine current and future supply anddemand for nursing care.

� Identify educational needs of populationhealth of existing and potential nursing staff.

� Identify and collaborate with academicpartners to provide required population-focused resources.

� Serve on academic advisory councils as anurse leader representing population health.

� Collaborate with nursing faculty in nursingresearch and incorporate nursing researchwith populations into practice.

� Provide the foundation that supports thecontinuum of learning and professionaldevelopment by closing the gap betweenthe population health setting, academicinstitutions and health care organizations.

� Partner with academic institutions byoffering clinical site placements as a methodof recruitment into community healthnursing.

� Acknowledge the need for interprofessionalcollaborative practice and education acrossprofessions.

COMMUNICATION AND RELATIONSHIP BUILDING1

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A. CLINICAL PRACTICE KNOWLEDGE

� Understand the differences betweenpopulation health and the medical care model/episodes of care.

� Maintain knowledge of current nursingpractice and the roles and functions ofpatient care team members.

� Articulate patient care standards aspublished by The Joint Commission, DNV,CMS, CHAP, ACHA and professional nursingliterature.

� Understand, articulate and ensurecompliance with the state nurse practiceact, state board of nursing regulations,regulatory agency standards and policies ofthe organization.

� Ensure that written organization clinicalpolicies and procedures are reviewed andupdated in accordance with current clinicalpractice, evidence-based practice andpopulation health strategies.

� Role model lifelong learning, includingclinical subjects such as healthpromotion, illness prevention, diseaseprocesses, chronic disease management,pharmaceuticals, clinical technology andcommunity engagement.

B. DELIVERY MODELS/WORK DESIGN

� Advance knowledge of current nursingpractice and the roles and functions ofpatient care team members and communitypartners.

� Identify, develop and evaluate variousdelivery systems and patient care models.

� Serve as change agent and new partnerwhen patient care work/workflow related topopulation health is redesigned.

� Identify the accessible communityresources and work to build linkages to thehealth care organization.

� Collaborate, partner and build relationships toincorporate community health resources intostrategic goals and management priorities.

� Understand and interpret the componentsof a community assessment,epidemiological data, social determinantsof health, environmental influences,community based partnerships, healthliteracy and community participation.

C. HEALTH CARE ECONOMICS

� Articulate federal and state paymentsystems and regulations, as well as privateinsurance issues which affect organizationfinances and patient care in a new value-based environment.

� Understand what correlated data, and therelevance of that data, are available—public,community, federal health, and social—regarding the health of the communityserved; allowing for understanding ofthe relevance of the data to interpret itsramifications to other health care leaders.Specific social determinants should includewellness, health literacy, environmental(living conditions), cultural (health beliefs,language, nutrition), personal characteristics(gender, race, ethnicity) and socioeconomic(income, education status) factors thatimpact health.

D. HEALTH CARE POLICY

� Articulate federal and state laws andregulations that affect the provision ofpatient care (e.g., tort reform, malpractice,negligence reimbursement).

KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT2

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� Participate in the legislative processconcerning population health care throughmembership in professional organizationsand personal contact with public officials.

� Educate patient care team members andcommunity partners on the legislative andregulatory processes and methods forinfluencing both.

� Influence and impact state and federallegislation on professional policiesaffecting nursing practice and health careorganizations, as well as community benefit.

� Advocate for population health by becominga nurse leader in the community.

E. GOVERNANCE

� Articulate the roles and responsibilities ofthe relevant accountable bodies directingthe services of all components of thecomprehensive program of care deliveryincluding:

» Fiduciary responsibilities

» Credentialing

» Performance management

� Represent care delivery and member issuesto the governing body.

� Participate in strategic planning and qualityinitiatives with the governing body.

� Represent nursing at all governancefunctions.

F. EVIDENCE BASED PRACTICE/OUTCOMEMANAGEMENT

� Interpret evidence-based practice andinformation from research for use inpopulation health initiatives.

� Utilize research findings for theestablishment of standards, practices andpatient care models in the organization.

� Disseminate research findings to caredelivery team members and incorporate intopractice as appropriate.

� Participate in studies that provide outcomemeasurements.

� Allocate nursing resources based onmeasurement of population needs.

� Apply research where applicable within thecontext of a seamless provision of careacross the continuum.

� Evaluate outcomes of practice within thecontext of a seamless and comprehensiveprogram of care delivery along the healthcontinuum.

G. PATIENT SAFETY

� Support the development and implementationof a patient safety program pertinent to everyaspect of a comprehensive program of caredelivery along the health continuum.

� Design safe clinical systems, processes,policies and procedures.

� Evaluate clinical activities to identify andaddress both expected and unexpectedrisks.

� Support a non-punitive reportingenvironment and a reward system forreporting unsafe practices.

� Support safety surveys, responding andacting on safety recommendations.

� Ensure staff is clinically competent andtrained on its role in patient safety ingeneral and as it relates to population healthmanagement.

� Articulate and take action to supportthe Joint Commission National PatientSafety Goals, as well as other national andprofessional standards.

H. UTILIZATION/CASE MANAGEMENT

� Articulate organization decision-making forthe criteria model adopted by the populationhealth management organization.

� Communicate the key points of the modelto all constituents, including, but not limitedto, nursing, financial, medical staff, payersand members.

� Involve physicians and other providers in on-going utilization management practices.


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� Design continuum of care mechanisms formanaging patient throughput through thecontinuum of care, including, but not limitedto, skilled nursing facilities, long-term carefacilities, urgent care centers and ambulatorycare centers.

� Develop processes which enhance everyclinician’s and team member’s ability toanticipate member needs at all stages of thehealth care delivery system.

I. QUALITY IMPROVEMENT/METRICS

� Articulate the organization’s quality programand goals, in general and specifically asrelated to population health.

� Determine patient/member care qualityimprovement goals and objectives in relationto population health.

� Define process improvement metrics forappropriate components of the populationhealth program.

� Explain and utilize metrics as a unit ofmeasure for any process.

� Articulate the link between metrics and goals.

� Articulate the link between organizationmetrics and national and professional qualityinitiatives/metrics.

� Target outcomes that are evidence-based(comparison data benchmarking).

� Define quality metrics by:

» Identifying the problem/process

» Measuring success at improving specificareas of patient care

» Analyzing the root causes of variationfrom quality standards

» Improving the process with the evidence

» Controlling solutions and sustainingsuccess

J. RISK MANAGEMENT

� Partner with risk management and otherleaders to identify areas and trends of risk/liability in aspects of practice and operations.

� Ensure staff is educated on riskmanagement and compliance issues asapplicable to their practice environments.

� Develop systems which encourage/requireprompt reporting of potential liability by staffat all levels in all practice environments.

� Envision and take action to correct identifiedareas of potential liability.


©2015 AONE, AONL


A. FOUNDATIONAL THINKING SKILLS

� Critically analyze research-based evidenceand apply to evaluation of population healthmanagement, organizational issues and policy.

� Demonstrate curiosity and eagerness toexplore new knowledge and ideas.

� Promote nursing leadership throughapplication of evidence and insight.

� Demonstrate leadership through applicationof decision-making strategies appropriate tovarying situations both internal and externalto the organization.

� Provide visionary thinking on populationhealth management and new care deliverysystems.

� Develop and support roles and processesthat demonstrate a focus on issuesgermane to population health (e.g., healthpromotion, disease prevention, wellness,care coordination).

� Promote the practice of nursing to the fullextent of knowledge and education.

B. PERSONAL JOURNEY DISCIPLINES

� Integrate feedback regarding strengths andweakness into personal and professionaldevelopment.

� Practice lifelong learning through theidentification of learning opportunities.

� Develop a professional portfolio as part ofcareer-planning strategy.

� Seek and provide mentorship in the fields ofleadership and population health.

� Engage in learning activities related topopulation health management and carecoordination across the continuum of care.

� Forge professional relationships withinand beyond the fields of nursing andpopulation health to extend collaborationand integration of knowledge.

C. SYSTEMS THINKING

� Demonstrate and promote systems thinkingas a means of addressing health across thefull continuum of care.

� Consider the impact of nursing decisions onthe health of the population.

� Promote engagement throughout theorganization to serve the needs of thepopulation across the continuum of care.

� Synthesize and integrate divergentviewpoints for the benefit of patientsand populations along the health carecontinuum.

� Identify and integrate the complex needs ofpopulation health through the inclusion ofpeople and communities in the assessment,development, implementation, andevaluation of initiatives.

D. SUCCESSION PLANNING

� Promote population health as a meaningfulspecialty.

� Address organizational need for successionplanning at all levels of the system.

� Serve as subject matter expert, role modeland mentor in the area of population health.

� Establish mechanisms to identify andmentor those with leadership potential inthe field of population health.

� Extend mentoring opportunities to thecommunity-at-large, including healthcare providers, academic institutions andprofessional organizations.

LEADERSHIP3

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E. CHANGE MANAGEMENT

� Use change theory to plan for and managechanges affecting the population andcaregivers.

� Serve as a change agent, assisting othersin understanding the importance, necessity,impact and process of change as theparadigm shifts to manage population healthacross the continuum.

� Support those affected by change duringthe transition.

� Demonstrate openness to change,particularly during periods of transition.

� Reward creative and innovative thinking.

� Adapt leadership style to meet situationalneeds.

LEADERSHIP3

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A. PERSONAL AND PROFESSIONALACCOUNTABILITY

� Collaborate with stakeholders acrossthe care continuum to establish goalswith measureable outcomes. Foster anenvironment of performance transparencypredicated on outcomes to create culture ofaccountability across the care continuum.

� Create innovative governance structureswhich encourages community and care continuum accountability with clear responsibility to achieve goals.

� Align one’s own personal core values withthose of their organization and/or professionalorganizations and apply regularly to theirpersonal and professional lives.

� Establish trust through timelycommunication of reliable and validinformation to the appropriate stakeholders.

� Create and maintain a professional portfoliobased on the AONE Nurse ExecutiveCompetencies.

B. CAREER PLANNING

� Create an environment in which professionaland personal growth is an expectation.

� Evaluate potential for innovative career pathsemerging in the population health space.

� Encourage pursuit of and collaboratewith academic partners to instill neededcompetencies for skills acquisition.

C. ETHICS

� Create a cross continuum collaboration thatencourages frank and open discussion aroundethical challenges and problem solving.

� Provide a venue for raising ethical issues orconcerns across disciplines and care settings,inclusive of patients and their families.

� Evaluate the communication betweennurses, our interprofessional colleaguesand persons/populations served to assessthe quality of health information, care andexperiences without bias.

� Analyze potential human ethical violationsthat place at risk the basic fundamentalethical principles of autonomy, beneficenceand nonmaleficence.

� Recognize and integrate the ANA NursingCode of Ethics into one’s own professionalpractice.

D. EVIDENCE-BASED CLINICAL ANDMANAGEMENT PRACTICE

� Analyze large datasets across the carecontinuum and develop platforms/venues for communication of results andrecommendations for action.

� Communicate best clinical and managementpractices effectively given the likelihoodof innovative perspectives with populationhealth metrics.

� Promote interoperability of disparatesystems to allow for data transparencyand aggregation across episodes of careto optimize care delivery/improvement ofhandovers.

� Establish information technologyinfrastructure to measure systemicperformance across boundaries.

� Allow for all ideas to be communicated andvalidated with evidence, as appropriate.

PROFESSIONALISM4

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E. ADVOCACY

� Promote and support community andsystems approach. Lead collaboration/partnership initiatives to improve goal alignment across care settings to benefit patient outcomes and experience.

� Advocate for inclusion of disparateviewpoints when making decisions.

� Ensure quality of life of the populationserved.

F. ACTIVE MEMBERSHIP IN PROFESSIONALORGANIZATIONS

� Lead cross organizational efforts toenhance population health, including thecreation of collaborative partnerships.

� Explore and integrate boundary spanningwork by other disciplines and organizations.

� Be engaged in at least one professionalorganization promoting leadershipdevelopment and refinement to improvepopulation health management.

� Maintain awareness of and demonstratecommitment to the expectations setforth by the representative professionalorganizations.

PROFESSIONALISM4

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A. FINANCIAL MANAGEMENT

� Articulate business models that supportprograms to address population health.

� Describe insurance and reimbursementmodels as they apply to population healthmanagement.

� Analyze data to measure key financial metrics.

� Manage financial resources by developingsound business plans.

� Ensure accurate billing and chargingmechanisms through collaboration withappropriate business units.

� Educate patient care team membersregarding financial implications of patientcare decisions across the population.

� Identify common demographic influenceson population health management.

� Integrate financial management tooutcomes in decision-making.

B. HUMAN RESOURCE MANAGEMENT

� Participate in workforce planning andemployment decisions.

� Champion a diverse workforce andunderstand cultural norms.

� Provide constructive feedback to addressworkplace opportunities for improvement.

� Interpret and evaluate employeesatisfaction/quality of work surveys.

� Create opportunities for employees to beinvolved in decision-making (e.g., sharedleadership).

� Reward and recognize exemplaryperformance.

� Formulate programs to enhance work-lifebalance.

� Interpret legal and regulatory guidelines.

� Manage collective bargaining environmentsor implement programs to avoid the need.

� Identify and eliminate sexual harassment,workplace violence and safety, and verbaland physical abuse.

� Implement ergonomically sound workenvironments to prevent worker injuryand fatigue.

� Develop and implement bioterrorist,biohazard and disaster readiness plans.

� Identify clinical and leadership skills/competencies necessary for performingjob related tasks.

� Provide mentorship and career counselingto aspiring clinicians and leaders to developrequired skill sets (e.g., successionplanning).

� Identify future skill sets needed to remaincompetitive.

� Analyze market data in relation to supply anddemand and manage resources to ensureappropriate compensation.

� Develop and implement recruitment andretention strategies.

C. STRATEGIC MANAGEMENT

� Connect with community leaders tocollaborate on industry growth.

� Project health care needs in thecommunities being served.

� Collaborate with and inspire multidisciplinaryteams to provide seamless and holistic care.

� Be open to and encourage innovative andcreative ways to provide care.

� Measure and analyze performance fromthe learning and growth, business process,customer and financial perspectives toremain competitive.

� Recognize and support the role ofaccountable care organizations in populationhealth management.

BUSINESS SKILLS5

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D. MARKETING

� Create a formal marketing plan, includingstrategies, budget, communication plan andreferral goals.

� Consider needs of the community andpopulation served in creating marketing plan.

� Use public relations and media outlets topromote your organization.

� Develop individual presentations thatare professional looking, articulate andknowledgeable.

E. INFORMATION MANAGEMENT ANDTECHNOLOGY

� Maintain competency in office technologyand web-based programs and applications,including use of telehealth platforms.

� Translate data into actionable informationto improve clinical practice and patientoutcomes in population health.

� Optimize computer and technicalapplications to promote population health.

� Participate in system change processes andutility analysis.

� Participate in evaluation of informationsystems in practice settings.

� Evaluate and revise patient care processesand systems.

� Utilize electronic medical record systems tocollect, manage and integrate data.

� Promote nursing involvement in theplanning, design, choice and implementationof information systems in the practiceenvironment.

� Demonstrate awareness of societal andtechnological trends, issues and newdevelopments as they apply to populationhealth.

� Demonstrate proficient awareness of legaland ethical issues related to client data,information and confidentiality.

� Analyze and interpret data relevant to clinicaland business intelligence.

BUSINESS SKILLS5

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Documents

AONE Nurse Executive Competencies: Population …...Value-based purchasing will decrease health care costs through efficiencies across the integrated delivery networks. The pressure