Mission Vision Worksheet - Excel

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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
Executive Director Name (if not the person completing survey)

Others Involved with the Assessment Process


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)                $                                                     -
                                                                                                     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
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
Mental health services for adults
Mental health services for children
Substance abuse services
Health education
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)


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 ~
   Assessment                  LEVEL ONE:                       LEVEL TWO:                          LEVEL THREE:                          LEVEL FOUR:
                                                                                                                                                                        Selection in
    Categories                  Clear need                       Basic level                         Moderate level                         High level
   (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
                                                         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 ~
  Assessment                LEVEL ONE:                         LEVEL TWO:                         LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                     Selection in
   Categories                Clear need                         Basic level                        Moderate level                        High level
   (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

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 ~
   Assessment              LEVEL ONE:                         LEVEL TWO:                           LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                      Selection in
    Categories              Clear need                         Basic level                          Moderate level                        High level
  (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
                   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
                   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
                                                       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

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 ~
   Assessment              LEVEL ONE:                          LEVEL TWO:                          LEVEL THREE:                            LEVEL FOUR:
                                                                                                                                                                         Selection in
    Categories              Clear need                          Basic level                         Moderate level                           High level
  (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 ~
   Assessment             LEVEL ONE:                    LEVEL TWO:                         LEVEL THREE:                        LEVEL FOUR:
                                                                                                                                                         Selection in
    Categories             Clear need                    Basic level                        Moderate level                       High level
  (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-
                  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

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 ~
   Assessment                LEVEL ONE:                       LEVEL TWO:                         LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                   Selection in
    Categories                Clear need                       Basic level                        Moderate level                        High level
  (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 ~
   Assessment              LEVEL ONE:                           LEVEL TWO:                         LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                      Selection in
    Categories              Clear need                           Basic level                        Moderate level                        High level
  (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

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 ~
   Assessment               LEVEL ONE:                       LEVEL TWO:                          LEVEL THREE:                          LEVEL FOUR:
                                                                                                                                                                    Selection in
    Categories               Clear need                       Basic level                         Moderate level                         High level
  (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;
                                                                                                                                monitored on a monthly basis

                             8a56f7ac-5bf0-4428-ab62-c455a5f0e04b1, Worksheet: 8, 4/14/2011, Page 13 of 18
                                                     ~ FINANCIAL SYSTEMS & POSITION ~
   Assessment             LEVEL ONE:                        LEVEL TWO:                         LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                 Selection in
    Categories             Clear need                        Basic level                        Moderate level                        High level
  (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 ~
   Assessment              LEVEL ONE:                        LEVEL TWO:                          LEVEL THREE:                           LEVEL FOUR:
                                                                                                                                                                     Selection in
    Categories              Clear need                        Basic level                         Moderate level                          High level
  (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
                   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 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

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 ~
   Assessment                LEVEL ONE:                         LEVEL TWO:                          LEVEL THREE:                           LEVEL FOUR:
                                                                                                                                                                        Selection in
    Categories                Clear need                         Basic level                         Moderate level                          High level
  (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

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 ~
   Assessment              LEVEL ONE:                         LEVEL TWO:                         LEVEL THREE:                         LEVEL FOUR:
                                                                                                                                                                  Selection in
    Categories              Clear need                         Basic level                        Moderate level                        High level
  (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

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 (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
Assessment of Community Needs & Clinic Environment                                 0
Local Community Presence & Involvement                                             0                       0.00
External Relationship Building (partnerships & collaboration)                      0
Management Team Composition                                                        0
Management Communication                                                           0
Management Decision-making                                                         0                       0.00
Management Experience & Expertise                                                  0
Management Team Collaboration & Leadership                                         0
Board Composition & Commitment                                                     0
Board Governance                                                                   0
Board Training & Orientation                                                       0
Committee Structure & Participation                                                0
Board Fundraising                                                                  0
Strategic Planning Role                                                            0
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 Strategy & Activities                                             0
Fund Development Staff, Budget, & Skills                                           0                       0.00
Private Revenue Sources (non-foundation or contract)                               0
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

Description: Mission Vision Worksheet document sample