Ohio Physician Leadership Institute

Ohio Physician Leadership Institute

Enrollment Form

Physician Name: ______

Specialty: ______

Address: ______

City: ______State: ______Zip: ______

Phone: Office ______Cell ______

E-mail: ______

______Full Payment $10,000

Physician Name: ______

Specialty: ______

Address: ______

City: ______State: ______Zip: ______

Phone: Office ______Cell ______

E-mail: ______

______Full Payment $10,000

Mail registrations to and make checks payable to OHA, Inc., 155 E. Broad Street, Suite 301, Columbus, Ohio 43215-3640. Deadline for cancellations is one week prior to the first session. After this date no refunds will be made. There will be a $40 processing fee attached to all refunds. Substitutions are welcome. If you have any questions please feel free to contact either Cliff Lehman, Sr. V. P. Membership Services OHA at

The Physician Leadership Institute of Ohio

Powered by the Ohio Hospital Association, the Ohio State Medical Association and the Center for Transformation and Innovation

APPLICATION FORM

ASSESSMENT OF LEADERSHIP POTENTIAL

1)What is your personal philosophy or definition of leadership?

2)What are your strengths?

3)What are your key development areas? What would you like to work on to improve yourself if you had the time?

4)How will The Physician Leadership Institute of Ohiohelp you improve your key development areas?

5)What are your values? What do you hold in high regard? What is of importance to you?

6)What do you view as the single most important issue/challenge to you as a leader today?

7)What do you view as the single most important issue facing healthcare or your organization? As aleader, what would you do about this issue?

8)Describe a situation in which you took a leadership role. Include the actions you took in addressing the situation.

9)Why would you like to participate in the Physician leadership Institute of Ohio?

The Physician Leadership Institute of Ohio

Powered by the Ohio Hospital Association, the Ohio State Medical Association and the Center for Transformation and Innovation

ASSESSMENT OF LEADERSHIP POTENTIAL

(Please use this form to assess YOUR leadership abilities)

Leading Self / Don’t Know / Low / Medium / High
Integrity: Demonstrates the highest level of ethical standards and responsibility.
Dependability and Reliability: Develops trust and credibility by acting in a consistent, genuine manner.
Self Discipline: Controls emotions effectively. Does not lose control easily.
Adaptability: Adapts quickly to new situations and requirements. Displays flexible thinking and openness to new ideas.
Resilience: Rebounds quickly from setbacks and unexpected disruptions.
Leading with Strategy / Don’t Know / Low / Medium / High
Visioning and Engagement: Creates, communicates, and enrolls others in a compelling vision.
Business Perspective: Applies critical thinking to identify and maintain focus on key success factors for the organization/department.
Change and Innovation: Develops and implements new initiatives and ideas that improve the organization’s or department’s performance.
Financial Acumen: Effectively manages the key business and financial drivers for the department/organization.
Sound Judgment: Focuses key initiatives to maximize support for the overall strategies and goals of the organization/department.
Leading People / Don’t Know / Low / Medium / High
Building Relationships and Trust: Treats everyone with respect and dignity. Respects and leverages individual differences in culture, background, style, and preferences.
Teamwork and Networking: Leads team members to maximize cooperation, leverage diverse talents, and share information and expertise.
Coaching and Performance Development: Provides team members constructive feedback, and support for development.
Communication and Influence: Expresses ideas clearly and concisely. Motivates and influences others, even when not in a position of authority.
Empathy: Able to identify with and address other’s feelings, concerns, and needs.
Managing Conflict: Has the difficult conversations with others when needed. Does not shy away from surfacing problems that must be resolved.
Leading For Results / Don’t Know / Low / Medium / High
Managing Time: Effectively manages time and priorities. Completes critical activities and goals in a timely, efficient manner.
Quality and Process Improvement: Seeks to continuously improve processes and services. Challenges the status quo.
Driving Results: Consistently drives critical activities to completion.
Taking Initiative: Takes ownership of problems and actively solves them.

For more information, please contactReggie Fields, OSMA at (614)527-6740 or , Cliff Lehman, OHA at (614)221-7614 or or Jeanne Bellew, The Leadership Institute, Center for Transformation and Innovation, at813-333-1401 x 1018, or via email at .

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