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Mission Vision Worksheet document sample
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CCI Building Capacities Self-Assessment Tool* Instructions
There are ten survey worksheets (numbered 1 through 10) included in this survey tool. Click on the various tabs at the bottom of the screen to move
through the various worksheets. The survey requests two types of answers: fill in the blank, and multiple-choice. To input your responses, click on
the cell to the right of each question. (Answer cells are highlighted in yellow.) If the question is multiple-choice, you will see the following message
when you click on the cell: “Click arrow to make selection.” When you click on the arrow, you will be presented with your answer options.
Worksheet 1: Contact information and financial data (for Executive Director only)
Worksheet 2: Fundraising strategies (for Executive Director only)
Worksheet 3: Access (for Executive Director only)
Worksheet 4: Mission, vision, and planning
Worksheet 5: Community engagement and collaboration
Worksheet 6: Leadership ~ management team
Worksheet 7: Leadership ~ board of directors
Worksheet 8: Financial systems and position
Worksheet 9: Fund development
Worksheet 10: Data-informed decision making
In worksheets 4 through 10 you will see a number of assessment categories. For each assessment category, identify the description that best
describes your organization's status or performance. Please provide a rating for all of the assessment categories; failure to do so will impact your
summary scores. If an assessment category does not apply to your organization, select "N/A". Summary scores will calculate automatically. (Note:
A "0" score on the summary page indicates that you missed a question.)
The first time you save the workbook file, you will be prompted to provide a name for the file. Use the name of your clinic for the name of the file.
To print the worksheets, right-click on any one of the worksheet tabs at the bottom of the screen, and click the "Select All Sheets" option. Then go to
"File" and select "Print". Be sure to ungroup the worksheets after you print; to do this, right-click on any one of the worksheet tabs, and click the
"Ungroup Sheets" option.
Please proceed to Worksheet 1 to begin.
*The Self-Assessment Tool is a derivative product of the Capacity Assessment Tool created by McKinsey & Company for Venture Philanthropy Partners
(www.vppartners.org), and published in Effective Capacity Building in Nonprofit Organizations (2001). Six questions (numbers 4.1, 4.2, 4.3, 4.4, 4.6, and 5.2) have been
reprinted directly from the McKinsey tool, with the permission of Venture Philanthropy Partners.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: INSTRUCTIONS, 4/14/2011, Page 1 of 18
~ CONTACT INFORMATION & FINANCIAL DATA ~
Survey Respondent Contact Information
First name of person completing survey
Last name of person completing survey
Title of person completing survey
Phone number (enter numbers only, without spaces)
Email address
Clinic Name
City
Executive Director Name (if not the person completing survey)
Others Involved with the Assessment Process
Name
Title
Name
Title
Name
Title
Name
Title
Name
Title
Revenues & Expenses
When did you complete your most recent fiscal year (mm/dd/yy)?
Do you own or lease your buildings?
Please tell us about your revenues and expenses for your most recently completed fiscal year:
Net patient service revenue (patient fees, Medi-Cal, Medicare, Healthy
Families, etc.)
Contributions / fundraising revenue
Foundation income / grants (including CCI)
Government contracts (not including patient service revenues such as
Medicare, Medi-Cal, & Healthy Families)
Other revenue
TOTAL REVENUE (this number will be calculated automatically) $ -
TOTAL OPERATING EXPENSES
Please proceed to Worksheet 2.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 1, 4/14/2011, Page 2 of 18
~ FUNDRAISING STRATEGIES ~
One of the key ingredients of a successful community organization is the capacity to implement a broad base of fundraising strategies, from
grantwriting for foundation and government grants, to individual donor solicitations, to marketing and communication strategies. To help us better
understand your current capacity to raise money from private sources, please respond to the questions below.
Number of full-time equivalent (FTE) staff at your clinic corporation dedicated to fund development—including
grantwriting, donor relations, etc.:
Is your organization currently working with a consultant (or consultants) to assist with fund development?
Indicate the frequency with
which your clinic corporation
utilizes these strategies—
Fundraising Strategies
never, occasionally, or at least
annually (click on cell to change
default answer):
Direct mail appeal to current donors —those who have contributed to your clinic during the last fiscal year—for
Never
general operating support
Direct mail appeal to prospective new donors for general operating support Never
Direct mail campaign for a special program or initiative (as opposed to general operating support) Never
Fundraising event to raise money and/or to strengthen relationships with current and prospective donors Never
Board and/or staff personal solicitations of existing individual donors Never
Collecting online donations via a website Never
Appeals to corporate foundations/donors for general operating support Never
Solicitation of corporate sponsors for special events or for a special campaign or initiative Never
Sales of products (such as t-shirts) Never
Solicitation of donations through United Way campaign Never
Concluding speaking engagements to community groups with a pitch for donations Never
Solicitation of patients for donations Never
Solicitation of board members for donations Never
Other (specify in cell B21)
Other (specify in cell B22)
Other (specify in cell B23)
Please indicate your top two
fundraising strategies:
Board Fundraising
What proportion of your board made an individual contribution to the clinic during the last fiscal year?
Does your board have a standing fundraising committee?
What proportion of your board actively assists in soliciting individual donations?
Please proceed to Worksheet 3.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 2, 4/14/2011, Page 3 of 18
~ ACCESS ~
One of the long range goals of the Community Clinics Initiative is to increase access to comprehensive, quality health care services. Listed below
are many components of access that CCI will be tracking over the next five years. Please give us your best estimate for your clinic corporation
during the last fiscal year.
Number of sites
Combined number of exams rooms across all sites
Number of new patients (those not seen in previous years)
Number of established patients
Unduplicated patient count (this number will be calculated automatically) 0
Total number of patient visits
Total number of hours that your providers—MDs, NPs, PAs, Dentists, Dental Hygienists, Nutritionists, Pharmacists,
etc.—delivered services to patients during the last fiscal year (not including administrative time)
Total number of hours of operation for the year across all sites (please account for days the clinic was closed for holidays or
other reasons)
Indicate the extent to which your clinic If provided at some
Services corporation provides these services—at sites , specify the
all sites, at some sites, or at no sites: number of sites:
Primary care for children
Primary care for adults
Family planning services
Prenatal care
OB deliveries
Specialty medical services
Dental care for children
Dental care for adults
On-site pharmacy
On-site radiology
Optometry
Mental health services for adults
Mental health services for children
Substance abuse services
Health education
Nutrition
Chronic disease care management
Other (specify in cell B31)
Other (specify in cell B32)
Other (specify in cell B33)
Are you able to provides services in the following languages at
Languages least 80 percent of the time —without accessing outside
translation services (click on cell to change default answer)?
Spanish No
Mandarin No
Cantonese No
Cambodian No
Tagalog No
Vietnamese No
Hmong No
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 3, 4/14/2011, Page 4 of 18
~ ACCESS ~
Other (specify in cell B43)
Other (specify in cell B44)
Other (specify in cell B45)
Other
Do you provide space for any other organizations or programs that provide
services for your clients, such as Women, Infants, and Children (WIC); Medi-
Cal; outside pharmacy, or community mental health services?
...If so, which ones?
How often does each client eligible for WIC services receive each of the following:
…written information about the benefits of WIC?
…referrals to WIC sites?
…written information on the location and times of WIC services?
…follow-up on WIC referrals?
Do you offer onsite enrollment for Healthy Families?
...If so, how many children did you enroll during your last fiscal year?
Do you offer onsite enrollment for MediCal?
...If so, how many clients did you enroll during your last fiscal year?
Please proceed to Worksheet 4.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 3, 4/14/2011, Page 5 of 18
~ MISSION, VISION, & PLANNING ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(7 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Mission (clinic's Mission not re-visited recently Mission reflects clinic's values Mission is a clear expression of Mission is a clear expression of
reason for and may not be as relevant and purpose, but may lack clinic’s reason for existence that clinic’s reason for existence that
existence) today; Very few staff can clarity or currency; Few staff, reflects its values and purpose; describes an enduring reality
articulate the mission and it is primarily those with long tenure, Held by many within clinic and and reflects clinic's values and
rarely referred to are familiar with it; Lacks broad often referred to purpose; Broadly held within
agreement and is rarely referred clinic and frequently referred to;
to Used to prioritize programs
2. Clarity of Little shared understanding, Somewhat clear understanding Clear and specific Clear, specific, and compelling
Vision (clinic's even among top management, of what clinic aspires to become understanding of what clinic understanding of what clinic
long-term goals of what organization aspires to or achieve; Held only by top aspires to become or achieve; aspires to become or achieve;
become or achieve beyond the management or “on the wall,” Held by top management and Held by most to all staff and
for itself & its
stated mission but rarely used to direct actions many others within the clinic and consistently used to direct
community)
or set priorities often used to direct actions and actions and set priorities
set priorities
3. Strategic Plan Medium- to long-term strategic Medium-to-long-term strategic Coherent medium-to-long-term Clear, coherent medium-to-long-
plan either non-existent, plan exists but is either not strategic plan has been term strategic plan that is
unclear, or incoherent (largely clearly linked to mission, vision, developed and is linked to actionable and linked to overall
set of scattered initiatives); and overarching goals, lacks mission and vision and a clear mission, vision, and overarching
Strategy has no influence over coherence, or is not easily timeframe but is not fully ready goals in a clearly defined
management decisions. actionable; Strategy is not to be acted upon; Strategy is timeframe; Strategy is broadly
broadly known and has limited mostly known and management known and consistently helps
influence over management decisions partly guided by it guide decisions at all levels of
decisions organization
4. Strategic Limited ability and tendency to Some ability and tendency to Ability and tendency to develop Ability to develop and refine
Planning Skills develop strategic plan, either develop strategic plan either and refine concrete, realistic concrete, realistic and detailed
internally or via external internally or via external strategic plan; Some internal strategic plan; Critical mass of
assistance; if strategic plan assistance; Strategic plan expertise in strategic planning or internal expertise in strategic
exists, it is not used roughly directs management access to relevant external planning, or efficient use of
decisions assistance; Strategic planning external, sustainable, highly
carried out on a near-regular qualified resources; Strategic
basis; Strategic plan used to planning exercise carried out
guide management decisions regularly; Strategic plan used
extensively to guide
management decisions
5. Performance Targets are non-existent or few; Realistic targets exist in some Performance targets in most Limited set of quantified,
Targets Existing targets are vague or key areas, and are mostly areas; Linked to aspirations and demanding performance targets
either too easy or impossible to aligned with aspirations and strategic plan; Mainly focused in all areas; Targets are tightly
achieve; Not clearly linked to strategic plan; May lack on “outputs/outcomes” (results linked to aspirations and
aspirations and strategic plan; milestones, or mostly focused of doing things right) with some strategy, output/outcome-
Targets largely unknown or on “inputs” (things to do right), “inputs”; Typically multiyear focused (e.g., results of doing
ignored by staff and board or often renegotiated; Staff and targets, though may lack things right, as opposed to
board may or may not know and milestones; Targets are known inputs, things to do right), have
adopt targets and adopted by most staff who annual milestones, and are long-
usually use them to broadly term nature; Staff consistently
guide work; Board evaluates adopts targets and works
performance based on targets diligently to achieve them; Board
evaluates performance based
on targets
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 4, 4/14/2011, Page 6 of 18
~ MISSION, VISION, & PLANNING ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(7 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
6. New Program No assessment of gaps in ability Limited assessment of gaps in Occasional assessment of gaps Continual assessment of gaps
Development of current program to meet ability of existing program to in ability of existing program to in ability of existing programs to
recipient needs; Limited ability meet recipient needs, with little meet recipient needs, with some meet recipient needs and
to create new programs; New or limited action taken; Some adjustments made; adjustments always made;
programs created largely in ability to modify existing Demonstrated ability to modify Ability and tendency to create
response to funding availability programs and create new and fine-tune existing programs new, highly innovative and
programs and create new programs effective programs to meet the
needs of potential service
recipients in local area or other
geographies; Continuous
pipeline of new ideas
7. Operational Organization runs operations Some ability and tendency to Ability and tendency to develop Clinic develops and refines
Planning purely on day-to-day basis with develop operational plan either and refine concrete, realistic concrete, realistic, and detailed
no short- or longer-term internally or via external operational plan, linked to operational plan linked to annual
planning activities; No ability or assistance; Operational plan annual budget and trend data; budget and trend data; Has
experience to conduct data- loosely linked to strategic Some internal expertise in critical mass of internal
based operational planning planning activities and used operational planning; expertise in operational
roughly to guide operations; Operational planning carried out planning; Operational planning
Operational planning not based on a regular basis; Operational exercise carried out regularly;
on trend data plan linked to strategic planning Operational plan tightly linked to
activities and used to guide strategic planning activities and
operations systematically used to direct
operations
Comments: Type comments (if any) here.
Please proceed to Worksheet 5.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 4, 4/14/2011, Page 7 of 18
~ COMMUNITY ENGAGEMENT & COLLABORATION ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(3 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Assessment of Planning is not supported by Clinic uses some data about Clinic uses some data about Clinic has clear, formal systems
Community systematically collected data community needs, opportunities, community needs and clinic's for assessing community needs
Needs & Clinic about community needs or or external threats to inform external opportunities and and external opportunities and
clinic's external opportunities planning although collection is threats to inform planning; Data threats; Data used
Environment
and threats; Clinic has very few haphazard; Clinic has some collected and used systematically to support
connections to community connections to community systematically to support planning and improve it; Clinic
members and opinion leaders members and opinion leaders planning effort and improve it; has many connections to
that could help clinic leaders who inform clinic leaders about Clinic has multiple connections community members and
understand evolving community evolving community needs to community members and opinion leaders with whom clinic
needs opinion leaders with whom clinic leaders regularly communicate
leaders regularly communicate about the evolving community
about the evolving community needs; Communication is two
needs way (community leaders often
initiate communication)
2. Local Clinic’s community presence Clinic’s presence somewhat Clinic reasonably well-known Clinic widely known within larger
Community either not recognized or recognized, and generally within community beyond just community, and perceived as
Presence & generally not regarded as regarded as positive within the potential patients, and perceived actively engaged with and
positive; Few members of local immediate community (e.g., as open and responsive to extremely responsive to it; Many
Involvement
community (e.g., patients, potential patients); Some community needs; Members of members of the larger
business leaders, other members of larger community larger community (e.g., community (e.g., business, civic,
nonprofit leaders) constructively (e.g., business, civic, and/or business, civic, and/or other and/or other nonprofit leaders)
involved in the organization other nonprofit leaders) nonprofit leaders) constructively actively and constructively
constructively involved with the involved in organization engaged with organization (e.g.,
organization board, fund-raising)
3. External Limited use of partnerships and Early stages of building Effectively built and leveraged Built, leverages, and maintains
Relationship alliances; Some coordination relationships and collaborating some key relationships with strong relationships with variety
Building with other clinics in areas such with other stakeholders; several types of relevant parties of relevant parties (local, state,
as resource development, but Coordinates primarily with other (for-profit, public health, and and federal government entities
(partnerships &
few or no formal relationships clinics but also is working to nonprofit sector entities); as well as for-profit, other
collaboration)
build relationships with other Belongs to a clinic consortium nonprofit, and community
community-based organizations; and actively coordinates work agencies), including
Coordination focused primarily with other clinics; Coordination membership in a consortium
on influencing public policy happens in areas such as and disease collaborative;
and/or resource development, business/operations, patient Relationships anchored in
but also is beginning to discuss care, advocacy, and public stable, long-term, mutually
coordinating things such as policy, understanding patient beneficial collaboration;
patient care, staff training, etc.; populations, population health, Integrates/shares some
May belong to clinic consortium, and clinical issues; Contributes business operations to take
but activities focused primarily disease registry data to a advantage of economies of
on information sharing as disease collaborative; scale Coordination exists
opposed to collaborative work Recognized for effective around understanding patient
alliances populations and population
health, improving individual
patient care, influencing public
policy, and resource
development
Comments: Type comments (if any) here.
Please proceed to Worksheet 6.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 5, 4/14/2011, Page 8 of 18
~ LEADERSHIP: MANAGEMENT TEAM ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(5 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Management Senior management Senior management Senior management Management team is
Team responsibilities concentrated responsibilities shared by a responsibilities shared by a interdisciplinary; All areas of the
Composition primarily in Executive Director management team that is management team that is organization are represented
position; Some functions (e.g., interdisciplinary; Members of the interdisciplinary; Most areas of (e.g., operations, development,
operations, development, team represent different areas the organization (e.g., finance, IT, personnel,
finance, IT, personnel, of the organization (e.g., operations, development, community outreach, patient
community outreach, patient operations, development, finance, IT, personnel, services, including dental and
services, including dental and/or finance, IT, personnel, community outreach, patient mental health), including active
mental health) outsourced; community outreach, patient services, including dental and participation and leadership of
Medical Director is uninvolved in services, including dental and mental health) are represented the Medical Director and other
management mental health); Medical Director on the team; Medical Director appropriate clinical managers
is relatively uninvolved in clinic actively participates as member
management of management team
2. Management Executive Director and senior Management team meets as Management team meets on a Management team meets
Communica-tion managers meet infrequently and needed on an infrequent and regular basis; Frequent frequently and regularly;
& Coordination irregularly; Management team irregular basis; Team members communication among Frequent and open
members know almost nothing communicate individually members between meetings; communication between
about the priorities and activities between meetings; Members Members know key issues and meetings; Members have strong
in departments beyond their know what the most urgent goals of other departments and understanding of issues, future
own issues are in all departments but how they affect their own work plans, and goals in each
not other department's goals department and how they affect
and priorities the whole organization, as well
as their own department.
3. Management Decisions made largely on an Process for management team's Clear, inclusive systems for Clear, formal lines/systems for
Decision-making ad hoc basis by the Executive decision making often breaks team decision making but decision making that draw upon
Director and/or whomever is down and not always inclusive; decisions are not always expertise and input of all team
accessible; Virtually all decision Management team authorized, appropriately implemented or members; Roles and
making authority is centralized but unlikely to make key followed; All roles and responsibilities among team
in one or two people; Divisions decisions in Executive Director's responsibilities among team members are formalized, clear
of roles and responsibilities absence; Most roles and members are formalized, but and compliment each other
among team members are responsibilities among team may not reflect organizational
neither formalized nor clear members are not formalized realities
4. Management Senior managers have very Senior managers have some Management team has Management team highly
Experience & limited experience in clinic or experience in clinic or other significant experience in clinic or experienced in clinic and other
Expertise other health related health related organizations; other health related health related organizations;
organizations; Managers have Some managers have limited organizations; Team members Team members have
very limited capabilities or track capabilities and track records of have relevant capabilities and outstanding capabilities and
record of managing large-scale managing large-scale projects track records of managing large- track records of managing large-
projects (e.g., IT, capital, (e.g., IT, capital, medical record scale projects (e.g., IT, capital, scale projects (e.g., IT, capital,
medical record system system conversion, medical record system medical record system
conversion, implementation of implementation of pharmacy or conversion, implementation of conversion, implementation of
pharmacy or dental services); dental services); Good track pharmacy or dental services); pharmacy or dental services);
Limited track record of learning record of learning and personal Good track record of learning Outstanding track record of
and personal development; development; Combined length and personal development; learning and personal
Combined length of service at of service around 5 years Combined length of service development; Combined length
clinic less than 5 years more than 10 years of service more than 15 years
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 6, 4/14/2011, Page 9 of 18
~ LEADERSHIP: MANAGEMENT TEAM ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(5 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
5. Management Management team members Management team members Management team members Management team members
Team work independently more than have built some trust and trust and respect one another function well as a team and
Collaboration & together; Little trust among respect for each other; Sense of and understand their respect and trust one another;
team members and team their role as a part of a team is responsibilities as a team; Team meetings are well-
Leadership
members sometimes undermine still in development; Team Meetings are well-planned and planned, efficient, and
team decisions; Meetings are meetings often have a simple efficient and often have effectively facilitated; Each
inefficient agenda and are reasonably assignment of action items and meeting ends with clear
efficient but lack clear responsibilities at the end, and assignment of action items and
facilitation; Follow-up action team processes are still responsibilities; All team
items aren't always clear; Other evolving and improving; Other members stand by team
staff are unfamiliar with or staff recognize individual team decisions; Management team
indifferent to the role of the members as leaders, but are members are respected by staff
management team unclear on the role of the and board as organizational
management team leaders and all understand the
role the management team
plays in organizational
leadership
Comments: Type comments (if any) here.
Please proceed to Worksheet 7.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 6, 4/14/2011, Page 10 of 18
~ LEADERSHIP: BOARD OF DIRECTORS ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(6 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Board Consumer members are not Consumer members not fully Consumer members well- Consumer members well-
Composition & fully utilized or integrated; utilized or integrated; integrated and remaining integrated and remaining
Commitment Membership drawn from a Membership represents a few members come from diverse members come from broad
narrow spectrum of different constituencies (e.g., fields of practice and expertise variety of fields of practice and
constituencies; Little or no attorneys, accountants, (e.g., attorneys, accountants, expertise (e.g., attorneys,
relevant experience; Low community-based organization community-based organization accountants, community-based
commitment to organization’s leaders, faith-based leaders, faith-based organization leaders, faith-
success, vision, and mission; organization leaders, other organization leaders, other based organization leaders,
Meetings infrequent and/or health care providers, local health care providers, local other health care providers,
poorly attended business owners); Moderate business owners); Membership local business owners); Strong
commitment to organization’s represents most constituencies; commitment and proven track
success, vision, and mission; Good commitment to record of investing in learning
Regular, purposeful meetings organization’s success, vision, about the organization and
are well-planned and and mission; Regular, addressing its issues;
attendance is good overall purposeful meetings are well- Outstanding commitment to the
planned and attendance is organization’s success, mission,
consistently good and vision; Regular, purposeful
meetings are well-planned and
full-attendance is the norm
rather than the exception
2. Board Board roles and responsibilities Understanding of roles and Roles and responsibilities of Board and management work
Governance are not clearly understood by responsibilities of board and board and management are well together from clear roles;
members; Board does not management varies; Board clear and function well; Board Board fully understands and
review budgets, audits or functions according to by-laws, reviews budgets, audits, fulfills fiduciary duties; Size of
regulatory and licensing reviews budgets, and regulatory and licensing board set for maximum
reviews, does not set occasionally sets organizational reviews; Size of board set for effectiveness with rigorous
performance targets and hold direction and targets, but does maximum effectiveness with nomination process; Board
CEO/ED accountable, or does not review CEO/ED rigorous nomination process; actively sets performance
not operate according to formal performance or its own Board sets performance targets, targets and regularly monitors
procedures functioning; Does not review but does not regularly monitor performance; Periodically
audit or regulatory and licensing them; Board does not evaluates itself and formally
reviews comprehensively systematically review CEO/ED’s evaluates CEO/ED on an
or their own performance annual basis
3. Board Training No plans for Board recruitment, No plans for Board recruitment; Board recruitment and training Board recruitment occurs
& Orientation orientation, or training; No Board training occurs 'on the plans developed; Some formal according to plan; All Board
formal training available and no job' rather than through any training for all Board members members receive formal
new board member orientations formal training sessions; Some loosely based upon a training; Board training needs
formal training provided on an curriculum; Orientation for new assessed annually and training
ad-hoc basis upon request; members occurs and is plan and curriculum developed
Limited orientation for new supported by written materials annually; Comprehensive Board
members orientation for all new Board
members occurs and is
supported by written materials
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 7, 4/14/2011, Page 11 of 18
~ LEADERSHIP: BOARD OF DIRECTORS ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(6 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
4. Committee Generally, board members do Most standing board committees Board functions through stable Board functions through stable
Structure & not contribute additional time to have some activity, although and active standing as well as and active standing as well as
Participation participate in committees; Most with varying levels of ad hoc committees meeting ad hoc committees charged with
standing committees are effectiveness; Some committees regularly and reporting to board; clear roles and responsibilities;
inactive and lack relevant include members with relevant Most committees include some All committees include members
expertise; Standing fund expertise to help inform decision members with relevant expertise with relevant expertise
development committee does making; Standing fund to help inform decision making; necessary to fulfill
not exist development committee does Standing fund development responsibilities and make sound
not exist committee is active and includes decisions; All committees meet
members with some expertise in regularly and present reports to
raising funds from private the board; Fund development
sources committee active and expert in
all types of fundraising,
including raising funds from
private sources
5. Board Most members do not recognize Members accept that the board Many members embrace Majority of members embrace
Fundraising fundraising as one of the has some fundraising fundraising as one of the fundraising as a core board role
board's roles and responsibilities, but concerns board's core roles and and responsibility; Most board
responsibilities; No goals or exist regarding ability of responsibilities; Core group of members have made financial
plans for board-driven consumer boards to be board members consistently contributions to the organization;
fundraising activities exist successful in this area; One or participates in fundraising; Realistic and appropriate board
two members have financially Realistic and appropriate board fundraising goals and plans are
contributed to the clinic; Board fundraising goals and plans in place; Board is actively
fundraising activities not yet exist; Majority of members have fundraising and has achieved
underway made financial contributions; measurable progress towards
Fundraising activities are goals
underway
6. Strategic Plans to address community Structured process for Clinic follows a structured Clinic follows a structured
Planning Role needs are developed by clinic community-based board to have process for community-based process for community-based
staff, without a structured input and approve clinic's board to have input and approve board to have significant input
process for board input; Insights strategic plan exists, but is not clinic's strategic plan; Process and approve clinic's strategic
about the community's current always followed; Board includes solicitation of members' plan; Process includes
and future needs are not members' insights about insights about the community's solicitation of members' insights
solicited by clinic staff or offered community's needs and needs to inform develop of about the community's current
by board members during strategies to address them are clinic's goals and plans; Board and future needs to inform
planning process; Board's drawn upon informally, often on regularly reviews and updates develop of clinic's goals and
strategic planning role limited to an individual basis, for planning strategic plan plans; Board utilizes data about
ratifying staff's plans; No purposes; No process exists for the community's health status in
process for board's regular board's regular review and planning process; Board
review and updating of plan updating of plan regularly reviews and updates
strategic plan
Comments: Type comments (if any) here.
Please proceed to Worksheet 8.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 7, 4/14/2011, Page 12 of 18
~ FINANCIAL SYSTEMS & POSITION ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(5 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Bottom Line Revenues have exceeded Revenues have narrowly Revenues have exceeded Revenues have exceeded
expenses in zero or one of the exceeded expenses in two of expenses in two of the past 3 expenses in all of the past 3
past 3 years the past 3 years years years
(Positive operating margin in 0-1 (Slightly positive operating (Positive operating margin in 2 (Positive operating margin in 3
of the last 3 years) margin in 2 of the last 3 years) of the last 3 years) of the last 3 years)
2. Cash Flow On average, clinic does not On average, clinic has just On average, clinic has enough On average, clinic has enough
have enough cash available to enough cash available to pay its cash available to pay its bills, cash available to pay its bills,
pay all of its monthly bills monthly bills, but not enough to and enough additional cash on and enough additional cash on
cover any unforeseen expenses hand to cover modest hand to cover significant
(Approximately <30 days cash unforeseen expenses unforeseen expenses
on hand) (Approximately 30-45 days cash
on hand) (Approximately 46-60 days cash (Approximately >60 days cash
on hand) on hand)
3. Diversity of Clinic highly dependent on a few Clinic's revenue primarily Clinic has grants and contracts Clinic has grants and contracts
Revenue Sources government grants and derived from government and from a variety of government from a variety of government
contracts, which make up over foundation grants and contracts and foundation sources, which and foundation sources, which
50% of clinic revenue; (over 50% of revenue from together account for less than together account for less than
Remainder of budget derived these two types of sources); 50% of its revenues; Just under 50% of its revenues; Half or
from foundations and a limited Remainder of budget derived half of its revenue is derived more of its budget is derived
amount of patient revenue; from patient revenue; Clinic from patient revenue (approx. from patient revenues (50%); A
Clinic highly vulnerable to vulnerable to fluctuations in 40%); Successful efforts are growing portion is derived from
fluctuations in government government and foundation underway to develop private private sources other than
funding priorities funding priorities; Clinic aware sources foundations (about 5%);
of need to diversify funding but Diversity of funding sources
lacks understanding and skills to provides insulation from
do so fluctuations in government and
foundation funding priorities
4. Financial Very limited financial Limited financial forecasting, ad Solid financial forecasts, Very solid financial forecasts,
Planning & forecasting; General budget hoc update; Annual budget updated at least semi-annually continuously updated; Annual
Budgeting developed and approved by utilized as operational tool; Used and discussed with budget updated regularly,
board of directors; Performance to guide/assess financial management team, staff, and reviewed monthly by
against budget loosely or poorly activities; Some attempt to board; Annual budget utilized in management team and board,
monitored isolate divisional (program or operations; Reflects and utilized in daily operations;
geographical) budgets within organizational needs; Solid As strategic tool, it develops
central budget; Performance-to- efforts made to isolate divisional from process that incorporates
budget monitored periodically (program or geographical) and reflects organizational
budgets within central budget; needs and objectives; Well-
Performance-to-budget understood divisional (program
monitored at least quarterly or geographical) budgets within
overall central budget;
Performance-to-budget
monitored on a monthly basis
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 8, 4/14/2011, Page 13 of 18
~ FINANCIAL SYSTEMS & POSITION ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(5 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
5. Use of Occasionally produces some Regularly produces basic At least quarterly, produces Produces comprehensive
Financial & basic financial management financial management reports, basic financial management financial management reports
Operations Data reports, such as budget-to- such as budget-to-actual reports, such as budget-to- (budget-to-actual financial
actual financial reports, cash financial reports, cash flow, actual financial reports, cash reports, cash flow, and/or
flow, and/or accounts and/or accounts flow, and/or accounts accounts payable/accounts
payable/accounts receivable; payable/accounts receivable; payable/accounts receivable; receivable, cost center reports,
Reports produced upon request, Occasionally produces more Produces some more administrative/overhead, cost
rather than at any regular time sophisticated financial reports sophisticated reporting/FQHC/cost
interval, and primarily reviewed on request such as cost center financial/operations reports such reconciliation, inventory, and/or
by Executive Director reports, as cost center reports, personnel tracking) with trends
administrative/overhead, and/or administrative/overhead, cost information that are reviewed
cost reporting/FQHC/cost reporting/FQHC/cost and discussed by management
reconciliation; Financial reports reconciliation, inventory, and/or team on a monthly basis and
reviewed by Executive Director personnel tracking; Reports shared with the Board at least
at least quarterly and by the include data from previous time quarterly; Information from the
Board at least twice per year period for comparison; Financial reports feeds directly into
reports reviewed by Executive planning, decision-making, and
Director monthly, and by the adjustments in operations
Management Team and Board
at least two times per year
Comments: Type comments (if any) here.
Please proceed to Worksheet 9.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 8, 4/14/2011, Page 14 of 18
~ FUND DEVELOPMENT ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(3 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Fund Board leadership and Executive Board leadership and Executive Board leadership and Executive Board leadership and Executive
Development Director not focused on Director recognize need to Director are committed to Director are committed to
Strategy & diversifying revenue sources; achieve a diverse balance of diversifying revenue sources; maintaining a diverse revenue
Fund development strategy not revenue sources; Fund Fund development strategy base; Well developed
Activities
well articulated and focuses on development activities includes multiple components fundraising strategy and
one type of development such somewhat opportunistic, not (e.g., grant writing, marketing systems to achieve and
as grant writing organized in a coherent and communications, direct maintain a diverse balance of
strategy; Activities go beyond mail, personal solicitation, revenue sources; Fund
grant writing to include planned giving); Clinic is actively development strategy includes
marketing and communications, identifying and pursuing new several complimentary
direct mail, personal solicitation revenue sources, including components (e.g., marketing
or planned giving efforts; Clinic targeting private funding and communications, direct
does not strategically target new sources (other than foundations mail, personal solicitation,
revenue sources and contracts); Has a short, but planned giving); Strategy
good track record of successful includes identifying and
fundraising from private sources pursuing new revenue sources,
including significant effort to
target private funding sources
(other than foundations and
contracts); Proven activities and
skills for generating funding
from private sources
2. Fund No dedicated fund development Some staff time and budget Some dedicated fund Fully staffed professional fund
Development staff and no budget for dedicated to fund development; development staff who have development team with
Staff, Budget, & development; Generally weak Regular development needs professional training/experience development budget; Highly
grantwriting and fundraising covered by internal staff, who in grant writing and fundraising; developed internal grantwriting
Skills
skills and lack of expertise also do other jobs, but have Main development needs and fundraising skills and
(either internal or access to some experience/training in covered by some combination of expertise in all funding source
external expertise) grantwriting; Occasional access internal skills and expertise, and types to cover all regular needs;
to some external grant writing access to some external Access to external expertise for
and fundraising expertise grantwriting and fundraising additional extraordinary
expertise development needs
3. Private Clinic has no experience with or Board leadership and ED do not Board leadership and ED Board leadership and ED put
Revenue Sources commitment to raising funds put high priority on private prioritize private fundraising; high priority on private
(non-foundation from private sources such as fundraising; Clinic does not Clinic consistently has annual fundraising; Clinic has ongoing
individuals and/or corporations; have an annual fundraising fundraising campaigns; strategies and systems for
or contract)
Less than 2% of the clinic's campaign; Solicitation of private Development team includes soliciting private donations and
annual revenue comes from contributions is infrequent and staff experienced in individual communicating with donors;
private charitable donations somewhat haphazard; Between donor relations; Between 3% to Development staff are expert at
(other than from philanthropic 2% and 3% of the clinic's annual 5% of the clinic's annual relations with individual donors;
foundations) revenue comes from private revenue comes from private More than 5% of the clinic's
charitable donations (other than charitable donations (other than annual revenue has come from
from philanthropic foundations); from philanthropic foundations); private charitable donations
The amount of revenue from The amount of revenue from (other than from philanthropic
private sources is inconsistent private sources is consistent, foundations) for at least three
from year to year but not increasing year to year years; The amount of revenue
from private sources has
consistently increased year to
year
Comments: Type comments (if any) here.
Please proceed to Worksheet 10.
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 9, 4/14/2011, Page 15 of 18
~ DATA-INFORMED DECISION MAKING ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(3 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
1. Data Analysis Limited capacity to work with Often uses simple data from Familiar with relevant sources Respected by peers as both a
Skills & Staff research data; Only sporadically internal or outside sources to for public health data that are consumer and producer of
uses data from outside sources support fund development regularly consulted to support research data; Staff positions
to support proposals or program and/or advocacy; Can read decisions, proposals, or are dedicated to research and
decisions; Little understanding research reports and evaluate advocacy; Can determine data data analysis; Regularly scans
of where to find useful data or the quality of data but does not quality, manipulate data from public health research for
how to assess its quality rely on data as part of regular existing data sets, and make relevant and valid data to
decision making; Familiar with generalizations about the support program planning and
one or two sources of public validity of findings for advocacy; Regularly works with
health data especially relevant community clinics and/or the management staff to identify
to community clinics; Little local population; Some staff important organizational
capacity to analyze raw data or members have research and questions and answer them
present it in graphical, engaging data analysis skills, though this through research, either
ways may be only part of their job collecting data from outside
descriptions; Some staff sources or conducting primary
capacity to conduct basic research; Strong relationships
primary research such as with other researchers in the
surveys; Can effectively present public health arena, and/or at
data using charts, tables, and other clinics
graphics for a variety of
audiences
2. Use of Clinical Minimal and haphazard tracking Tracks basic clinic Regularly tracks clinic Tracks clinical data such as
Data of basic clinic management data management data such as management data such as service utilization by different
such as patient demographics; patient demographics, utilization patient demographics and demographics, quality
Reports can be produced upon of different services and/or provider productivity, and assurance, and/or utilization
request, are produced provider productivity; Produce maintains at least one disease reports with trend information;
irregularly and reviewed by the reports at least twice a year that registry; Reports are produced Small number of clear,
Medical Director; Cannot identify are reviewed by the Medical at least quarterly and are measurable, and meaningful
patients by different types of Director; Reports do not include reviewed and discussed by the key performance indicators;
diseases trend information comparing Medical Director, Executive Reports are produced at least
current data to previous time Director, and Management quarterly and are reviewed and
periods Team; Can identify patients by discussed by the Medical
different diseases and Medical Director, Executive Director, and
Director requests this data on Management Team; Program
an occasional basis, but not planning and/or adjustments are
regularly; Has occasionally made based upon information
conducted some small analyses from the reports and impact of
of patterns in patients' health but changes is also tracked by
does not do so on a regular reviewing changes in these
basis data; Maintains multiple disease
registries; Can conduct
sophisticated analysis of patient
population health and chronic
disease management and
adjust services appropriately
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 10, 4/14/2011, Page 16 of 18
~ DATA-INFORMED DECISION MAKING ~
Input
Assessment LEVEL ONE: LEVEL TWO: LEVEL THREE: LEVEL FOUR:
Selection in
Categories Clear need Basic level Moderate level High level
This
(3 questions) for increased capacity of capacity in place of capacity in place of capacity in place Column
3. Performance Rarely compares performance Some efforts made to Benchmarking of financial Comprehensive external
Management: data such as financial benchmark performance against performance, patient benchmarking part of the culture
Benchmarking performance, patient the outside world; Compares demographics, and/or service and takes place up to four times
demographics, service financial performance, patient utilization occurs at least once per year; Performance
utilization, or population health demographics, and/or service per year, but driven largely by compared to objective external
status to other clinics or any utilization with local clinics top management; Comparisons standards (e.g., Federal
objective standards and/or consortia members on an made to local/regional clinics as benchmarks, local/regional
irregular basis but at least once well as to other clinics primary care standards, MGMA
per year; No comparisons made statewide, but no comparisons standards, etc.) as well as to
to any objective standards, such made to any objective external other clinics; Benchmarking
as Federal or local/regional standards (e.g., Federal used by staff in target-setting
primary care standards benchmarks, local/regional and daily operations; High
primary care standards, MGMA awareness of how all activities
standards, etc.); Learnings from rate against internal and
these activities shared with all external best-in-class
staff and often used to make benchmarks; Systematic
adjustments and improvements practice of making adjustments
and improvements on basis of
benchmarking
Comments: Type comments (if any) here.
Your survey is complete. Thank you!
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 10, 4/14/2011, Page 17 of 18
Organizational Capacity Grid Summary
Please print this worksheet for future reference.
Individual Assessment Average Ratings
Category Ratings for Each Capacity Area
MISSION, VISION, & PLANNING
Mission (clinic's reason for existence) 0
Clarity of Vision (clinic's long-term goals for itself & its community) 0
Strategic Plan 0
Strategic Planning Skills 0 0.00
Performance Targets 0
New Program Development 0
Operational Planning 0
COMMUNITY ENGAGEMENT & COLLABORATION
Assessment of Community Needs & Clinic Environment 0
Local Community Presence & Involvement 0 0.00
External Relationship Building (partnerships & collaboration) 0
LEADERSHIP: MANAGEMENT TEAM
Management Team Composition 0
Management Communication 0
Management Decision-making 0 0.00
Management Experience & Expertise 0
Management Team Collaboration & Leadership 0
LEADERSHIP: BOARD OF DIRECTORS
Board Composition & Commitment 0
Board Governance 0
Board Training & Orientation 0
0.00
Committee Structure & Participation 0
Board Fundraising 0
Strategic Planning Role 0
FINANCIAL SYSTEMS & POSITION
Bottom Line 0
Cash Flow 0
Diversity of Revenue Sources 0 0.00
Financial Planning & Budgeting 0
Use of Financial & Operations Data 0
FUND DEVELOPMENT
Fund Development Strategy & Activities 0
Fund Development Staff, Budget, & Skills 0 0.00
Private Revenue Sources (non-foundation or contract) 0
DATA-INFORMED DECISION MAKING
Data Analysis Skills & Staff 0
Use of Clinical Data 0 0.00
Performance Management: Benchmarking 0
8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: SUMMARY, 4/14/2011, Page 18 of 18
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