Health Care Administration, Leadership, and Management Content Outline

Core Content Areas

Content Area	Percent of Exam
1.0 Business of Health Care Finance and Accounting Principles 8%	9%
2.0 Care Innovation, Health Equity, and Population Health	10%
3.0 Governance	8%
4.0 Health Care Policy, Law, and Advocacy	11%
5.0 Health Information Technology	9%
6.0 Human Resource Management and Workforce Development	10%
7.0 Leadership in Patient Safety and Quality Improvement	14%
8.0 Organizational Leadership and Communication Skills	13%
9.0 Professionalism and Ethics	8%

1.0 Business of Health Care

• 1.1 Accounting principles, financial controls, P&L, and financial statements
• 1.2 Business plan development (e.g., adding new services, return on investment)
• 1.3 Capital budgeting and asset management (e.g., funding sources, long-term
  implications of capital planning, such as depreciation)
• 1.4 Contracts legal and financial implications
• 1.5 Financial decisions’ impact on operations, health care, human resources, and quality
  of care
• 1.6 Fundamental productivity measures (e.g., hours per patient day, cost per patient day,
  units of service per labor hour)
• 1.7 Funding sources (e.g., issuance of bonds, philanthropy, grants, and foundations)
• 1.8 GME reimbursement models and associated regulatory/compliance law (e.g., IME,
  DME)
• 1.9 Interpretation of marketing data (e.g., market analysis, market research, sales,
  advertising)
• 1.10 Methods for determining community gaps/need for health care services (community
  need)
• 1.11 Methods for determining the fair market value for services provided (clinical, academic
  affiliations, teaching, or research)
• 1.12 Negotiation strategies and techniques
• 1.13 Operating budget principles (e.g., fixed vs. flexible, zero-based, variance analysis,
  contribution margin)
• 1.14 Prioritization of capital resources and associated conflict resolution
• 1.15 Reimbursement methodologies (e.g., academic, managed care models, federal/state
  matching, value-based, fee-for-service, risk-based)
• 1.16 Centers for Medicare and Medicaid payer-based models
• 1.17 Revenue generation (e.g., billing, coding, new ways to generate revenue, pricing
  strategies, and transparency)
• 1.18 Stark, antitrust, and kickback laws related to physician services
• 1.19 Mergers and acquisitions
• 1.20 Vendors and payor relations
• 1.21 Contract and vendor sourcing
• 1.22 Business community relations
• 1.23 Advertising and marketing
• 1.24 Taxation law
• 1.25 Collaborating with competitors

2.0 Care Innovation, Health Equity, and Population Health

• 2.1 Health disparities
• 2.2 Health care access, quality, cost, resource allocation, accountability, and the
  community
• 2.3 Health care trends and barriers across the continuum of care (e.g., extended care,
  acute hospital care, ambulatory care, home care)
• 2.4 Non-traditional settings and methods to improve access
  • 2.4.1 Hospital-at-Home
• 2.5 Patient-centered care
• 2.6 Social determinants of health
• 2.7 Community Social Services Relations
• 2.8 Telehealth impact and other emerging technologies
• 2.9 Value-based care models
  • 2.9.1 ACOs
  • 2.9.2 Bundled payment models
  • 2.9.3 Clinically integrated networks
  • 2.9.4 Co-management agreements
  • 2.9.5 MIPPS/MACRA
  • 2.9.6 The transition from volume to value-based care implementation

3.0 Governance

• 3.1 Health system governance structure (e.g., bylaws, articles of incorporation) and operations (e.g., board member selection, education, orientation, monitoring, and
  assessment)
  • 3.1.1 Board member conflicts of interest, dualities of interest
  • 3.1.2 Administrative staff conflicts of interest, dualities of interest
• 3.2 Health system governing board models, roles, and responsibilities, e.g.:
  • 3.2.1 Financial oversight (nonprofit vs. for-profit settings)
  • 3.2.2 Patient safety and assurance of the quality of care
  • 3.2.3 Preservation of assets, reputation, and risk management
  • 3.2.4 Statutory and regulatory compliance
  • 3.2.5 Strategic planning
• 3.3 Health system physician leader’s role (e.g., CMO/VPMA) with board/institutional governance and medical staff
• 3.4 Medical staff structure and its relationship to governing bodies (e.g., board oversight of credentialing, privileging, employed vs. voluntary models, and disciplinary process)
• 3.5 Medical staff call obligations and compensation
• 3.6 Public policy, legislative, and advocacy processes
• 3.7 Philanthropic and investment processes
• 3.8 Organizational-level committee structure and participation
• 3.9 Management of single-entity versus federation of entities
• 3.10 Matrix management (e.g., medical group, health plan)
• 3.11 Coalition building
• 3.12 Managing competition (internal and external)
• 3.13 Interface to Medical Transport Systems
• 3.14 Foundational Model and Health System Direction

4.0 Health Care Policy, Law, and Advocacy

• 4.1 Auditing
• 4.2 Clinician roles and qualifying criteria (e.g., administrative versus clinical)
• 4.3 CMS Conditions of Participation
• 4.4 Compliance and regulatory (e.g., antitrust, conflict of interest, EMTALA, Stark, billing, and coding)
• 4.5 Continual readiness for accrediting/regulatory organization inspection and compliance (e.g., TJC, ACGME, OSHA, FDA, NRC, CDC, state, federal/tribal accreditation/certification/licensure)
• 4.6 GME policies and accreditation requirements
• 4.7 Information security management (e.g., PHI, HIPAA, FOIA, the release of information)
• 4.8 Management of information security breaches
• 4.9 Medicare and Medicaid regulations
• 4.10 Other third-party payment regulations (e.g., PPO, HMO)
• 4.11 Patients’ rights laws and regulations (e.g., informed consent, advance directives, involuntary commitments)
• 4.12 Regulatory reporting requirements
• 4.13 Research office leadership compliance and regulation (HIC, IRB, grants management)
• 4.14 Advocacy and engagement
  • 4.14.1 Lobbying entities
  • 4.14.2 Federal agencies (e.g., MedPac)
  • 4.14.3 Organized Health care (e.g., NQF, AHA, AMA, etc.)

5.0 Health Information Technology

• 5.1 Applications
• 5.2 Clinical documentation auditing and improvement strategies (role of physician advisors)
• 5.3 Compliance (e.g., HIPAA security requirements, HITECH Act meaningful use requirements)
• 5.4 Data and equipment interoperability
• 5.5 Data management
  • 5.5.1 Security breaches, malware, ransomware, etc.
  • 5.5.2 Ongoing innovation, maintenance
  • 5.5.3 Upgrading and conversions
• 5.6 Decision support and alert fatigue
• 5.7 Health care analytics
• 5.8 Big data
• 5.9 Augmented intelligence
• 5.10 HIPAA
• 5.11 HITECH Act meaningful use
• 5.12 Information systems continuity and redundancy
• 5.13 Physician and end-user engagement in IT strategies
• 5.14 Technology lifecycles
• 5.15 Technology policies and regulations
• 5.16 Social media trends
• 5.17 Workforce engagement and compliance with institutional systems

6.0 Human Resource Management and Workforce Development

• 6.1 Compensation and benefits practices
• 6.2 Conflicts and dualities of interest (e.g., industry relationships)
• 6.3 Conflict resolution and grievance procedures
• 6.4 Diversity, inclusion, and equity strategies
• 6.5 Employee safety, security, and health issues (e.g., OSHA, workplace violence)
• 6.6 Employee satisfaction assessment, engagement, motivation, and career development tools
• 6.7 Labor relations and laws (e.g., FMLA, FLSA, EEOC, ERISA, worker compensation)
• 6.8 Performance management systems (e.g., performance-based evaluation, rewards systems, disciplinary policies, and procedures)
• 6.9 Physician satisfaction assessment and engagement tools and techniques
• 6.10 Recruitment and retention approaches and techniques
• 6.11 Staffing models, productivity management, and the impact of changes on the quality of care
• 6.12 Interprofessional care delivery teams
• 6.13 Succession planning models
• 6.14 Workforce cultural competency strategies
• 6.15 Workforce wellness
• 6.16 Burnout mitigation
• 6.17 Impaired individuals
• 6.18 Utilization and impact of external staffing agencies

7.0 Leadership in Patient Safety and Quality Improvement

• 7.1 Benchmarking standards to define, monitor, and assure evidence-based, efficient, timely, appropriate, cost-effective, equitable, patient-centered care
• 7.2 High-reliability care organizational (HRO) principles, tools, and monitoring processes (e.g., error reduction, serious safety event and near-miss reporting, just culture, root
  cause analysis, regulatory safety event reporting requirements, corrective action plans, and error disclosure)
• 7.3 Performance standard-setting, documentation, measurement, and monitoring (e.g., evidence-based clinical pathways, value-based care, population health, pay-forperformance, patient satisfaction)
• 7.4 Principles of patient safety, methods, and legal aspects of medical staff credentialing and peer review, including OPPE and FPPE
• 7.5 Process and quality improvement principles, measurement tools, and techniques (e.g., plan-do-study-act, lean daily management, Six Sigma)
• 7.6 Quality program leadership, strategic planning, operations, and financing
• 7.7 Risk management principles and programs (e.g., insurance, education, workplace safety, injury management, patient complaints, patient and staff safety, and security)
• 7.8 Utilization review and leadership of case management teams
• 7.9 Education in identifiable gaps in system-based practice
• 7.10 Longitudinal understanding of the system-wide organizational structure
• 7.11 Community initiatives (e.g., violence prevention)
• 7.12 External agency engagement (e.g., NAHQ, AHRQ, NAM, etc.)

8.0 Organizational Leadership and Communication Skills

• 8.1 Clinical operational leadership for interprofessional teams across the continuum (e.g., planning, direction, execution, evaluation) for:
  • 8.1.1 Ancillary services (e.g., lab, radiology, pharmacy)
  • 8.1.2 Providers (e.g., nonprofit, for-profit, federal, public health)
  • 8.1.3 Support services (e.g., the environment of care, plant operations, materials management, supply chain management, hospitality services)
• 8.3 Contingency planning (e.g., emergency preparedness, disaster management, National Incident Management System)
• 8.4 Organizational systems (e.g., span of control, chain of command, interrelationships of organizational units)
• 8.5 Principles of media relations, advertising, social media, and community relations
• 8.6 Resource allocation methods and related conflict management
• 8.7 Team Leadership
• 8.2 Collaborative techniques for engaging and working with physicians
  • 8.7.1 Change management
  • 8.7.2 Conflict resolution
  • 8.7.3 Diversity, equity, and inclusion
  • 8.7.4 Emotional intelligence
  • 8.7.5 Group dynamics
  • 8.7.6 Interpersonal communication
  • 8.7.7 Organizational culture development and resources
  • 8.7.8 Public relations and media
  • 8.7.9 Risk communication
  • 8.7.10 Situational leadership skills
  • 8.7.11 Team building
    • 8.7.11.1 Assembly
    • 8.7.11.2 Development

9.0 Professionalism and Ethics

• 9.1 Conflict of interest issues and solutions as defined by organizational bylaws, policies, and procedures (futile care)
• 9.2 Consequences of unethical actions
• 9.3 Cultural and spiritual diversity of patients and staff as relates to health care needs
• 9.4 Patient-centered care and shared decision making
• 9.5 Ethical implications of human- or animal-subject research
• 9.5.1 Research enterprise initiatives
• 9.6 Ethics committees’ roles, structure, and functions
• 9.7 Patients’ rights and responsibilities (e.g., informed consent, withdrawal of care, advance directives)
• 9.8 Professional standards, licensure, board certification, code of conduct
• 9.9 Educational program integration and continuing education
  • 9.9.1 Staff
  • 9.9.2 Medical Professionals
• 9.10 Role modeling professionalism in the learning environment
• 9.11 Strategies for management of the disruptive physician
• 9.12 Organizational policies on misinformation
• 9.13 Medical marijuana