FACHE credential
Application
Completing this application is the first step toward earning the FACHE
credential. Please read and complete each section fully and accurately in clear,
legible handwriting or type. If you have any questions, please call ACHE’s
Customer Service Center at (312) 424-9400 Monday through Friday, from
8 a.m. to 5 p.m. Central time or email [email protected].
If you are sending in a hard copy application, it is
required you mail in a check for security purposes.
To pay via credit card, apply online at ache.org/FACHE.
Personal Information Fellow of the American College of Healthcare Executives
PREFIX
FIRST
The Distinction of Board
LASTSUFFIX
MIDDLE
Certification
ACHE MEMBER ID NUMBER (IF KNOWN)
Uniformed services personnel and USPHS commissioned officers, please enter rank. Please indicate any other prefixes as applicable and
include all doctoral degrees.
Education
Fellow of the American College of Healthcare Executives
List all academic degrees earned.
The Distinction of Board Certification
UNDERGRADUATE
SCHOOL NAME AND LOCATION
DEGREE OR DIPLOMA (ABBREV.) ATTENDED (FROM–TO: LIST MONTH/YEAR)
MAJOR SUBJECT
GRADUATE
SCHOOL NAME AND LOCATION
DEGREE OR DIPLOMA (ABBREV.) OTHER ADVANCED
DEGREE (Optional)
ATTENDED (FROM–TO: LIST MONTH/YEAR)
MAJOR SUBJECT
SCHOOL NAME AND LOCATION
DEGREE OR DIPLOMA (ABBREV.) Fellow of the American College of Healthcare Executives
Fe
The Distinction of Board Certification
T
ATTENDED (FROM–TO: LIST MONTH/YEAR)
MAJOR SUBJECT
Current Position
Civilian TITLE/RANK
Check here if this is a Veterans Affairs organization.
Uniformed Services
START DATE (MM/DD/YY)
ORGANIZATION NAME/BRANCH
ADDRESS
CITY BUSINESS PHONE STATE/PROVINCE
BUSINESS FAX
ZIP/POSTAL CODE
COUNTRY BUSINESS EMAIL ADDRESS
Job Description, Organizational Chart and Resume
A copy of your current job description, organizational chart showing your position and resume must be included with your application.
Healthcare Management Experience
At the time you submit your Fellow application you must currently hold an executive-level healthcare management position, and you
will need at least five years of executive healthcare management experience.
An executive-level healthcare management position is one in which the applicant is employed by a healthcare organization or by an
organization whose purpose is to influence the growth, development or operations of a healthcare organization. To be eligible for
advancement an applicant’s position must be at a department director/department head level, which includes control of departmental
budgeting, planning and staffing and accountability to senior management for department performance. Eligible positions include
C-suite executives, vice presidents and directors/department heads. Additional titles may be accepted if job responsibilities reflect
departmental control as described above. Applicants whose management authority is at a project and/or program level do not
qualify. Examples of this level of authority might include: analyst, coordinator, program manager, project manager and specialist.
Administrative fellowships, residencies and internships do not qualify.
Need help determining your qualified years of executive healthcare management experience? View our matrix on the next page.
Planning
Organizing
Organization:
Organizing: This function refers to the overall design of
the organization or the specific division, unit, or service
for which the individual is responsible. It means designating reporting relationships and intentional patterns
of interaction. Determining positions, teamwork assign-
Planning: This function refers to setting direction and
determining what needs to be accomplished. It means
setting priorities and determining performance targets.
Healthcare Management: Healthcare management is
the profession that provides leadership and direction to
organizations that deliver personal health services, and
to divisions, departments, units, or services within those
organizations.
Definitions
Manages
system or
multiple
organizations
Manages
organization
Manages
multiple
departments
Manages
department
Manages unit
or team
Manages self
Level of
Management
Name:
Controlling
Directing
Decision Making
Directing: This function refers to initiating action in the
organization through effective leadership and motivation
of, and communication with, subordinates.
Controlling: This function refers to monitoring staff
activities and performance, and taking the appropriate
actions for corrective action to increase performance.
Staffing: This function refers to acquiring and retaining human resources. It also refers to developing and
maintaining the workforce through various strategies and
tactics.
ments, and distribution of authority and responsibility
are components of this function.
Total Years of
Experience
Total HME: X years, X months
Financial
Management
Resource: Understanding Healthcare Management
(Longest, Rakich, & Darr, 2000)
Financial Management: This function refers to the
efficient and effective management of money (funds)
in such a manner as to accomplish the objectives of the
organization.
Decision making: This function refers to making effective decisions based on consideration of benefits and the
drawbacks of alternatives.
HME is not applicable at this level of management
Staffing
Position:
Instructions: Work your way down the left-hand side of the table and find the highest level of organizational management you believe your position falls under. Then, indicate
your years of experience (in years and months) managing each of the functional areas. Add the years of experience up and mark it in the Total Years of Experience column. Note
that you do not have to have a timeframe in each function – if you do not have experience with one or more of the functions, simply enter zero (0).
Purpose: This tool is intended for use by candidates to assist in determining qualified years of HME to use toward advancement to Fellow with ACHE.
ACHE Healthcare Management Experience (HME) Decision Matrix
References
Submitting reference forms
Submit two references: One in the form of a structured interview with a current Fellow; one written reference from a senior-level executive (VP or higher) in your organization OR a second Fellow.
Identifying references
• Use the online Member Directory on ache.org to locate Fellows in your area or across the world.
Your references do not need to be located near you.
• Contact your Regent or Chapter officials and ask for assistance with identifying Fellows to serve as references
(go to ache.org/Regent to find the Regent for your area).
• Contact ACHE’s Customer Service Center at (312) 424-9400 Monday through Friday,
from 8 a.m. to 5 p.m. Central time or via email at [email protected].
In the spaces provided below, please list your two references and identify which one is the structured interview.
We will keep this information on file to help you track the status of each completed form.
REFERENCE
NAME
TITLE
ORGANIZATION
STRUCTURED
INTERVIEW
NAME
TITLE
ORGANIZATION
Continuing Education
Demonstrate 36 hours of healthcare-related continuing education within the last three years—12 hours of which must be ACHE
Face-to-Face hours.
Organization
Date Attended
Program Title
Faculty or Participant
Credit hours
Participation in Healthcare and Community/Civic Activities
Please include examples of your participation over the past three years. No specific number of hours is required; however, you must list
at least two healthcare and two community/civic activities.
Service Type
Service Start Date
Description
Service End Date
(if applicable)
Community/Civic
Community/Civic
Healthcare
Healthcare
Accompanying Materials
ENCLOSED
ENCLOSED
Current job description
Copy of most recent diploma or final conferred transcript
Current organizational chart
36 Hours of healthcare-related continuing education (including 12 ACHE Face-to-Face hours)
Resume
Volunteer activities
Mail completed application with payment to: American College of Healthcare Executives
3439 Eagle Way, Chicago, IL 60678-1034
APFEL0116
Statement of Release and Agreement
By submitting this application to advance to Fellow of ACHE, I pledge to abide by ACHE’s Bylaws, Code of Ethics, Regulations and other
rules (available on ache.org). I release ACHE and its agents from liability with respect to any evaluation of my fitness for membership or
continued membership in ACHE.
SIGNATURE
DATE
Application Fee*
Check in the amount of $250 is enclosed (payable to the American College of Healthcare Executives)
Receipt of your application will be acknowledged within three weeks.
Please mail this application, the $250 non-refundable application fee by check and accompanying materials to the address below. Keep
a copy of your application for your files. Upon approval, your application will remain valid for two years. If you have questions,
contact ACHE’s Customer Service Center at (312) 424-9400 or [email protected].
*Note: Check payment is required with hard copy applications. To pay with credit card, please apply online at ache.org/FACHE.
Fellow or Senior-Level Executive
Reference Form—
Confidential
Fellow of the American College of Healthcare Executives
The Distinction of Board Certification
Side A: Completed by Candidate
Fellow Candidate: Complete the information on this side and then forward this form to your reference for his or
her completion of the reverse side. Remember, all three of your references must Fellow
be ACHE
Fellows.
of the American
College of Healthcare Executives
The Distinction of Board Certification
Reference: Please complete the reverse side of this form and fax (312-424-9405) or mail it to ACHE as soon as possible.
You may also complete and submit your reference form at ache.org/FACHE.
Date
Reference Information
Fellow of the American College of Healthcare Executives
F
The Distinction of Board Certification
T
NAME
TITLE
ADDRESS ORGANIZATION
CITY STATE
ZIP
STATE
ZIP
Candidate Information
NAME
TITLE
ADDRESS ORGANIZATION
CITY Page 1 of 2
Fellow or Senior-Level Executive
Reference Form—
Side B: Completed by Reference
Reference: Please fax, mail or complete this form online at ache.org/FACHE.
Confidential Inquiry on Applicant to Become a Fellow of the American College of
Healthcare Executive
You have been listed as a reference by the candidate whose name appears on the reverse side. We would appreciate
your completing and returning this form to ACHE as soon as possible. Your reply will be held in strict confidence.
ACHE is interested in learning of the candidate’s professional reputation for competence, judgment,
integrity and ethics. Candidates also must have executive healthcare management experience in order to advance to
Fellow status. Please review the definition at ache.org/FACHE. Thank you.
Do you recommend this candidate for Fellow status in the American College of Healthcare Executives? Yes
No
Questions
This reference may be completed by an ACHE Fellow or a senior-level executive (vice president or higher in the
candidate’s organization).
1.) Please describe how you know the candidate
2.) What are the candidate’s responsibilities in the organization?
3.) The candidate must have five years of executive healthcare management experience to be eligible for Fellow status (see executive healthcare management definition at ache.org/FACHE). Does the candidate meet this definition?
Yes or
No
Please provide your rationale
4.) Do you recommend this candidate for Fellow in ACHE?
Yes or
No
PRINTED NAME
SIGNATURE
DATE
Send to:
American College of Healthcare Executives (Confidential)
1 N. Franklin St., Ste. 1700
Chicago, IL 60606-3529
Phone: (312) 424-9400
Fax: (312) 424-9405
Page 2 of 2
6
Structured Interview
Fellow Reference Form—
Confidential
Fellow of the American College of Healthcare Executives
The Distinction of Board Certification
Side A: Completed by Candidate
Fellow Candidate: A structured interview is a face-to-face meeting or telephone call between the Fellow candidate
and the reference. During the interview, the reference should ask questions about
your
ethFellow
of thecompetence,
American College ofjudgment,
Healthcare Executives
ics and integrity. Complete the information on this side of the form and then forward
it
to
your
reference
to
comThe Distinction of Board Certification
plete the reverse side. You are responsible for contacting the reference to arrange the interview.
To prepare for the structured interview with your Fellow reference, please review the questions on the reverse side of
this form.
Reference: Please complete the reverse side of this form and fax (312-424-9405) or mail it to ACHE as soon as possible.
You may also complete and submit your reference form at ache.org/FACHE.
Date
Fellow of the American College of Healthcare Executives
F
The Distinction of Board Certification
T
Reference Information
NAME
TITLE
ADDRESS ORGANIZATION
CITY STATE
ZIP
STATE
ZIP
Candidate Information
NAME
TITLE
ADDRESS ORGANIZATION
CITY Page 1 of 2
Structured Interview
Fellow Reference Form—
Confidential
Side B: Completed by Reference
Confidential Inquiry on Applicant to Become a Fellow of the American College of Healthcare Executives
You have been listed as a reference by the candidate indicated on the reverse side. As a Fellow reference, the
candidate will contact you to schedule an interview. We strongly recommend that this interview be conducted face
to face; however, a telephone interview is acceptable if a face-to-face meeting is not possible. Your reply will be held
in the strictest confidence. ACHE is interested in learning the candidate’s professional reputation for competence,
judgment, integrity and ethics. Candidates also must have executive healthcare management experience in order to
advance to Fellow status. Please review the definition at ache.org/FACHE. Thank you.
Structured Interview Questions
As a reference, please ask the candidate the following questions in your interview. Then provide your comments
regarding the candidate in the space below.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Describe your healthcare administration career path to present. What are your career goals?
Why do you want to achieve Fellow status, and how do you plan to use your credential?
How do you plan to promote your board certification in healthcare management?
What role has mentoring played in the development of your career? Do you plan to mentor healthcare
leaders in their careers? How?
How has the ACHE Code of Ethics guided your behavior? Why is this code important?
What does professionalism mean to you? Why do you think individuals join ACHE (list at least three reasons)?
As communities become more diverse, so must the healthcare organizations that serve them. In what ways does your organization support a racially/ethnically diverse and equal work force?
What can you do personally to foster diversity and equality?
Describe ACHE’s governance structure. Include the following:
• Council of Regents: Who may serve as a Regent? How are they elected? What is the role of the Regent and
the Council of Regents?
• Board of Governors: Who may serve as a Governor? How are they elected? Describe the role of a Governor
and the Board of Governors.
10. Please describe your healthcare management experience.
Comments
SIGNATURE
DATE
Send to:
American College of Healthcare Executives (Confidential)
1 N. Franklin St., Ste. 1700
Chicago, IL 60606-3529
Phone: (312) 424-9400
Page 2 of 2
Fax: (312) 424-9405
IF KNOWN, PLEASE INCLUDE YOUR ACHE MEMBER ID NUMBER