2023 NCHL GLW Leadership Award Nomination Form FINAL V2

NATIONAL CENTER FOR HEALTHCARE LEADERSHIP 2023 GAIL L. WARDEN LEADERSHIP EXCELLENCE AWARD The National Center for Healthcare Leadership is accepting nominations for the 2023 Gail L. Warden Leadership Excellence Award. The Award honors a healthcare leader whose commitment, values, and contributions have improved the health of the public through leadership and organizational excellence. The Leadership Award is given to an individual who has made significant and lasting leadership contributions to the health and healthcare field. Nominees can represent any sector, including healthcare delivery, community health, public health, insurance, suppliers, public policy, government, professional/trade associations, research, and academic institutions. Nominees for the Award must be actively engaged in the field and have broad national influence. Self-nominations are not eligible. The nominee does not have to be from one of NCHL’s member organizations to be nominated. The recipient of the 2023 GAIL L. WARDEN LEADERSHIP EXCELLENCE AWARD will be honored at a celebration event on Tuesday, November 14, 2023, at the Field Museum in Chicago, IL. Nominations are due Friday, June 2, 2023 Please send the completed nomination package via email to NCHL at info@nchl.org If you have any questions about the nomination form or process, please email info@nchl.org. Copies of prior award recipients’ nominations are also available upon request. NOMINATION CRITERIA: 1)Demonstrates significant innovation and impact, such as transforming care delivery to improve value, safety, or patient experience, reducing health disparities, addressing social determinants of health, improving access and equity of care for underserved populations, contributing to research/public policy that advances the field, fostering a culture of health and wellness, or advancing technological solutions to improve healthcare value. 2)Creates and fosters diverse and inclusive leadership teams who have achieved quantifiable improvements in organizational performance, health and wellness, community health status, quality, equity, and value. 3)Demonstrates strong leadership competencies by serving as a mentor and role model to current and future generations of leaders, focusing on employee and provider engagement to transform care and improve organizational performance, exhibiting courage for transformational initiatives, and advancing the field through evidence-informed leadership best practices. 4)Demonstrates the ability to lead across organizational and professional boundaries to bring about transformation within communities, regions, and beyond. 5)Is recognized and respected in the field and is sought out to provide perspective, guidance, and direction through national forums, policymaking, and other strategic alliances to shape the industry. NOMINATION PACKAGE: These items are required for a nomination to be considered by NCHL’s Selection Committee: ✓ Completed nomination form ✓ Signatures of two nominators ✓ Nominee’s curriculum vita or résumé 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 1 NATIONAL CENTER FOR HEALTHCARE LEADERSHIP 2023 GAIL L. WARDEN LEADERSHIP EXCELLENCE AWARD NOMINATION FORM ABOUT THE NOMINEE Name: _______________________________________________________________________________ Title: ________________________________________________________________________________ Organization/Institution: ________________________________________________________________ Address: _____________________________________________________________________________ _____________________________________________________________________________________ City: __________________________________________ State: ______________ Zip Code: __________ Country: ________________________________________ Phone: ___________________________________ Email: ____________________________________________________________________ I ndustry Sector (choose all that apply): Healthcare Provider / DeliveryResearch / Academic InstitutionSupplier / Vendor Community Health / Public HealthProfessional / Trade AssociationTechnology Public Policy / Think TankMilitary / GovernmentPayor / Insurer Other: _____________________________________________________________________ Race/Ethnicity: ___________________________________ Age: ____________ 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 2 Education (schools, degrees): Principal Honors and Awards: 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 3 Major National Leadership Positions, Societies, and Boards: Over the years, what has been the nominee’s level of engagement in NCHL? 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 4 NOMINATORS’ SIGNATURES We recommend that one nominator be internal to the organization and one nominator be external to the organization. Electronic signatures, or signatures sent under separate cover, are acceptable. (1)Nominator Signature: ______________________________________________________________ Name (print): _____________________________________________________________________ Title: ____________________________________________________________________________ Organization/Institution: ___________________________________________________________ Phone: __________________________________________________________________________ E-mail: __________________________________________________________________________ (2)Nominator Signature: ______________________________________________________________ Name (print): _____________________________________________________________________ Title: ____________________________________________________________________________ Organization/Institution: ___________________________________________________________ Phone: __________________________________________________________________________ E-mail: __________________________________________________________________________ 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 5 NOMINEE’S ACCOMPLISHMENTS Use the space below (or a separate document) to describe how the nominee meets the Leadership Award criteria. When describing th e person ’s accomplishments, please be as specific as possible and provide examples of how they differ from other healthcare leaders in the field. Do not exceed more than four (4) total pages of narrative for A and B. The response for each question is limited to 4,400 characters. Attachments can be included with the nomination form (i.e., CV, articles, certificates, etc.). NOTE: The Selection Committee will utilize the narrative provided as the basis for their ranking and scoring of the nominee. While attachments with supporting documentation is acceptable, please understand that the narrative provided will be the primary basis for their review. A. PLEASE DESCRIBE THE NOMINEE’S MOST SIGNIFICANT CONTRIBUTION AND IMPACT TO HEALTHCARE LEADERSHIP: 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 6 B.PLEASE DESCRIBE THE NOMINEE’S CONTRIBUTIONS RELATIVE TO EACH CRITERIA: 1.Demonstrates significant innovation, such as transforming care delivery to improve value, safety, or patient experience, reducing health disparities, addressing social determinants of health, improving access and equity of care for underserved populations, contributing to research/public policy that advances the field, fostering a culture of health and wellness, or advancing technological solutions to improve healthcare value. 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 7 2.Creates and fosters diverse and inclusive leadership teams who have achieved quantifiable improvements in organizational performance, health and wellness, community health status, quality, and value. 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 8 3.Demonstrates strong leadership competencies by serving as a mentor and role model to current and future generations of leaders, focusing on employee and provider engagement to transform care and improve organizational performance, and advancing the field through evidence-informed leadership best practices. 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 9 4.Demonstrates the ability to lead across organizational and professional boundaries to bring about transformation within communities, regions, and beyond. 2023 NCHL Gail L. Warden Leadership Excellence Award Nomination Form 10 5.Is recognized and respected in the field and is sought out to provide perspective, guidance, and direction through national forums, policymaking, and other strategic alliances to shape the industry.