Toward An Understanding of Competency Identification and Assessment in Health Care Management

14
Toward an Understanding of Competency

QUALITY MANAGEMENT IN HEALTH CARE/FALL 2002
Identification and Assessment in Health Care

Management
Judith G. Calhoun, Pamela L. Davidson, Marie E. Sinioris, Eric T. Vincent,
and John R. Griffith
Given the revolutionary changes The process of educational design at the professional school
level must be some combination of the core knowledge and
occurring in the health care
skills needed in our field, influenced by a timely response to
industry, there is increasing the challenges our graduates will face. This involves knowl-
agreement that academicians edge of both the demands of employers and feedback from
and practitioners must alumni and students. It is also our responsibility as educators
and practitioners to look ahead for developing trends and
collaborate to identify and
paradigms for action in the health sector that will allow our
prioritize major educational students, and our own intellectual inquiry, to push the
outcomes for health care envelope further, and to proactively shape the field of man-
management. Several agement in health, not just to respond to it. In a sense, we face
a double challenge in teaching health sector management—
competency initiatives have been not just teaching “how to,” but also “what for.”
undertaken or completed in —Jo Ivey Boufford, MD
health care and health care
As in many professions during the past decade,
management in the last 5 to 7 there has been a resounding call for both curricular
years. Health care leaders who content and process review for potential reform in
have undertaken such endeavors health administration education and training pro-
reveal that the task is most grams.1–4 Both Boufford5 and Griffith6 in their An-
formidable. This article provides: drew Patullo lectures delivered at the annual meet-
(1) a summary of progress in ings of the Association of University Programs in
competency identification for Health Administration (AUPHA) called for the re-
health management, (2) an thinking of current educational practices. Boufford
historical overview on stressed the need for a paradigm change from the
competency-based education
and assessment, (3) a glossary of Judith G. Calhoun, PhD, is Associate Professor, Health
terms used in discussions on Management and Policy, School of Public Health, Univer-
competency-based education sity of Michigan, Ann Arbor.
and training, and (4) an outline Pamela L. Davidson, PhD, is Associate Adjunct Professor,
of the challenges and benefits Center for Health Policy Research, University of California,
Los Angeles.
associated with competency
modeling. Marie E. Sinioris, MPH, is Vice President and Chief Ad-
ministrative Officer, National Center for Healthcare Lead-
Key words: competency, comptency- ership, Chicago.
based learning, evidence-based Eric T. Vincent, MS, is an Industrial/Organizational Psy-
learning chologist, ACT, Inc., Iowa City, Iowa.
John R. Griffith, MBA, is Professor, Health Management
Quality Management in Health Care, 2002, 11(1), 14–38 and Policy, School of Public Health, University of Michi-
© 2002 Lippincott Williams & Wilkins, Inc. gan, Ann Arbor.
14
Competency Identification and Assessment 15
current curricular emphasis on managing provider education by providing: (1) a summary of recent
organizations to a focus on the broader health sector, progress in competency identification for health
the larger society, and the health of the populations management, (2) an historical overview on compe-
served. Griffith challenged colleagues to consider tency-based education and assessment, (3) a glossary
initiatives such as evidence-based health administra- of terms frequently used in discussions surrounding
tion education and other more standardized, quanti- competency-based education and training, and (4) an
fiable approaches to assessing program quality. In an outline of the key challenges and benefits associated
article also on future educational approaches in the with competency modeling.
profession, Griffith6a pointed out the need for agree-
ment on the concept of an evidenced-based, cus-
Background: Calls for Action in Health
tomer-oriented approach to education by: (1) identi-
Care Management Education
fying the key knowledge, skills, and abilities that
contribute to the success of health care organizations
and managers; (2) measuring student mastery of such; In the Winter and Spring 2000 issues of the Journal
and (3) moving toward a higher level of mastery of Health Administration Education, several authors
throughout the field. summarized their research and related recommenda-
During the past decade, there has been a growing tions for improving the educational programs in
interest in learning and competency-based systems health administration and adapting them to
in various areas of education, training, and profes- current changes in the industry’s environment (Tables
sional development, especially in higher education.7,8 1–4).9–12 Given the impact variables identified by
Several competency initiatives have been under- these and other authors,13,14 as well as the revolution-
taken or completed in health care and health care ary changes occurring in the health care industry,15
management during the last 5 to 7 years, including: there is increasing agreement that both academicians
the Accreditation Council for Graduate Medical Edu- and practitioners in the industry will need to collabo-
cation (ACGME), the Health Financial Management rate to identify and prioritize the major educational
Association (HFMA), the Council on Linkages be- outcomes for the field to pursue in the next decade.
tween Academia and Public Health Practice, the In February 2001, 200 national leaders in health
Association to Advance Collegiate Schools of Busi- care attended a National Summit on the Future of
ness, the Association of Schools of Public Health, the Education and Practice in Health Management and
American College of Medical Practice Executives Policy, sponsored by the Accrediting Commission on
(ACMPE), the Healthcare Information and Manage- Education for Health Services Administration,
ment Systems Society (HIMSS), the American Col- AUPHA, and the Health Research and Development
lege of Healthcare Executives, the American Nurses Institute. Several widely recognized needs for change
Association, the American Hospital Association, and were reported, including:
the National Association of Boards of Pharmacy. The • Deficiencies of the current health care system in
specific domains and competencies that have been cost, quality, and patient satisfaction
disseminated to date by these organizations and other • Difficulties in attracting a fair share of young
authors addressing management competencies have leaders
been summarized in Table 1. • Lack of documented contribution from accred-
Both formal interviews and informal discussions ited academic preparation
with the health care leaders who have undertaken • Breakdown of communication between practi-
initiatives reveal that the task is most formidable and tioners and academic institutions
at times rife with controversy. This article has been • Declining support for young managers, particu-
developed to facilitate discussions associated with larly in close mentoring relationships and
competency modeling in health care management planned career development
(text continues on p. 20)

16 QUALITY MANAGEMENT IN HEALTH CARE/FALL 2002
Table 1
SELECTED COMPETENCY MODELS IN MANAGEMENT
Goleman Competency Model—3 domains:a Competency Assessment Tool Approach—4 domains, 52

• Purely technical competencies:44
• Cognitive • Technical skills
• Emotional intelligence (operations, finance, information resources, human
resources, strategic planning/external affairs)
• Industry knowledge
(Clinical process and health care institutions)
• Analytical and conceptual reasoning
• Interpersonal and emotional intelligence
Program Director Survey of Essential Graduate Skills and Key Health Services Management Effectiveness Skills
Abilities and Abilities10
• Personal and interpersonal skills • Communications
• Oral and written communication • Analytical skills
• Information systems and management • Leadership
• Financial analyses • Human relations
• Leadership • Computer literacy
• Conceptual/critical thinking • Other:
• Management/strategy –Conflict resolution
• Quantitative/analytical –Decision making
• Health care industry knowledge change management –Flexibility
• Issue/Important topics knowledge –Team-based work
• Solving problems/making decisions –Critical approval
• Systems thinking/integrative –Business issue management
• Health status improvement –Networking
–Utilization management
–Patient information management
Accreditation Council For Graduate Medical Education— Symposium on Building the Knowledge for Leadership
6 general competencies and 28 subcompetencies:54 Development for the Improvement of Healthcare—Host:
• Patient care Dartmouth Medical School:23
• Medical knowledge • Health care as a process and system
• Practice-based learning and improvement • Variation and measurement
• Interpersonal and communication skills • Customer/beneficiary knowledge
• Professionalism • Collaboration
• Systems-based practice • Develop locally useful knowledge
• Leading and making change
• Social context and accountability
• Professional subject matter
continues
Table 1
CONTINUED
Future Health Care Management Skills:b Competency Clusters for Financial Health Care Roles—3
• Leadership clusters and 8 subcompetenciesc
• Analytical • Understands the business of the environment
• Ethical practice –Strategic thinking
• Social responsibility –Systems
• Customer orientation/market acumen • Make it happen
• Community and health care team involvement/ –Results orientation
collaboration –Collaborative decision making
• Negotiation –Action orientation
• Interpersonal skills • Leads others
• Cultural diversity management –Championing business thinking
• Information systems management –Coaching and mentoring
–Impact and influence
Skill Combinations Most Desired by Employers— The Body of Knowledge for Medical Practice Manage-
4 domains:d ment—5 domains, one with 8 performance domains and
• Managing self 21 subcompetenciese
–Analyzing and solving problems • Professionalism
• Communicating • Leadership
–Listening • Communication skills
–Hearing • Organizational and analytical skills
–Persuading • Technical/professional knowledge and skills
• Managing people and tasks –Financial management
–Decision making –Human resource management
–Resolving conflict –Planning and marketing
–Leading change –Information management
• Mobilizing innovation and change –Risk management
–Thinking creatively –Governance and organizational dynamics
–Taking risks –Business and clinical operations
–Envisioning a better future –Professional responsibility
Healthcare Information and Management Systems American College of Healthcare Executives—10 general
Society—3 general competencies, 10 subcompetencies:f competencies, 57 knowledges:g
• General • Governance and organizational structure knowledge
–Health care environment • Human resources knowledge
–Technology environment • Financial knowledge
• Systems • Health care technology and information management
–Analysis knowledge
–Design • Quality and performance improvement knowledge
–Selection, implementation, support, and maintenance • Laws and regulations
–Testing and evaluation • Professionalism and ethical knowledge
–Data integrity • Health care knowledge
–Security/privacy • Management knowledge
• Administration • Business knowledge
–Leadership
–Management
continues
Table 1
CONTINUED
American Hospital Association American Nurses Associationl

Certified Health Care Facility Managerh • Organization and structure
• Compliance • Economics
• Planning, design, and construction • Human resources
• Maintenance and operations • Ethics
• Finance • Legal and regulatory
• Administration
National Association of Boards of Pharmacym—3 compe-
i
Certified Professional in Health Care Risk Management tency domains, 9 competency statements, and 37
• Loss prevention/reduction subcompetencies:
• Claims management Area 1 Manage drug therapy to optimize patient
• Risk financing outcomes
• Regulatory/accreditation compliance – Evaluate the patient and/or patient informa-
• Operations tion to determine the presence of a disease or
• Bioethics medical condition; determine the need for
treatment and/or referral; and identify patient-
Certified Health Care Environmental Services specific factors that affect health, pharmaco-
Professionalj therapy, and/or disease management
• Regulatory compliance – Assure the appropriateness of the patient’s
• Design and construction specific pharmacotherapeutic agents, dosing
• Operations related to environmental sanitation regimens, dosage forms, routes of administra-
• Operations related to waste management tion, and delivery systems
• Operations related to textile management – Monitor the patient and/or patient information
• Finance and manage the drug regimen to promote
• Administration health and assure safe and effective pharmaco-
therapy
Certified Materials and Resource Professionalk Area 2 Assure the safe and accurate dispensing of
• Purchasing/product value analysis medications
• Inventory distribution management – Perform calculations required to compound,
• Support services dispense, and administer medication
• Information systems – Select and dispense medications
• Finance – Prepare and compound extemporaneous
• Strategic planning/leadership preparations and sterile products
Area 3 Provide drug information and promote public
health
– Access, evaluate, and apply information to
promote optimal health care
– Educate patients and health care professionals
on prescription medications, nonprescription
medications, and medical devices
– Educate patients and public on wellness,
disease states, and medical conditions
a. D. Goleman. “What Makes a Leader?” Harvard Business Review, 76, no. 6 (1996): 93–102.
b. T.T.H. Wan. “Evolving Health Services Administration Education: Keeping Pace with Change.” Journal of Health Administration
Education 18, no. 1 (Winter 2000): 11–29.
c. See reference 32.
d. F.T. Evers et al. The Bases of Competence. San Francisco: Jossey-Bass Publishers, 1998.
continues
Table 1
continued
e. American College of Medical Practice Executives. Defining the Profession: A Guide to the Body of Knowledge for Medical Practice
Management. Chicago, IL: 2001.
f. Healthcare Information and Management Systems Society. (2001, December). Candidate Handbook and Application. Retrieved May
22, 2002, from http://www.himss.org/content/files/CPHIMS_handbook.pdf
g. American College of Healthcare Executives. (2002). American College of Healthcare Executives Board of Governors Examination
Outline 2002. Retrieved May 15, 2002, from http://www.ache.org
h. American Hospital Association Certification Center. (2002). Certified Healthcare Facility Manager: Candidate Handbook and
Application. Retrieved May 22, 2002, from http://www.aha.org/certification
i. American Hospital Association Certification Center. (2002). Certified Professional in Healthcare Risk Management: Candidate
Handbook and Application. Retrieved May 22, 2002, from http://www.aha.org/certification
j. American Hospital Association Certification Center. (2002). Certified Healthcare Environmental Services Professional: Candidate
Handbook. Retrieved May 22, 2002, from http://www.aha.org/certification
k. American Hospital Association Certification Center. (2002). Certified Materials & Resource Professional: Candidate Handbook.
Retrieved May 22, 2002, from http://www.aha.org/certification
l. American Nurses Credentialing Center. (2001). Generalist Catalog for ANCC Certification. Retrieved May 2002, from http://
nursingworld.org/ancc/certify/cert/catalogs/index.htm# admin
m. National Association of Boards of Pharmacy. Pharmacy Curriculum Requirements. Retrieved June 4, 2002, from http://www.nabp.net/
Table 2
COMPARISON OF THE STUDIES IDENTIFYING THE MOST IMPORTANT SKAs (IN DESCENDING ORDER—
HIGHEST RATED IS LISTED AT THE TOP)
Hudak et al. 1993 (ACHE) Hudak et al. 1994 (Federal CEO/COOs) Duperroir 1995 (Federal Nurses)
– patience, listening skills, and – patience, listening skills, and – diplomacy, tact, patience, open-
communications communications mindedness, ability to visualize
– leadership, management, human – leadership, management, human – work with multidisciplinary
relations relations leadership
– strategic thinking and sense of – understanding managed care – knowledge in case management/
vision initiatives contracts utilization review
– understand physician motives, – conflict management, team build- – communicate effectively: read,
needs, and politics ing, motivational leadership write, and listen
– conflict management, team build- – strategic thinking and sense of
ing, and motivational leadership vision
Sentell and Finstuen 1998 Brooke et al. 1998

Hudak et al. 1997 (ACMPE) (Federal CEO/COOs) (Physicians in Ambulatory Settings)
– listen, hear, respond – people skills – build and maintain credibility and
– build trust, respect, integrity – team-building trust
– ability and adaptability to change – personal responsibility – be honest when facing hard
– speak effectively, write with – innovation decisions
purpose, and listen attentively – communication skills – articulate a course for the organiza-
– work with many types of individu- tion
als – persuade others to work as a team
to achieve group’s goal
– look for win/win solutions
Source: Reprinted with permission from R.P. Hudak et al. “Identifying Management Competencies for Healthcare Executives: Review
of a Series of Delphi Studies.” The Journal of Health Administration Education 18, no. 2, pp. 213–243, © 2000, AUPHA.
Table 3 Table 4
CATEGORIES OF PROGRAM DIRECTORS’ RECOMMENDED EDUCATIONAL OUTCOMES

RECOMMENDATIONS FOR TRANSFORMING
HEALTH SERVICES MANAGEMENT EDUCATION • Change management
PROGRAMS – Environmental scanning, forecasting, and competency
analyses
Rank Category – Consolidation management
– Managed care contracting
1 Professional practice – Organizational design/redesign
2 Information systems/new technology – Negotiation
3 Leadership/ethics – Interorganizational relations
4 Changes in health management programs – Strategic human versus management
5 Population/outcomes-based management • Finance and reimbursement
6 Workforce development – Resource allocation
7 Expanding student base – Risk contracting
8 Navigating industry change • Populations-based organizational management
9 Integrative perspectives – Systems integration
10 General management – Evaluation research
11 Specific health industry topics – Data analysis and interpretation
12 Communication – Continual process improvement
12 Quantitative skills – Building and managing effective teams
12 Finance • Information systems and technology
– Cost-effective systems development
Source: Reprinted with permission from R.M. Andersen et al. – Internet use
“Program Directors’ Recommendations for Transforming Health
Services Management Education.” The Journal of Health Admin- – Standardization and compliance
istration Education 18, no. 2, pp. 153–173, © 2000, AUPHA. – Ethical/legal issue management
– Security and confidentiality assessment
• Quality improvement (Baldridge criteria)
(text continues on p. 15) • Standardization
• Consumer Satisfaction
• Shortfalls in mid-career education in health care – Environmental analysis
compared to the leading corporations in other – Continuous quality improvement
industries – Team development
• Failures in the advancement of women and – Employee training and development
underrepresented minorities, and • Market and regulatory
– Strategic management of health services
• An acute shortage of individuals prepared for – Lifelong learning
the senior ranks of the emerging multibillion
dollar health care systems and health insurance Source: Reprinted with permission from P.L. Davidson et al. “A
Framework for Evaluating the Impact of Health Services Manage-
companies.17 ment Education.” The Journal of Health Administration 18, no. 1,
Based on these problem areas—and the “new rules” pp. 1–48, © 2000, AUPHA.
of the Institute of Medicine’s report16 on quality—it
was argued that a new level of leadership in Ameri- Also reported at this Summit were the preliminary
can health care was demanded. A four-part program reports of six task forces—faculty forums—organized
of continuous improvement was subsequently rec- by AUPHA to identify specific teachable skills and
ommended by the Summit attendees, including the knowledge in health care management in the follow-
documentation of learning outcomes for the enhanced ing areas:
development of entry-level health care management • Diversity leadership
careerists and continual improvement in educational • Ethics
programs. • Health care finance
tives (n = 90) and organized into three sections:

Based on problem areas and the new theory, research, and practice.19
rules of the Institute of Medicine’s • The Health Care Finance Forum focused on the
methodological issues that emerged from their
report on quality, a new level of identification and specification process, involv-
leadership in American health care ing: (1) structural problems related to how the
was demanded. competencies should be defined, (2) applicabil-
ity across courses, and (3) problems related to
the scope and purpose of the competencies—
generalist versus specialists measurement.20
• Human resource management • A key observation from the Human Resources
• Organizational behavior and theory Management Forum was that the specific com-
• Quality improvement petencies may have to be changed, over time, in
Drawing on the texts and syllabi traditionally used response to changes in the health care environ-
in health administration curricula and prior research ment.21
and recommendations for transformation in the health • The Organizational Behavior and Theory Forum
services management education, these groups identi- learned that specific competencies might differ
fied skills they felt could be taught, mastered, and
measured.17 All groups retrospectively reported on
Table 5
the difficulty of reaching consensus without an
overarching framework to guide their work and deci- HEALTH CARE INDUSTRY ENVIRONMENT: 1998
sion making. Many of the representatives from the HEALTH ADMINISTRATION EDUCATION
faculty forums also agreed with the Diversity Leader- PROGRAM DIRECTORS’ VIEWS
ship and Quality Improvement forums—that their
initial identification activities served as the first step % of
in a long-term initiative to encourage: (1) academics total
Major change affecting the industry responses
to increase health services management research and
(2) health care managers to rely on this research to Structural changes 30
ensure their practices were evidence-based. Brief Reimbursement and cost control 13
overviews of each of these faculty forum initiatives Focus on populations and medical outcomes 11
are provided in Table 5. Advances in information systems and
technology 9
In the process of identifying and prioritizing com- Market and regulatory environment 9
petencies, the faculty forums’ work resulted in a Provider roles and relationships 7
number of reconceptualizations and conclusions. Law, ethics, and accountability 6
• The Diversity Leadership Forum used a three- Changing population demographics 4
step process to ensure broad-based involvement Quality 4
Uncertainty 2
from both academics and professionals from the
Access 2
industry. Bloom’s Taxonomy18 was used to de- Globalization 2
fine the progression in competence as the health Other 1
services manager advances through undergradu- Total response 100
ate study, graduate studies, and continuing Source: Reprinted with permission from P.L. Davidson et al. “A
professional education. Three competency do- Framework for Evaluating the Impact of Health Services Manage-
mains—individual, group, and organizational— ment Education.” The Journal of Health Administration 18, no. 1,
pp. 1–48, © 2000, AUPHA.
and eight subcompetencies were identified and Data reported from the 1998 National Survey of Program Direc-
further refined into specific behavioral objec- tors.
significantly based on organizational context sional education competency identification and as-
(i.e., health system versus skilled nursing facili- sessment. The implications for application of the
ties), span of control, variety of management competency-based movements within health care
experiences, professional career development, management and policy education are discussed in
and mentoring history.22 the concluding remarks.
• The Quality Improvement Forum raised several
key issues in developing a framework for compe- Historical Perspective: Competency-Based
tency identification, including: Education and Assessment
– Reconciliation and linkage with other industry
segment Competency modeling gained the greatest recogni-
– Extent of transferability across career stages tion in the 1970s with the work of David McClelland,7
– Applicability to the review and refinement of a Harvard psychologist with a research emphasis in
educational programs human motivation and achievement. McClelland
– Articulation with other disciplines developed a set of personality tests to identify which
The report from this forum also stressed that the patterns of behaviors, attitudes, and habits were shared
development of core competencies in health admin- and demonstrated by high achievers. His methodol-
istration needed to be conducted in recognition of the ogy primarily included research on two groups: (1)
interdependent roles in health care and the evolving outstanding performers in a job class and (2) those
structure of health care practice, while taking into whose jobs in the same class were secure but who
account the broader context of health care delivery.23 were not exceptional in performance. Nevertheless,
As can be noted, these expert panels encountered the true roots of competency-based education and
a number of significant difficulties and methodologi- training (CBET) extend as far back as the 1920s, with
cal issues in determining the specific competencies the work of Fred E. Taylor, the “Father of Scientific
and related measurable outcomes for their discipline. Management,” who specialized in work flow and task
Their experiences parallel the literature regarding analyses. CBET also gained from the work of J.
competency identification and assessment, which Flanagan during World War II, when he developed
reveals that most endeavors such as those undertaken the critical incident interview to identify crucial
by these faculty forums are rarely successful and are traits and skills for successful performance by gather-
quickly abandoned because of: ing data on the behavior and observations of people
1. Lack of a common understanding of the specific in relevant situations, job events, crises, and perfor-
goals for the endeavor mance problems. His focus, however, did not deal
2. Inconsistencies and variability in the applied with patterns of thinking and feeling as reflected in
language for carrying on an investigative dialogue McClelland’s work.7
3. Variability in organizational structures and mem- The seminal work in educational competency iden-
bership for the initiative (volunteers/appoin- tification and measurement was that of Bloom18 and
tees, experts/lay, practitioners/academics) Krathwohl.24 In the early 1950s, Benjamin S. Bloom,
4. Differences in stakeholder motivations and an educational psychologist at the University of Chi-
“buy-in” cago, led a series of conferences with more than 30
To add perspective to these current initiatives in “expert” educational leaders to address the lack of
competency identification in health care manage- consensus and communication difficulties among
ment education, an overview of competency model- educators in relation to identifying, prioritizing, and
ing in general from both the education and psychol- assessing educational outcomes. The results of these
ogy literature is provided. The remainder of this conferences led to a theoretical framework to be used
article focuses on the key issues, benefits, implemen- to facilitate communication about curriculum devel-
tation processes, and prescripts for success in profes- opment and assessment among educators.
In 1956, Bloom and colleagues published the first Competency-based education had its next boost
Taxonomy of Educational Outcomes in the cognitive with the “outcome-based educational” movement
domain (thinking, remembering, and problem solv- initiated in the 1980s by many state legislatures. In
ing) for enhancing educational development. The spite of extensive results showing these approaches
Taxonomy was expected to be of assistance to all raised achievement—especially when assessments
teachers, administrators, professional specialists, and were competency-based and used for external exit
researchers dealing with curricular and evaluation standard adherence25—the fierce battles served to
problems by facilitating communication across the diminish the worth of the approach by many educa-
various educational arenas. By using the Taxonomy tors and researchers in both education and social
as a set of standard classifications, it was expected science. Nevertheless, with the changing sociopolitical
that educators should be able to better define the environments and increasing competitive market-
many nebulous terms often encountered in curricu- places surrounding the delivery of health care, many
lum development and evaluation initiatives. agencies and professions started to consider compe-
Bloom and colleagues’ theoretical framework ad- tency-based educational approaches for both work-
dressed educational outcomes in three major areas: force planning and competitive positioning purposes.
• Cognitive domain: Those outcomes/objectives As previously mentioned, interest in competency mod-
that deal with recall or recognition of knowledge els and their potential to facilitate education and devel-
and the development of intellectual abilities and opment efforts has increased dramatically during the
skills. (This domain remains the one most cen- past 5 years in many of the professions associated with
tral to traditional curriculum development pro- business, management, and leadership. Competency-
grams and to standardized test development and based outcomes from a number of health care manage-
instrumentation.) ment initiatives are illustrated in Table 7.
• Affective domain: Objectives that describe changes
in interest, attitudes, and values, and the develop- Issues in Competency-Based Education
ment of appreciation and adequate adjustment. and Assessment
(This domain is often the most difficult to describe
because of the lack of clarity and agreement among The pros and cons for the deployment of compe-
educators in their specification of appropriate tency-based systems are many and equally balanced
behaviors for assessment. As well, using proce- on both sides of the equation. One of the key barriers
dures in this domain remains somewhat primitive to educational program enhancement and adoption
by today’s evaluation standards.) is fear of the change itself and the losses that may
• Psychomotor domain: Those objectives address- occur for the guardians of status quo. Many of the
ing manipulative or motor skill areas (i.e., ice critics of CBET take the stand that all is still well in
skating, surgical procedures). (This was the last higher education and professional training. We have
of the three educational domains to be classified long had perfectly adequate curricular and educa-
in the 1970s). tional assessment methods that have stood the test of
A condensed version of the Cognitive and Affective time and been validated by the rigorous standards of
Domains is provided in Table 6. Of the three domains, both public and private business scrutiny.26 So, many
these two are more relevant to the development of ask, why expend all the energy, effort, and cost that
knowledge, skills, attitudes, and values (KSAVs) in will be incurred to change now?
health care management education and professional The six areas of focus that seem to characterize the
development. This table provides an overview of the key issues and barriers to competency modeling are
classification system, a brief definition of the catego- discussed below:
ries, and illustrative objectives for each category in • confusing terminology
these two domains. • costs and time requirements
Table 6
TAXONOMY OF EDUCATIONAL OBJECTIVES: THE CLASSIFICATION OF EDUCATION GOALS
THE COGNITIVE DOMAIN THE AFFECTIVE DOMAIN

1.0 Knowledge (of): 1.0 Receiving/attending
1.1 Specifics (to know, to recall…) 1.1 Awareness (to observe with increasing
1.11 Terminology (to define, be familiar with, differentiation, develop some consciousness of,
acquire an understanding) recognize the importance of, realize the
1.12 Specific facts—dates, events, persons, importance of, sensitive to…)
places, sources of info (to identify, state, 1.2 Willingness to receive (to have a disposition
specify, recall, recognize…) toward, be interested in, willingness to take,
1.2 Ways and means of dealing with specifics (to be amenable toward, develop a tolerance for,
aware of, develop an awareness of…) accept differences, have an appreciation for…)
1.21 Conventions (to be conscious of, develop 1.3 Controlled or selected attention (listen to with
an awareness…) discrimination, listen for, be sensitive to, have
1.22 Trends and sequences (to understand, an alertness toward, appreciate, have a
know how…) preference for…)
1.23 Classifications and categories (to recognize, 2.0 Responding
distinguish…) 2.1 Acquiescence (be willing to comply, obey, have
1.24 Criteria an increased preference for, visit, read…)
1.25 Methodology 2.2 Willingness to respond (to be of service to,
1.3 Universals and abstractions in a field assume responsibility for, engage in a variety of,
1.31 Principles and generalizations voluntarily look for, practice the rules of,
1.32 Theories and structures respond with, perform, contribute to…)
2.0 Comprehension 2.3 Satisfaction in response (to find pleasure in,
2.1 Translation (to comprehend, interpret, enjoy, derive satisfaction from, respond
extrapolate, report, prepare…) emotionally, develop an interest in…)
2.2 Interpretation (to grasp, distinguish, to interpret) 3.0 Valuing
2.3 Extrapolation (to deal with, draw conclusions, 3.1 Acceptance of a value (to desire to, grow in
predict, be sensitive to, determine consequences, sense of, have a sense of responsibility for…)
differentiate…) 3.2 Preference for a value (to assume responsibility
3.0 Application (to apply principles, theorems, for, initiate, deliberately examine, influence,
abstractions; to predict effects, classify…) actively participate…)
4.0 Analysis (of): 3.3 Commitment (to be loyal to, accept, have faith
4.1 Analysis of elements (to recognize, distinguish in the power of, be devoted to…)
between, identify…) 4.0 Organization
4.2 Relationships (to comprehend 4.1 Conceptualization of a value (to attempt to
interrelationships, check consistencies, detect…) identify, find out and crystallize, relate own,
4.3 Organizational principles (to infer, see as, analyze…) form judgments...)
5.0 Syntheses 4.2 Organization of a value system (to weigh
5.1 Production of a unique communication alternatives, attempt to determine, develop
(to write, tell, make…) techniques for, begin to form…)
5.2 Production of a plan (to illustrate, propose, 5.0 Characterization by value or value complex
integrate, plan, design…) 5.1 Generalized Set (to change mind when, have a
5.3 Derivation of a set of abstract relations (to readiness to, be willing to face facts, view
formulate, perceive, discover, generalize…) problems objectively, rely increasingly on,
6.0 Evaluation judge problems in terms of…)
6.1 Judgments in terms of internal evidence (to 5.2 Characterization (to develop a consistent
assess, apply, indicate…) philosophy of, view problems) objectively,
6.2 Judgments of external criteria (to compare, develop a conscience, adopt codes of behavioral
weigh, appraise, distinguish between, evaluate, principles…)
apply standards…)
Source: Reprinted with permission from Benjamin S. Bloom, ed. Taxonomy of Educational Objectives, Books 1 and 2. Published by
Allyn and Bacon, Boston, MA. Copyright © 1984 by Pearson Education. Reprinted by permission of the publisher.
Table 7
FACULTY FORUM OUTCOME COMPETENCIES
Diversity Leadership19 Human Resource Management21

3 domains—8 competencies and 9 subcompetencies 3 systems domains—14 competency areas and 18
• Individual domain competencies competencies
• Group domain competencies • Process systems
• Organizational domain competencies • Structural systems
• Behavioral systems
Ethics56 Organizational Theory22

5 domains—37 competencies 4 domains—17 outcome competencies
• Process of decision making in ethics • Motivating and leading
• Professional ethics • Operating the technical system
• Clinical ethics • Renewing the organization
• Organizational ethics • Charting the future
• Social ethics
Finance20 Quality Improvement23

4 subject domains—9 behavioral competencies and 32 8 domains—32 outcome competencies
measurable skills • Health care as process and systems
• Financial management and health care organization • Variation and measurement
• Financing and investment decisions • Customer beneficiary knowledge
• Financial analysis, planning, and control • Collaboration
• Health services payment systems • Developing locally useful knowledge
• Leadership and making change
• Social context and accountability
• Professional subject matter
• methodological deployment based modeling and measurement. The terms are

• consensus/acceptance often used in many different ways or interchange-
• questionable assessment mechanisms and de- ably. CBET in itself has a number of other frequently
fensibility used synonyms, such as “outcome-based education,”
• new development vs. adoption “criterion-based outcomes,” “criterion-referenced
education,” “standards-based instruction,” or “evi-
Terminology
dence-based education.”
One of the most difficult tasks associated with As a result, confusion often arises among educa-
competency identification is establishing agreement tional development groups, even in identifying “what
on the terminology to facilitate communication among it is” that they are striving to achieve through “its”
those involved with the initiative. Many struggle deployment. As Marcolin and colleagues report,27 the
with their own definition and frameworks regarding proliferation of approaches on the concept of compe-
competency modeling. Even educators had signifi- tency has hindered the creation of a cumulative body
cant difficulties with such initiatives until Bloom of knowledge for educational enhancement. In fact,
and Krathwohl developed the taxonomies for educa- in relation to the concept of competence specifically,
tional objectives in the 1950s and 1960s. performance is frequently used to describe the con-
A great deal of variability still exists today in struct. However, many educational specialists follow
relation to the terms associated with competency- Chomsky’s28 approach in relation to differentiating
between competence and performance. Indeed, mas- 5. Commitment to patient (financial) services
tery of relevant knowledge and skills alone is no 6. Other:
guarantee of successful performance in complex en- • Shared accountability for results
vironments.8 One can be competent but not necessar- • Change initiation
ily perform well. Such is often the case in many • Excitement for new levels of involvement
competitive situations (i.e., Olympic competition, • New roles flexibility7
where all participants are exceptionally competent, Finally, Lucia and Lepsinger derived a definition
but all do not perform equally). Westera8 further of competence from the suggestions of several hun-
points out that there are two distinct denotations of dred experts in human resources at a conference on
competencies in education. From a theoretical per- the subject of competencies:
spective, competence is perceived as a cognitive Competency embodies a cluster of related knowledge,
structure that facilitates specific behaviors. From an skills, and attitudes that:
operational approach, competencies are seen to cover 1) affect a major part of one’s job (a role or responsibility)
a broad range of higher order skills (including knowl- 2) correlate with performance on the job
edge, skills, attitudes, metacognition, and behaviors 3) can be measured against well-accepted standards, and
4) can be improved by training and development.7(p.82)
that represent the ability to cope with complex and
unpredictable situations and strategic thinking) and It is also important to note that the concept of
behaviors that presuppose conscious and intentional competency has not been reserved exclusively for
decision making. education, but has been recently used in the domains
Many associate competence29,30 with expert behav- of professional practice, management, and business
ior. For instance, the HFMA competency definition administration. Pralahad and Hamel33 introduced the
focuses on “outstanding performance” and “top per- term “core competency” in their landmark article in
formers.”31 However, just as the Oxford English and the Harvard Business Review, which subsequently
Webster’s International dictionaries associate com- generated one of the highest number of requests for
petence with a set of minimum requirements,32 some reprints. Core competencies include particular sets
treat competence as a stage preceding advanced stages of skills and resources a firm possesses, as well as the
of proficiency and expertise. Hence, the range of way those are used to produce outcomes. The authors
proficiency varies across different groups, as well as used the term to identify the qualities associated with
across the different career stages. Similarly, in the the competition of companies. They equate core
general human resource literature, the construct is competency with individual or organizational char-
operationalized as the minimal level of performance acteristics that are related to effective behavior or
to successfully complete a task. performance.8 Pralahad and Hamel33 built their core
As noted in Table 2, a number of competency competency work from that of Porter in 1985.34 Porter
models have been developed for various health care offered the assumption that a firm could achieve and
providers. Although these models frequently differ, sustain a competitive advantage by establishing a
Goldstein29 points out that they tend to have some unique position relative to its competitors, thereby
common elements, such as: allowing the firm to consistently outperform them.
1. Analytical thinking that incorporates creativity Many argue today that given the instability of today’s
and innovation business environment, it is not possible to sustain a
2. Flexibility and comfort with change and ambi- long-term competitive advantage; that only tempo-
guity rary advantages can be realized. Nevertheless, the
3. Operating styles that build and leverage team- concept of core competency for creating competitive
work and cooperation advantages is widely embraced.
4. Approaches to work that embody initiative and The construct of subcompetencies also presents
proactivity articulation and transfer difficulties. Learning is both
hierarchal and cumulative—building from simple

facts and concepts to principles and the eventual
synthesis of all. Competencies also can be decom-
posed into contributing subcompetencies, often at Behavior
times called skills as well, with the results being a
“hierarchal structure of conditional subcompetencies
that become more specific and limited as one travels
down the hierarchy eventually to a stage in which Skill Knowledge
sub-competencies are identical to supportive skills.”8
Figures 1 and 2, which are adaptations of Westera’s
conceptualization,8 reflect this gradual transition of Personal
competency (the effective application of KSVs— Aptitudes Characteristics
knowledge, skills, and values—in a specific context)
into skills such that the distinctions between the two Figure 2. Competency Pyramid. Source: Adapted from A.D.
Lucia and R. Lepsinger. The Art and Science of Competency
are negligible.
Models: Pinpointing Critical Success Factors in Organizations.
Lucia and Lepsinger7 also present similar relation- San Francisco: Jossey-Bass/Pfeiffer, 1999.
ships in their competency pyramid, as noted in Fig-
ure 2. At the top of the pyramid is a specific set or
cluster of behaviors that comprise inherent talents,
innate and acquired abilities, skills, and knowledge Griffith6 refer to SKAs as specific sets of skills, knowl-
that can be acquired through learning, effort, and edge, and abilities that can be learned by students and
experience. tested in graduates. Tanner35 refers to KSAs as knowl-
Equally confusing is the frequent referencing of edge, skills, and attitudes and, as with a number of
KSAV and SKAs with the “A” representing different researchers,36–38 expands the acronym to include val-
concepts (attitudes versus abilities), depending on ues leading to KSAVs. Further, in contrast, Harvey39
the user. Westera8 combines abilities with skills and developed a KSAO model in which K refers to knowl-
uses attitudes in the KSA acronym. Hudak9 and edge, S represents skills, and A stands for abilities,
with O representing other personal characteristics,
such as motivation, independence, and commitment.
This model is very similar to Lucia and Lepsinger’s7
Competency Domain/Cluster competency pyramid as depicted in Figure 2.
Rather than review all the different definitions
available in the literature since Bloom’s and
Krathwohl’s24 breakthrough taxonomic classifications
Subcompetencies for educational objectives, a listing of definitions that
seemed to be best fitted to the field of health admin-
istration was derived for the purposes of this article,
Specific Abilities (Behavioral Indicators are required)
and perhaps to facilitate dialogues among those work-
ing on competency modeling and assessment in health
care management and policy education in the future.
These terms are summarized in Table 8. Again, by
Knowledge, Skills, and Values creating a common language and understanding of
Figure 1. Gradual Transition of Competency. Source: Adapted these widely variable terms, communication should
from W. Westera. “Competencies in Education: A Confusion of be enhanced for the more difficult tasks of identify-
Tongues. Journal of Curriculum Studies 33 no. 1 (2001): 75–88. ing, specifying, and assessing competency.
Table 8
GLOSSARY
Term Synonyms Consensus definition Source
Ability Capabilities Physical, mental, or legal power Hudak 20009

Competence
Performance
Skills
Traits
Affective domain Appreciations Encompasses an individual’s feelings, Evers 1998a
Attitudes attitudes, beliefs, self-concept, aspirations,
Interests and interpersonal relationships
Emotions
Values
Attitude Ethics State of mind, feelings, or beliefs regarding Bassellier and
Motivations a particular matter Horner 2000b
Predispositions Pascarella and
Values Terenzini 1991c
Cognitive/cognition Mental knowledge Knowledge and the use of higher order Astin 1991d
(intellectual skills mental processes such as thinking, Bloom 195618
and abilities) remembering, reasoning, analyzing,
problem solving, and evaluating
Competency analysis Task analysis Identification of performers and McNerney &
examination of what their differentiating Briggins 1995e
characteristics are
Competence/ Ability Effective application of available Tanner 200135
competency Accomplishment knowledge, skills, attitudes, and values
Capability in complex situations
Expertise
Performance
Proficiency
Skill
Core competency Competitive advantage Unique bundle of technical know-how Pralahad &
that is: (1) central to the organization’s Hamel 199033
purpose, (2) translatable to perceived
customer value, and (3) can provide a
competitive advantage
Competency-based Competency modeling (CM) A teaching-learning process that: Tanner 200135
education (CBE)/ Evidence-based 1. is individualized
Competency-based education (EBI) 2. emphasizes actionable & measurable
education and Outcomes-based outcomes in terms of what the learner
training (CBET) education (OBE) must know and be able to do
Results-oriented 3. allows for flexible pathways for achieving
accountability (ROA) outcomes
Standards-based
instruction (SBI)
continues
Table 8
CONTINUED
Term Synonyms Consensus definition Source
Knowledge Awareness Complex process of remembering, relating Bloom 195618

Mental capability or judging an idea or abstract phenomenon
Understanding: in a form very close to that in which it was
- Information originally encountered
- Insight
- Facts
- Concepts
- Principles
Outcomes Results indicators Observable results and indicators indicating ACGME 200254
(educational) that goals and objectives have been
accomplished
Performance Accomplishment Act or process of executing an action Webster’s

Competing that is facilitated by repetition Unabridged
Doing Dictionary 2000f
Psychomotor Doing Physical manipulative or motor skills Bloom 195618

Motor skills
Skill Abilities Automated routines that allow for the Kirby 1988g
Competency execution of well-specified tasks
Technical expertise
Task Analysis Competency analyses Examination of “what is done” McNerney &

Briggins 1995e
Understanding Awareness knowledge Intellectual capability to use information Kirschner 1997h

in sensible and meaningful way
Values Appreciation An abstract generalized principle of behavior Evers 1998i

Attitudes to which members of a group feel a strong
Beliefs emotionally-toned commitment and that
Emotions provides a standard for judging specific acts
Ethics and goals
Motivations
a. F.T. Evers et al. The Bases of Competence. San Francisco: Jossey-Bass Publishers, 1998.
b. G. Bassellier and B. Horner. “Information Technology Competition of Business Managers: A Definition and Research Model.” Journal
of Management Information Systems (Spring 2000), 1–19.
c. E.T. Pascarella and T.P. Terenzini. How College Affects Students: Findings and Insights from Twenty Years of Research. San Francisco:
Jossey-Bass, 1991.
d. A.W. Astin. Assessment for Excellence: The Philosophy & Practice of Assessment and Evaluation in Higher Education. New York:
American Council on Education, MacMillan, 1991.
e. D.J. McNerney and A. Briggins. “Competency Assessment Gains Favor Among Trainers,” Human Resource Focus 72, no. 6 (1995):
18–22.
f. Webster’s New International Dictionary, Unabridged. Springfield, MA: Merriam-Webster, Inc., 2000.
g. J.R. Kirby. “Style, Strategy and Skill in Reading,” In R.R. Schmeck, ed. Learning Strategies and Learning Styles: Perspectives on
Individual Differences. New York: Plenum Press, 1988: 229–274.
h. P. Kirshner et al. “The Design of a Study Environment for Acquiring Academic and Professional Competence.” Studies in Higher
Education 22, no. 2 (1997): 151–171.
i. F.T. Evers et al. The Bases of Competence. San Francisco: Jossey-Bass Publishers, 1998.
Costs hundreds of objectives.40 Other criticisms include

charges of ambiguity, vagueness, and the difficulties
Beyond the difficulties of managing the wide array encountered in specifications for assessment. As
of terms for collaborative planning and dialogue, the Hyland26 addresses, the use of competency-based
next major barrier that is often referenced is the cost modeling “de-skills” and “de-professionalizes” learn-
of competency modeling. Not only is a high level of ing and other public service occupations because of
faculty involvement and time required, but a substan- its reductionistic and technicist approach to human
tial amount of investment is required across the values. As well, the focus is perceived as being only
organization or profession considering the deploy- on performance outcomes and not with the process of
ment of the approach. Given the wide variability in growth and development.
contextual situations across all programs and seg- Indeed, many faculty members see the process of
ments, it is extremely costly and laborious to set up a identifying and specifying competencies as extremely
comprehensive modeling system professionwide. As complicated and time-consuming, often requiring
well, the profession faces continual adaptation to this new ways of thinking about their courses and instruc-
instability as a result of shifting social attitudes and tional methods. Others view the development of
profound societal, internal, and ecological change.8 competency models as arcane and difficult to under-
Consumers and marketplaces are, indeed, constantly stand. As Lucia and Lepsinger note,7 competency-
changing, with expectations also in perpetual evolu- based modeling has its historical roots solely in the
tion, if not revolution. There are no guarantees that domain of social scientists; hence there is huge use of
either will have the same educational needs tomor- technical jargon and statistics versus practical “how
row as today. Again, so why reassess current educa- to” for “discipline-specific faculty outside the field of
tional, training, and development practices to education.” Nevertheless, referencing a common
change—to change to what? Nevertheless, there re- enigma in strategic planning—“if you do not know
mains a growing interest in competency-based edu- where you are going, any road will get you there!”
cation. Survey findings show most Americans sup- Most would agree that a roadmap based on continual
port such an approach and that many educators are review of pedagogical practice and research in the
out of touch with their consumers and the markets field, as well as other related disciplines, is far better
they are supplying, since both public and employer than intuition, habit, or tradition. Whatever the defi-
concerns are often ignored.40 ciencies, competency agreement is essential to create
Goldstein29 counters that given the environment of a better alignment between educational goals and
continual restructuring and realignment, new educa- content with evolving societal needs, and an ever-
tion, development, and training approaches are es- changing professional environment.41
sential. Managers have no choice but to run their
Consensus-building and acceptance
organizations as highly competitive businesses. Hence
investments in human resources to obtain defined Stakeholder buy-in also ranks highly as a major
competencies in line with the organization’s strategic challenge to the effective deployment and realization
direction are no longer optional; the price has to be of the benefits that can be obtained with enhanced
paid for survival. definition and specification of educational standards
and assessment. Specifically in relation to health
Methodological deployment administration, the differences in competencies for
different levels of management and career stages, in
Critics of the competency movement see it as ex- addition to the many variances in management com-
cessively redundant, rigid, and prescriptive,35 yield- petencies across providers, have been addressed by
ing no more than long lists of so-called outcomes with Loebs and Dalston.42 Other frequently identified bar-
riers to consensus-building regarding necessary –differentiation of beginning to advanced com-

change are listed below: petencies
• Rapidity of change 5. Wider target audience review and comment
• Diversity of entering learners (survey/interviews)
• Program differences –querying regarding importance and relevance
– directions to the profession
– evaluation processes –prioritization with needs in the field
– approach to quality improvement 6. Final model development
– educational processes –Verification of the model with the profession
• Differences in industry segment needs 7. Dissemination of the general competencies to
• Enormity of the complexity innate to the health constituent groups, disciplines, work groups,
care system at large specialty groups
Most often, the major deterrent to developing a –specialized adaptation and development
CBET system or model, however, is determining an 8. Development of final “specialized” competen-
effective and manageable process for identifying and cies and identification of measurement out-
measuring competencies. The general consensus comes
among all those who advocate for the identification of 9. Test/assessment “blueprint development”
competencies for professional education is that they –specification of behavioral indicators
should be developed using a broad-based, consen- –weighting of critical elements
sus-building process across all stakeholders.40 10. Testing methodology selection
Literature review, expert panel interviews, stake- –identification of assessment methodologies
holder analysis, benchmarking, and the Delphi tech- for the entire continuum of competencies from
nique, as developed by Rand Corp., are usually the novice to expert and across all career stages
most common techniques used to initiate the identi- 11. Assessment
fication process. As noted below, the process gener- –identification of key data points for future
ally proceeds sequentially as follows: decision making regarding transformation ef-
1. Purpose/goal identification and clarification forts43
–identification of current expectations, needs, However accomplished, the mere engagement in
changes, strategic challenges, mandates, cur- competency identification and specifications pro-
rent strengths and weaknesses, and gaps in vides an important vehicle for productive and neces-
the field sary dialogue regarding key areas for continual edu-
–goal specification cational improvement and ongoing leadership
2. Potential identification of a pool of competen- development. As well, it provides a more vigorous
cies mechanism for facilitating professionwide collabora-
–literature review tion among practitioners and academicians.44
–benchmarking with similar professions or or-
Assessment difficulties and defensibility
ganizations
3. Expert/stakeholder analysis and input Another barrier to competency system acceptance
–including both practitioners, academicians, is the ambiguity and lack of understanding of testing
and exemplary leaders in the field and assessment by nonmeasurement specialists—lay
–initiation of professional buy-in faculty. Few faculty members are trained in either the
4. Formulation and communication of a draft set art or science of testing. Therefore, many of the testing
of general/key competencies (focus groups/ex- mechanisms traditionally utilized are questionable.
pert panels) Nevertheless, this problem exists today even without
the use of competency-based testing in health admin- cies de novo, or adapting or modifying those of other
istration education. related disciplines or professions, are basically obvi-
Indeed, there is currently a lack of valid assess- ous. New development is plagued with issues associ-
ments and standards appropriate to complex situa- ated with the identification and specification of the
tions in health management education.8 Concerted competencies, costs, and acceptance. However, once
efforts and investment in the refinement of perfor- accomplished, the applicability and relevance to the
mance expectations and related assessment tech- developing organization or problem are far higher
niques, as well as the profession’s investment in than solutions created by other groups. Nevertheless,
such, may lead to a significant elevation in higher to the extent that some of the efforts and critical
level testing acumen for all. Investments in compe- paths—and findings of others who have gone be-
tency-based approaches would require greater atten- fore—can be benchmarked, there may be significant
tion in dealing with validity, reliability, reproduc- cost savings and advantages to adopting parts of any
ibility, transfer, and portability of testing mechanisms other group’s work. For instance, as a peer group,
across the profession. Detailed professional stan- ACGME’s extensive research and development of its
dards can guide the procedures for conducting stud- general competencies may provide one model for
ies of the validity and reliability of any process that consideration and adaptation of components most
affects an individual’s performance. When properly relevant and applicable to health administration.
applied, these standards could also facilitate the After their general competencies were identified and
development of a measurement strategy for assessing operationalized within the context of the entire out-
specified competencies.45 comes project and subsequently sanctioned by
By establishing a common set of goals and perfor- ACGME’s board, they were then turned over to the
mance metrics, the process of evaluation can be different ACGME constituency groups as general
greatly enhanced. Gaps between an individual’s com- guidelines to facilitate specialty group-specific de-
petencies and the needs of specific practice settings velopment of subcompetencies, measurement crite-
can be more easily identified. As well, having a ria, and testing methodologies. ACGME also has
common understanding and communication vehicle assisted with professionwide assessment research
facilitates the identification of essential content, and development initiatives to provide resources
courses, or practices that might otherwise be omitted that will facilitate the development of appropriate
from education and training programs.46 Broad, com- testing methods and standards by each group, per
petency-based guidelines clearly provide a commu- their own “blueprints” for assessment.
nications vehicle and more vigorous methods for
fine-tuning educational practices, anticipating fu- Benefits
ture skill requirements, and improving performance
overall in the profession. In addition, a collective The benefits and potential applications for CBET
understanding and agreement on future professional can be grouped into four primary categories for addi-
requirements can provide a strong foundation for tional discussion and analysis:7
making decisions regarding educational restructur- 1. Recruitment
ing and transformation efforts, as well as ongoing 2. Education, training, and development
career development, coaching, and mentoring initia- 3. Performance appraisal
tives across the entire profession.43 4. Succession planning
In their recent text on the art and science of compe-
New development versus adoption tency modeling, Lucia and Lepsinger7 provide a sum-
mary of these four categories of benefits for human
As discussed previously, the pros and cons to resource management in today’s ever-changing work
either specifying the profession’s desired competen- environment (Table 9). Green’s survey research45 of
Table 9
HOW COMPETENCY MODELS CAN ENHANCE HUMAN RESOURCE MANAGEMENT SYSTEMS—BENEFITS OF

COMPETENCY MODELS
HRM system Benefits
Selection • Provides a complete picture of the job requirements

• Increases the likelihood of hiring people who will succeed in the job
• Minimizes the investment (both time and money) in people who may not meet the company’s
expectations
• Ensures a more systematic interview process
• Helps distinguish between competencies that are trainable and those that are more
difficult to develop
Training and • Enables people to focus on the skills, knowledge, and characteristics that have the most
development impact on effectiveness
• Ensures that training and development opportunities are aligned with organizational
values and strategies
• Makes the most effective use of training development time and dollars
• Provides a framework for ongoing coaching and feedback
Appraisal • Provides a shared understanding of what will be monitored and measured
• Focuses and facilitates the performance appraisal discussion
• Provides focus for gaining information about a person’s behavior on the job
Succession planning • Clarifies the skills, knowledge, and characteristics required for the job or role in question
• Provides a method to assess a candidate’s readiness for the role
• Focuses training and development plans to address missing competencies
• Allows an organization to measures its “bench strength” (number of high potential
performers)
Source: Reprinted with permission from A.D. Lucia and R. Lepsinger. The Art and Science of Competency Models: Pinpointing Critical
Success Factors in Organizations. © 1999, Jossey-Bass/Pfeiffer. Reprinted by permission of John Wiley and Sons, Inc.
managers and rankings of the reasons they used CBET potential competitive advantages through people,
are also depicted in Table 10. excellence in customer service, enhanced product
As Sandler points out,47 competency and recruit- development, and leadership.7,49,50
ment go hand-in-hand in today’s ever-changing mar- From an educational benefit perspective, employ-
ketplace. With increasingly tight labor markets, high ers today are looking for graduates who are able to
rates of employee turnover, lengthy training and function in extremely complex environs, often being
adjustment periods, and downsizing, employers are involved with ill-defined problems, contradictory
looking for ways to address these problems. There information, informal collaboration, and abstract,
appears to be a strong political impetus to prepare the dynamic, and highly integrated processes. As a re-
workforce for the competitive global economy.35 In sult, new standards for curriculum design, training,
1991, the Business Roundtable, a group of chief and professional development are being embraced by
executive officers from 2,000 of the largest U.S. cor- both educators and personnel offices.8
porations, adopted nine Essential Components of a Competency-based educational systems are viewed
Successful Educational System. Second on this list as being especially beneficial in relation to: (1) clarify-
was having a system based on performance out- ing goals and targets for education and training, (2)
comes.48 Investments in education and development assisting with the identification of gaps in the curricula
are viewed as essential for survival and creating for training and development programs, (3) mapping
Table 10 In light of an increasingly litigious world, compe-

tency-based assessment and appraisal systems are
SURVEY FINDINGS ON THE OBJECTIVES OF
also gaining in popularity and legitimacy. With well-
COMPETENCY SYSTEMS
defined, job-specific performance competencies and
widely embraced assessment techniques, such as
Rank Objectives
360-degree appraisals, employers are finding human
1. Link interviews, appraisal, coaching, training, resource oversight, employee recognition, and com-
and compensation to vision, mission, values, pensation programs much more manageable. For
and culture
example, Capital One, recognized in Fortune’s “100
2. Plan for the skills needed to grow the Best Places to Work in America” for the last 4 years,
organization
has relied upon their five-factor competency model
3. Communicate valued behaviors
as the unifying guide for the organization’s human
4. Clarify the focus of our leadership resource practices such as recruitment and employ-
5. Focus attention on quality/customer-oriented ment marketing, selection, training and develop-
behaviors
ment, compensation and benefits, and performance
6. Close skill gaps appraisal. By using the competency model to drive
7. Develop our competitive advantage their human resource practices, the organization has
8. Identify selection criteria for interviews been able to define successful outcomes of their
9. Structure the topics discussed in a perfor- programs, routinely monitor the practices through
mance appraisal formal and informal means, and make decisions for
10. Develop a 360-degree feedback system improvement based upon results that are directly tied
11. Plan for succession to the competencies.51
12. Orient managers to corporate strategy and Another key benefit from competency-based man-
culture agement is enhanced succession planning. The em-
13. Encourage cross-functional cooperation phasis on, commitment to, and investment in educa-
14. Guide promotional decisions tion and development, such as General Electric
15. Ease the flow of people across business and launched with Jack Welch’s direct involvement,
global boundaries greatly facilitate the replacement of outstanding mana-
Source: Reprinted with permission from P.C. Green. Building gerial performers from the pool of other equally
Robust Competencies: Linking Human Resource Systems to Orga- outstanding candidates.52
nizational Strategies. © 1999, Jossey-Bass. Reprinted by permis-
sion of John Wiley and Sons, Inc.
Several professional societies within the field of
health care management have engaged in identifying
competencies for the purposes of providing certifica-
program components in line with external marketplace tion credentials to their particular membership. For
expectations, (4) facilitating learner-mentor-preceptor example, ACMPE, HIMSS, HFMA, and the American
dialogue regarding training experiences, and (5) serv- College of Healthcare Executives have developed
ing as a vehicle for discussing and evaluating specific certification tests and then engaged in either aligning
developmental objectives and experiences across the existing training and development courses or devel-
entire continuum of professional career develop- oping new courses with the competencies. Although
ment—from career entry to senior leadership roles.46 this is important work that is beneficial for the mem-
As well, Bernstein further notes that competency bers of the individual professional groups, the com-
specification can greatly enhance career planning petencies are limited to the members served by the
based on goal-oriented criteria matched to current respective professional memberships. This is be-
accomplishments, strengths, and areas for improve- cause the development of the competencies was
ment in line with real market expectations. based upon input from the particular membership
served by the respective groups, versus in conjunc- comes have resulted to date from the ACGME’s out-
tion with other health care groups representing the comes project, including:
extremely varied field and practice of health care • Collaboration with the American Board of Medi-
management at large. cal Specialties to improve the evaluation for
In relation to potential applications for compe- residents during their residency education pro-
tency-based professional development, a model for grams
analysis and evaluation by other professions embark- • Development of a toolbox of 13 assessment meth-
ing on similar endeavors is the ACGME.53 The ACGME ods with references to articles for more complete
serves as the centralized institutional and program and in-depth information
accrediting body for nearly 7,800 residency educa- • Provision of reference sources for six topics
tion programs across 110 specialty and subspecialty affecting graduate medical education, including
areas in medicine, including all programs leading to – general assessments
primary board certification by the 24-member boards – interpersonal and communications skills
of the American Board of Medical Specialties.54 In – professionalism
1998, with funding by the Robert Wood Johnson – patient care
Foundation, ACGME initiated a 13-month compe- – practice-based learning and improvement
tency system research and collaborative review pro- – systems-based practice
cess, called the Outcomes Project. In general, their • Regular review and updating of assessment
process followed many of the same steps proposed in methods
the Consensus-Building and Acceptance section of • Specification of Guidelines for Selecting Assess-
this article. With the assistance of rigorous review ment Instruments and Implementing Assess-
and input from its expert panel and constituencies, ment Systems
ACGME cut the original list of 86 identified compe- • Serving as a clearinghouse for information about
tencies to 6. After completing this lengthy process of initiatives underway at programs and institu-
competency identification, specification, and valida- tions across the country, to integrate the teaching
tion in 1999, the ACGME leadership endorsed six and assessment of competencies into Graduate
general competencies for residents in medicine (see Medical Education curricula
Table 1). A more detailed listing of the ACGME ACGME has more than proven the utility of and
General Competencies and Sub-Competencies from applicability of competency-based education and
their Outcomes Project is provided in David Leach’s assessment for an entire educational program. One of
article on page 40 of this issue. the recently recognized residuals of their outcomes
Key ACGME goals have included: (1) collaboration project has also been the inquiry about and adoption
with other health care organizations, (2) improve- of the competencies for curriculum planning in a
ment of the evaluation of residents during their resi- number of medical schools, which may ultimately
dency education programs, (3) working with resi- affect the educational practices and assessment of an
dency review committees to define their specific entire profession.
competencies, incorporate them into their existing As a result of all of these projects and related
program requirements, and adopt an evaluation ap- activities, ACGME has significantly increased the
proach to fit its specialty, (4) increasing emphasis on emphasis on educational outcomes in the accredita-
educational outcome assessment in the accreditation tion of residency education programs and ultimately
process, and (5) using outcome data to facilitate improved the quality of graduate medical education
continuous improvement of both resident and resi- across the country. Its real accomplishment, which
dency program performance. few others have accomplished to date, was gaining
Based on these competency-focused strategic goals, the acceptance of its many diverse and complex
a significant number of other applications and out- constituent programs. Getting thousands of different
program directors and stakeholders to reach consen- Physician Education—Quality of Education in Non-Hospi-
sus and “buy-in” to the standardization of its educa- tal Settings Lags Behind Quality of Training in Hospitals55
tional and testing strategic directions is laudable and Starting with a broad-based, collaborative assess-
a model for other professional organizations. ment of the profession’s goals and strategic impera-
tives in relation to the strengths, weaknesses, and
Conclusion gaps of its educational methods and processes will
benefit the profession as a whole and as well, perhaps
If one accepts the principles of the core compe- improve the overall quality of the health of a nation.
tency models, as outlined by Porter34 and Pralahad
and Hamel33 for individual and organizational or
professional development and strategic positioning,
REFERENCES
it is clear how applicable and beneficial the develop-
ment of competency-based education and testing 1. Pew Health Professions Commission. Health Professions Edu-
models may be. As Hudak and colleagues point out,9 cation for the Future: Schools in Service to the Nation. San
it is the role and responsibility of health care educa- Francisco: Pew Health Professions Commission, 1993.
2. J. Dalston and P. Bishop. “Health Care Executive Education
tors to prepare future health care executives to cope and Training.” The Journal of Health Administration Education
with an environment that will be ever-changing. 13, no. 3 (1995): 437–452.
Therefore, it is imperative that the essential manage- 3. F. Wenzel et al. “The Health Services Delivery Environment.”
Journal of Health Administration Education 13, no. 4 (1995):
ment competencies for the future be identified and 611–630.
incorporated into and across all education, training, 4. S. Schweikart. “Reengineering the Work of Caregivers; Role
and development curricula for the profession. Redefinition, Team Structures, and Organizational Redesign.”
Hospital and Health Services Administration 41 no. 1 (1996):
The identification of broad competencies based on
19–36.
the well-documented needs for future health care 5. J.I. Boufford. “Health Future: The Managerial Agenda.” The
executives will greatly facilitate communication and Journal of Health Administration Education 17 no. 4 (Fall
collaboration across all segments and organizations 1999): 271–295.
6. J.R. Griffith. “Towards Evidence-Based Health Administration
involved with the training and development of future Education: The Tasks Ahead.” The Journal of Health Adminis-
health care leaders. A collaboration among academic tration Education 18 no. 2 (Spring 2000): 1–12.
groups and practitioners, with leadership from the 6a. J.R. Griffith. “Can You Teach the Management Technology of
Health Administration? A View of the 21st Century.” The
industry’s professional associations, is essential for Journal of Health Administration Education 16 (Summer 1999):
developing the best learning systems for the profes- 323–338.
sional development of future graduates and leaders 7. A.D. Lucia and R. Lepsinger. The Art and Science of Compe-
tency Models: Pinpointing Critical Success Factors in Organi-
in health care management and policy.41
zations. San Francisco: Jossey-Bass/Pfeiffer, 1999.
If the charge to continually review, self-assess, 8. W. Westera. “Competencies in Education: A Confusion of
diagnose, and adapt educational practices to envi- Tongues.” Journal of Curriculum Studies 33 no. 1 (2001): 75–
ronmental changes and the needs of the profession is 88.
9. R.P. Hudak et al. “Identifying Management Competencies for
not heeded, leaders in health care management and Healthcare Executives: Review of a Series of Delphi Studies.”
policy may one day, as well, be reviewing headlines The Journal of Health Administration Education 18 no. 2
similar to those from a recent task force in medicine (Spring 2000): 213–243.
10. D.E. Angus and C.M. Lay. “Responses of Canada’s Health Care
appointed to conduct an external assessment. Note Management Education Programs to Health Care Reform
this recent press release by The Commonwealth Fund Initiatives.” The Journal of Health Administration Education 18
Task Force on Academic Health Centers: no. 2 (Spring 2000): 181–204.
11. R.M. Andersen et al. “Program Directors’ Recommendations
for Transforming Health Services Management Education.”
Task Force Finds Training at the Nation’s Medical School’s The Journal of Health Administration Education 18 no. 2
Is Uneven; Calls for Improvements in Cost and Quality of (Spring 2000): 153–173.
12. P.L. Davidson et al. “A Framework for Evaluating the Impact of for University Programs in Health Administration, Chicago,
Health Services Management Education.” The Journal of Health March 2001.
Administration 18 no. 1 (Winter 2000): 1–48. 32. H.L. Dreyfus and S.E. Dreyfus. Mind over Machine: The Power
13. G. Mecklenburg. “Career Performance: How Are We of Human Intuition and Experience in the Era of the Computer.
Doing?” Journal of Healthcare Management 46 no. 1 (2001): Oxford: Basil Blackwell, 1986.
8–13. 33. C.K. Pralahad and G. Hamel. “The Core Competence of the
14. A.R. Kovner et al. “Evidence-Based Management.” Frontiers of Corporation.” Harvard Business Review 68 no. 3 (May-June
Health Services Management 16 no. 4 (2000): 324. 1990): 79–91.
15. D.D. Pointer. “Value-Added Governance.” Paper presented to 34. M.E. Porter. Competitive Advantage: Creating and Sustaining
the Healthcare Executives of Southern California, Irvine, Cali- Superior Performance. New York: Free Press, 1985.
fornia, October 1999. 35. C.A. Tanner. “Competency-based Education: The New
16. Institute of Medicine. “Crossing the Quality Chasm: A New Panacea? Journal of Nursing Education 40 no. 9 (2001): 387–
Health System for the 21st Century!” (2001). 388.
17. National Summit on the Future of Education and Practice in 36. J. Stephenson and S. Weil. Quality in Learning: A Capability
Health Management and Policy. Association of University Approach in Higher Education. London: Kogan Page, 1992.
Programs in Health Administration, Health Research and 37. R.M. Gagne. The Conditions of Learning. New York: Holt,
Development Institute, Orlando, Florida, Feb. 8–9, 2001. Rinehart & Winston, 1977.
18. B.S. Bloom et al. Taxonomy of Educational Objectives: Hand- 38. R. Barnett. The Limits of Competence: Knowledge, Higher
book I: Cognitive Domain. New York: David McKay, 1956. Education and Society. Buckingham, UK: Open University
19. J.L. Dreachslin and A. Agho. “Domains and Core Competen- Press, 1994.
cies for Effective Evidence-Based Practice in Diversity Leader- 39. R.O. Harvey. “Job Analysis.” In M.D. Dunnelle and L.M.
ship.” The Journal of Health Administration Education Supple- Haugh, eds. The Handbook of Industrial and Organizational
ment (Fall 2001): 130–145. Psychology vol. 2, 2d ed. Palo Alto, CA: Consulting Psycholo-
20. R.T. Maurer and K. Grazier. “Development of Core Competen- gists Press, 1991.
cies in Health Care Finance.” The Journal of Health Adminis- 40. B.V. Manno. “Educational Outcomes Do Matter.” Public Inter-
tration Education Supplement (Fall 2001): 157–174. est (Spring 1995): 19–24.
21. M.A. Counte and J.F. Newman. “Essential Competencies in 41. N.L. Bennett et al. “Continuing Medical Education: A New
Human Resource Management.” The Journal of Health Admin- Vision of the Professional Development of Physicians.” Aca-
istration Education Supplement (Fall 2001): 166–169. demic Medicine 75, no. 12 2000): 1167–1172.
22. L.H. Friedman and W.C. McCaughrin. “Outcome Competen- 42. S.L. Loebs and J.W. Dalston. “Issues in Management: Develop-
cies for Organizational Behavior and Theory.” The Journal of ment for Health Services Executives.” The Journal of Health
Health Administration Education Supplement (Fall 2001): 171– Administration Education 11, no. 2 (1993): 235–253.
174. 43. J. Brown and S. Barboek. “Skillful Inventory.” Bank Marketing
23. G.R. Baker and D. Wakefield. “Domains and Core Competen- (August 1991): 16–24.
cies for Effective Evidence-based Practice.” The Journal of 44. C.J. Robbins et al. “Developing Leadership in Healthcare
Health Administration Education Supplement (Fall 2001): 175– Administration: A Competency Assessment Practitioner Appli-
183. cations. Journal of Healthcare Management (May/June 2001):
24. D.R. Krathwohl et al. The Taxonomy of Education Objectives: 188–202.
The Classification of Educational Goals, Handbook II: Affec- 45. P.C. Green. Building Robust Competencies: Linking Human
tive Domain. New York: Longman, 1964. Resource Systems to Organizational Strategies. San Francisco:
25. J.H. Bishop et al. “How External Exit Exams Spur Achieve- Jossey-Bass, 1999.
ment.” Educational Leadership (September 2001): 58–63. 46. P.J. Bernstein. “The Proposed Global Business Credential: Do
26. T. Hyland. “Reconsidering Competence.” Journal of Philoso- Financial Planners Need It?” The Planner (Jul/Aug 2001): 9–12.
phy of Education 31 no. 3 (1997): 491–503. 47. L. Sandler. “Hand in Hand: Competency and Recruitment.”
27. B. Marcolin et al. “Assessing User Competence: Techniques (March 2002): 18–20.
Conceptualization and Measurement.” Information Systems 48. “Outcomes-based Outrage Runs Both Ways.” The Education
Research 11 no. 1 (March 2000): 37–60. Digest (Jan 1994): 1–4 [editorial].
28. N. Chomsky. Aspects of the Theory of Syntax. Cambridge, MA: 49. N.M. Tichy. “A Master Class in Radical Change.” Fortune
MIT Press, 1965. (Dec. 13, 1993): 1–6.
29. E.R. Goldstein. “Competency Models Help Identify Promising 50. N.M. Tichy. “Revolutionize Your Company.” Fortune (Dec.
Candidates.” Healthcare Financial Management (May 1995): 13, 1993): 1–4.
76–78. 51. A.B. Yost. “Maximizing Organizational Fit: Capital One’s
30. A.L. Klein. “Validity and Reliability for Competency-Based Approach.” In J. Canger et al., eds. Tailor-Made: Selecting
Systems: Reducing Litigation Risks.” Compensation and Ben- Employees for Organization Fit. Workshop conducted at the
efits Review (Jul/Aug 1996): 31–39. meeting of the Society of Industrial/Organizational Psycholo-
31. R.L. Clarke. “Senior Financial Executives Competency Model.” gists, Toronto, Canada, April 2002.
Presentation at the Leadership Conference of the Association 52. N.M. Tichy. “GE’s Crotonville: A Staging Ground for Corpo-
rate Revolution.” The Academy of Management Executive III, 55. L. Laranger et al. “Task Force Finds Training at the Nation’s
No. 2 (1989): 99–106. Medical Schools is Uneven: Calls for Improvement in Cost and
53. D. Leach and P. Bataldan. “Some Observations on the ACGME Quality of Physician Education.” The Commonwealth Fund,
Process of Change.” Unpublished paper, Accreditation Coun- news release (May 15, 2002): 1–3. Available online at http://
cil for Graduate Medical Education (April 18, 2001): 1–27. www.cmwf.org/media/releases/ahc_training_release
54. Accreditation Council for Graduate Medical Education 05152002.html
(ACGME) Outcome Project General Competencies. (Septem- 56. Accrediting Commission on Education for Health Services
ber 28, 1999). ACGME General Competencies Vers. 1.3. Administration (ACEHSA). Criteria for Accreditation. Wash-
Retrieved May 22, 2002, online from http://www.acgme.org/ ington, DC: ACEHSA, 1998.
outcome/comp/compFull.asp

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14

Toward an Understanding of Competency

Identification and Assessment in Health Care

(text continues on p. 20)

SELECTED COMPETENCY MODELS IN MANAGEMENT

Goleman Competency Model—3 domains:a Competency Assessment Tool Approach—4 domains, 52

American Hospital Association American Nurses Associationl

Sentell and Finstuen 1998 Brooke et al. 1998

CATEGORIES OF PROGRAM DIRECTORS’ RECOMMENDED EDUCATIONAL OUTCOMES

tives (n = 90) and organized into three sections:

THE COGNITIVE DOMAIN THE AFFECTIVE DOMAIN

FACULTY FORUM OUTCOME COMPETENCIES

Diversity Leadership19 Human Resource Management21

Ethics56 Organizational Theory22

Finance20 Quality Improvement23

• methodological deployment based modeling and measurement. The terms are

hierarchal and cumulative—building from simple

Term Synonyms Consensus definition Source

Ability Capabilities Physical, mental, or legal power Hudak 20009

Term Synonyms Consensus definition Source

Knowledge Awareness Complex process of remembering, relating Bloom 195618

Performance Accomplishment Act or process of executing an action Webster’s

Psychomotor Doing Physical manipulative or motor skills Bloom 195618

Task Analysis Competency analyses Examination of “what is done” McNerney &

Understanding Awareness knowledge Intellectual capability to use information Kirschner 1997h

Values Appreciation An abstract generalized principle of behavior Evers 1998i

Costs hundreds of objectives.40 Other criticisms include

riers to consensus-building regarding necessary –differentiation of beginning to advanced com-

HOW COMPETENCY MODELS CAN ENHANCE HUMAN RESOURCE MANAGEMENT SYSTEMS—BENEFITS OF

HRM system Benefits

Selection • Provides a complete picture of the job requirements

Table 10 In light of an increasingly litigious world, compe-

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