SHO Management cheat sheet

SWOT analysis classifies internal Strengths and Weaknesses and external Opportunities and Threats before strategy formulation.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; each strategic objective should meet all five criteria.

Porter's five forces: rivalry, new entrants, substitutes, supplier power, buyer power; used to assess competitive position of a service line.

Balanced Scorecard perspectives: financial, customer, internal process, learning and growth; strategy map links objectives causally across perspectives.

Strategic plan horizon is typically 3–5 years; annual operating plan and budget translate it into 12-month targets.

Mission defines purpose and scope; vision describes future state; values state behavioral commitments; all three anchor strategic priorities.

Stakeholder analysis maps interest versus influence to set engagement approach for each group (high influence/high interest = manage closely).

Environmental scan (PESTLE): Political, Economic, Social, Technological, Legal, Environmental factors affecting demand and regulation.

Governance roles: board sets policy and hires CEO; CEO executes strategy; medical staff bylaws govern clinical privileging separately.

Operating margin = (operating revenue − operating expenses) ÷ operating revenue; expresses core operations' profitability.

Total margin = (total revenue − total expenses) ÷ total revenue; includes non-operating income such as investments and grants.

Current ratio = current assets ÷ current liabilities; a value below 1.0 signals short-term liquidity risk.

Days cash on hand = (cash + marketable securities) ÷ (total expenses − depreciation) ÷ 365.

Break-even volume = fixed costs ÷ (price per unit − variable cost per unit).

Variance analysis: favorable if actual revenue > budget or actual expense < budget; unfavorable if the reverse.

Zero-based budgeting builds each line from zero each cycle; incremental budgeting adjusts prior-year actuals by a percentage.

Capital budget evaluates projects using net present value (NPV > 0 accept), internal rate of return, and payback period.

Accounts receivable days = (net AR ÷ net patient service revenue) × 365; rising days indicate collection slowdown.

FTE = paid hours ÷ 2,080 annual full-time hours; used to size staffing budgets and productivity ratios.

Nursing hours per patient day (HPPD) = total nursing hours ÷ patient days; compare against unit benchmark.

Turnover rate = separations ÷ average headcount × 100; annualize partial-year data for comparability.

Vacancy rate = vacant FTEs ÷ budgeted FTEs × 100; persistent high vacancy drives agency and overtime cost.

FTE productivity = paid FTEs ÷ workload units (e.g., visits, cases, patient days); higher ratio may signal overstaffing.

Position control: each approved position has a unique requisition; hiring beyond budgeted FTE requires formal approval.

FLSA: exempt employees are salaried and not eligible for overtime; non-exempt employees must receive overtime at 1.5× for hours over 40 per week.

Competency validation occurs at hire, annually, and when practice changes; records are retained in the personnel file.

Succession planning identifies key roles and develops internal candidates using competency gaps and readiness ratings.

CMS Conditions of Participation (CoPs) are federal requirements for Medicare/Medicaid participation; state licensure adds local requirements.

The Joint Commission accreditation is deemed status: CMS accepts it in lieu of routine federal survey for participating hospitals.

HIPAA Privacy Rule governs use and disclosure of protected health information (PHI); Security Rule covers electronic PHI safeguards.

HIPAA breach notification: notify affected individuals within 60 days of discovery; HHS notification required for breaches affecting 500+ individuals.

EMTALA requires a medical screening examination and stabilizing treatment for anyone presenting to an emergency department, regardless of insurance.

Stark Law prohibits physician self-referral for designated health services when a financial relationship exists, unless an exception applies.

Anti-Kickback Statute prohibits knowingly offering or receiving remuneration to induce referrals for federally reimbursed items or services.

Corporate Integrity Agreements (CIAs) impose compliance program obligations, monitoring, and reporting after certain settlements.

Compliance program elements: written policies, compliance officer, training, hotline, auditing, discipline, and corrective action.

PDSA cycle: Plan (define change and measures), Do (test on small scale), Study (compare results to prediction), Act (adopt, adapt, or abandon).

Six Sigma DMAIC: Define, Measure, Analyze, Improve, Control; targets reduction of process variation to 3.4 defects per million.

Lean identifies value and eliminates waste (waiting, overproduction, defects, transport, inventory, motion, overprocessing, talent).

Root cause analysis (RCA) is a structured retrospective review after a sentinel event; failure mode and effects analysis (FMEA) is prospective.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

Never events (e.g., wrong-site surgery, retained foreign body) are serious reportable events subject to mandatory review.

Structure–process–outcome model (Donabedian): structure = resources; process = what is done; outcome = result for the patient.

Control chart: points outside control limits or non-random patterns (runs, trends) indicate special-cause variation requiring action.

Hand hygiene compliance = observed compliant opportunities ÷ total observed opportunities × 100.

Capacity (beds) × occupancy rate = average daily census; occupancy = patient days ÷ (beds × days in period).

Patient flow constraints: admission, discharge, and transfer timing; discharge before noon improves bed availability.

Emergency preparedness follows an all-hazards approach: mitigation, preparedness, response, and recovery phases.

Life Safety Code (NFPA 101) governs egress, fire alarm, and sprinkler requirements; annual fire drills are required for accredited facilities.

Environment of care rounds cover safety, security, hazardous materials, fire safety, medical equipment, and utilities.

Preventive maintenance schedules follow manufacturer recommendations; equipment history is documented in a maintenance log.

Supply chain: par levels set reorder points; economic order quantity balances ordering cost against holding cost.

Utilization review evaluates appropriateness of admission, length of stay, and resource use against criteria.

Space planning considers adjacencies, workflow, infection control, and future volume growth before design approval.

Data governance assigns ownership: data owners approve access and use; data stewards maintain quality and definitions.

Data quality dimensions: accuracy, completeness, timeliness, consistency, validity, and uniqueness.

HIPAA Security Rule safeguards: administrative, physical, and technical controls protecting electronic PHI.

Role-based access control grants permissions by job function; least-privilege principle limits access to what the role requires.

Business associate agreement (BAA) is required before a vendor handles PHI on behalf of a covered entity.

Interoperability standards: HL7 for messaging, FHIR for web-based exchange, DICOM for imaging.

Disaster recovery metrics: RTO (recovery time objective) is maximum acceptable downtime; RPO (recovery point objective) is maximum acceptable data loss.

Data dictionary defines each element's name, format, allowed values, and source system to ensure consistent reporting.

Audit trail logs record who accessed or changed a record and when; required for ePHI accountability and breach investigation.