VA-CASE LEAN
CERTIFICATION
PROGRAM
Recognizing
healthcare
Lean expertise
to motivate
continued
learning and
application
Kimberly E. Johnson, PsyD, HSPP Carlos M. Garcia, MBA, CM, CLGB Professional Development Program
VISN 11 VA Center for Applied Systems Engineering (VA-CASE) [email protected]
Introduction
The VA-CASE Professional Development Program works with Veterans Health Administration (VHA) facilities and offices nationwide to provide educational content, tools, and support needed to establish Lean healthcare solutions. In simplest terms, Lean is a process improvement methodology that shortens the time between start and finish of any given process by eliminating sources of waste. Waste in this context is defined as anything that does not add value to the final product or service from the veteran’s perspective. The purpose of these educational services is to provide VHA staff with the knowledge, skills, and support needed to implement and sustain successful Lean and Lean Six Sigma healthcare or business practices within VHA facilities. The formal training sessions presented by VA-CASE faculty incorporate both didactic and hands-on learning experiences in Lean or Lean Six Sigma methods and techniques. In addition, participants are offered opportunities to utilize the knowledge acquired by participating in actual VA process improvement events to solidify learning and increase value in services offered to our Veterans. After successfully completing educational training, assessment, and process improvement application, participants have the option of obtaining VA-CASE Lean Certification at varying levels of expertise. Establishment of Lean certified VA staff nationally is a key component in the transformation of VHA Medical and Business Centers to a culture of targeted process improvement and overall cost reduction.
Abstract
The purpose of this paper is to highlight the focus, process, and progress achieved by the VA-CASE Lean Certification Program to support Lean and Lean Six Sigma process improvement within the VHA. Due to the anticipated increase in service needs by current and future generations of veterans, the VHA must embrace innovative strategies to reduce service cost, speed service delivery, and provide services viewed as valuable by our veterans. Lean and A3 Thinking have been selected as key elements for the change needed to champion the transition to a VHA culture of continuous process improvement.
VHA’s Need for Trained and Skilled Process Improvement Staff
As military troops return from the current wars and fewer troops are managed under the Department of Defense, there is an urgent need for a business, process and cultural transformation within the VHA system. The VHA has chosen Systems Redesign and its Lean components as one of the various improvement strategies to achieve this transformation. The ultimate goal is to improve healthcare quality, reliability, and access to care for our 22 million veterans nationwide. The VHA’s Systems Redesign leadership has chosen the process improvement methodologies called Lean and Lean Six Sigma as its vehicle of transformation.
Lean and its effectiveness to reduce organizational cost, increase process efficiency, and improve customer value have been proven for decades in numerous industries. Within the past decade, Lean has become a key management strategy and driver of change within civilian hospitals. The VA Medical Centers have also embraced Lean as the fundamental quality and process improvement tool for clinical, business, and management teams to champion VHA process improvement in the 21st century. The Lean principles exist within the VHA framework for improvement: Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS). However, despite attempts by VA Medical and Business Centers at the local, regional, and National level to incorporate Lean and Systems Redesign into their organizations, barriers exist. Success was initially hampered due to few staff members having training or experience applying Lean principles to healthcare. Furthermore, few possessed understanding and application of Lean Thinking. Fundamentally, the Lean principles and approaches originated by the Toyota Production System (TPS) in Japan were foreign to most VA healthcare professionals and administrators. Therefore, a comprehensive solution was needed to educate, assess, and certify VA staff as they acquired Lean Process Improvement knowledge and application experience.
VA-CASE Lean Certification Program
The purpose of the VA-CASE Lean Certification Program is to provide VA staff who have acquired Lean or Lean Six Sigma training and skill with the Lean Yellow Belt (Practitioner), Green Belt (Facilitator), or Black Belt (Strategic) National level certification. The requirements for certification at each level are outlined below. There is no charge associated with the VA-CASE Lean Certification.
Lean Yellow Belt Certification
The requirements for the Lean Yellow Belt certification through either VA-CASE or Purdue are:
Attend the VA-CASE Yellow Belt Certification Workshop or obtaining equivalent Lean education from a difference source.
Complete the online multiple-choice competency exam with a score of 70% or higher.
Participate in a Lean or Systems Redesign improvement project within the VA. Submit for approval an A3 report on the 9-box A3 format for an improvement
project that you participated in.
These requirements can be completed in any sequence. For example, the participant may take the exam before or after participating in a project, or submit the A3 for a project they participated in prior to attending Lean Yellow Belt training. The purpose of the certification exam is to assess the level of understanding of Lean principles that VA uses in conjunction with its process improvement framework, Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS). It is also designed to provide a learning experience.
VA-CASE Lean Yellow Belt Certification Process
Education
• Complete LEAN Yellow Belt Course
Knowledge Assessment
• Pass Yellow Belt Examination
Participation
• Participate in LEAN project or event
• Submit project A3 showing your role
The Lean Yellow Belt certification candidate is assumed to have received knowledge and gained skill, normally through participation as a member of a process improvement project, of the following Lean topics: Lean in healthcare, Lean principles and concepts; definition of Value, Value Stream Mapping, A3 Problem Solving, Voice of the Customer, SIPOC, GAP Analysis, Root Cause Analysis, PDSA/RCC, 5S and Workplace Organization; Measurement Systems, Standard Work, Just-In-Time and Single Piece Flow, Pull Systems, and Error Proofing (Poke-Yoke).
Targeted participants include VHA supervisors and mid-level managers at medical centers, VISNs, and other VHA facilities; VHA Systems Redesign Coordinators (SRC); VHA Systems Redesign facilitators; and Health System Specialists.
Lean Green Belt Certification
The requirements for the Lean Green Belt certification through either VA-CASE or Purdue are:
Attend the VA-CASE Green Belt Certification Workshop or obtain equivalent Lean education from a difference source.
Complete the online multiple-choice competency exam with a score of 70% or higher.
Participate in a Lean or Systems Redesign improvement project within the VA as a leader or facilitator of a project team.
Submit for approval an A3 report on the 9-box A3 format of the improvement project that you led.
As with Lean Yellow Belt certification, these requirements can be completed in any sequence. For example, the participant may take the exam before or after leading or facilitating a process improvement project, or submit the A3 for such project prior to attending Lean Green Belt training.
VA-CASE Lean Green Belt Certification Process
The Lean Green Belt certification is advanced in that the focus is facilitation of a Lean Improvement project. It presumes basic familiarity with Lean Healthcare and builds on that knowledge. Lean Yellow Belt certification is generally considered a prerequisite for the Green Belt certificate. Targeted participants include VA Systems Redesign Coordinators (SRC) and process improvement team leaders or facilitators.
Candidates should have knowledge of and experience leading or facilitating a process improvement team using Lean principles, Lean tools, and the VA-TAMMCS framework for improvement. Familiarity with the following is necessary for certification and successful completion of the exam: Planning and executing Rapid Process Improvement Workshop (RPIW) events; project charter development, including project selection and scope; team dynamics; Voice of the Customer tools and analysis; workflow analysis, including Current and Future State Process Flow diagrams; Process Observation tools and methods; data collection tools; identifying operational barriers; Plan-Do-Study-Act (PDSA) cycles; how to develop plans to sustain and spread improvements; and how to develop implementation and control plans.
Lean Black Belt Certification
The primary objective of the Lean Black Belt certification program is to recognize VHA staff that possess Lean knowledge and proven skills and are able to support and independently facilitate or lead others who lead Lean projects in VHA healthcare facilities, and who actively participate in strategic oversight, planning and management of healthcare Lean programs. The program presumes that candidates are fluent in Lean
Education
• Complete LEAN Green Belt Course
Knowledge Assessment
• Pass Green Belt Examination
Participation
• Facilitate a LEAN project or event
• Submit project A3 showing your role
and Systems Redesign concepts and principles; basic and advanced graphing; basic and advanced statistics; Project Management, and Program/Project Evaluation, including Return-on-Investment Analysis (ROI). Targeted participants include VA Systems Redesign Coordinators (SRC) and facilitators who have obtained Lean Green Belt certification.
Requirements for certification include:
Independent facilitation of at least two Systems Redesign or Lean process improvement teams and documentation of the projects using the A3 format. Active contribution to the VHA Lean Healthcare Community of Practice, and Successful completion of a competency-based assessment.
Certification Knowledge and Competency Requirements
Knowledge and competency requirements for the three levels of Lean certification are listed in Appendices I and II, respectively. All three levels require detailed knowledge of the VA-TAMMCS framework for improvement and of specific elements within each one of the framework’s stages. Programmatic and strategic Lean principles, project management and return on investment (ROI) knowledge requirements are common to the Facilitator level (Green Belt) and the Program/Strategic level (Black Belt). Competencies required by the Green and Black Belt certification levels are similar, but the latter emphasizes teaching and a high degree of understanding of management and mathematics principles, and of healthcare regulations and legal requirements. Listed in Appendix III are the key personal attributes that are desirable in all candidates for Lean certification. These artifacts were translated utilizing a modified Delphi method by VA-CASE Health Services Research Partners.
Lean Certification Program Results: June 2013 – May 2014
Figure 1: Lean Yellow and Green Belt certification results for one year.
Between June 2013 and May 2014, monthly completion of the certification process for Yellow and Green Belt remained relatively stable. Completed certifications at the Yellow Belt level averaged 13 per month and 6 per month at the Green Belt level. It is reasonable to conclude that the monthly Green Belt certification average of 6 recognizes a more limited need in our client organizations for skilled facilitators vs. Lean improvement project participants. It is likely that as organizations mature in relation to a Lean culture, there will be greater demand for Green and Black Belt certification as organizations learn and experience the value of Lean Improvement events. VA-CASE expects this increased demand for Lean Certification and is actively planning for the demand through the development of program infrastructure, improved administration of the certification web site, expansion of exam questions, and a feedback loop to students identifying recommended areas of review.
18 28 39 54 75 88 104 110 121 131 143 160 0 5 9 12 22 33 42 47 49 52 58 71 0 20 40 60 80 100 120 140 160 180
Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14
N umb er C an di da te s C ert ifi ed
Yellow and Green Belt Certification
June 2013 to May 2014
YB Certified GB Certified
VA-CASE Lean Certification Completions
*Number of certifications derived from a hand count due to the inability of the software to quantify numbers.
Future Direction and Focus
Participation in the VA-CASE Lean Certification Program has grown since 2012. Interest in the application of Lean principles and approaches to improve the timeliness, quality and cost of VA healthcare services is anticipated to continue to grow, as more staff develops the necessary skill sets and experience to achieve recognition and Lean certification. Our Primary goal of developing Lean Improvement capacity in our client organizations will remain. We work to enable VA healthcare facilities to execute process improvement initiatives at all levels of their organizations with minimal external support and guidance, and to promote and support the new culture of process improvement. We know that I cultural transformation is a journey. The VHA has embarked upon this journey. The influx of new and existing veterans to VA healthcare over the next decade will serve to hasten the need for more Lean trained, experienced and certified workers. The continuation of the development and spread of the VA-CASE Lean Certification Program within VA healthcare will ensure that management and staff will acquire professional Lean knowledge and appropriate skill levels, while advancing continuous process improvement efforts at every organizational layer.
The expansion of Lean process improvement thinking and utilization within VA will be a result of the VA-CASE Professional Development Program’s continued offering of:
Lean Certification Level
Certified from June 2013 to May 2014*
Total certifications since inception (June 2012)*
Yellow Belt 160 236
Green Belt 71 83
Black Belt 0 12
Nationwide competency, facilitation, and management training on Lean process improvement methodology and tools, enabling the spread of process improvement initiatives.
Facilitation, coaching, and technical support of VHA process improvement initiatives at the local, VISN, and national levels.
Communication forums to promote and expand process improvement discussions and sharing of knowledge and best practices.
Lean Certification options to recognize Lean expertise and provide motivational incentives for continued learning.
Recommendation
The need for veteran-centered, cost efficient services has become a central objective for the VA. Embracing innovative and effective initiatives is crucial to achieving this goal. Proven process improvement methods and philosophies, such as Lean and A3 Thinking, have been chosen as the vehicles of change for VA facilities. Therefore, the Professional Development Program within VA-CASE will continue to expand its educational, training and certification options for all VA employees. Due to the volume of potential participants, continued flexibility in Lean training methods should be explored, such as continued onsite training, webinars, video, and online educational forums. However, regardless of the instructional method, timely and practical application of acquired process improvement skills and recognition through Lean certification should be emphasized. This will serve to enable and solidify delivery of valuable and efficient services to our current and future generations of veterans. Finally, VA healthcare organizations must continue to create improvement team facilitation opportunities for Lean certified Yellow Belts and strongly encourage and reward Lean Green Belt training and certification.
Appendix I – Knowledge Requirements for Certification Levels
Knowledge Requirements Practiti oner Level (Yellow Belt) Facilitator Level (Green Belt) Program/Strategic Level (Black Belt)I. Enablers for Lean
• VA-TAMMCS Framework
X (Basic)
X
(Intermediate) X (Advanced)
• Principles of Lean Leadership
o Lean Corporate Culture, Lean Roles
X (Basic)
X
(Intermediate) X (Advanced)
O SR Methods (RPIWs, Kaizen, 100D Projects, etc.) X (Basic) X (Advanced)
o Teamwork and Team Dynamics X (Basic) X (Advanced)
o Levels of Employee Training and Development X (Basic) X (Advanced)
o Principles of Empowerment
X (Basic)
X
(Intermediate) X (Advanced)
o Linkage to Business Vision, Mission, Values,
Strategies and Goals X
o Data extraction, analysis and feedback X
o Motivation Theory, Teaching Adult Learners X X
II. Core Operations and Processes
• Vision/Analyze
o Opportunity Identification
o Project Selection X (Basic) X (Advanced)
o Value Stream Analysis X (Basic) X (Advanced)
• Team/AIM o Project Charter X (Basic) X (Intermediate) X (Advanced)
o Appropriate Project Scope
X (Basic) X (Intermediate) X (Advanced) o AIM Statement X (Basic) X (Intermediate) X (Advanced) o Team Selection X (Basic) X (Intermediate) X (Advanced)
o Voice of the Customer X
• MAP/Measure • Workflow Analysis o Process Mapping X (Basic) X (Advanced) o Process Observation X (Basic) X (Advanced)
o Process Observation Worksheet
X
(Basic) X (Advanced)
o Spaghetti Diagramming
X
(Basic) X (Advanced)
o Prospective Data Collection and Analysis
X (Basic)
X
(Intermediate) X (Advanced)
o Retrospective Data Collection and Analysis
X (Basic)
X
(Intermediate) X (Advanced)
(Basic) (Intermediate)
• Change
• Systematic identification and elimination of waste (A-3)
o Operational Barrier (Waste) identification and
elimination X
o Value Stream Mapping X
o 5S standards X
o Visual workplace X
o Mistake proofing (Poka-Yoke) X
o Continuous improvement methods (PDSA, IHI
Model for Improvement) X
• Just-in-Time Operations
o Capacity (Demand/Supply) Analysis X
o Process Triggers (Andon, Kanban) X
o Pull systems X
o Continuous flow X
o Just-in-time (JIT) X
o Quick changeover/set-up reduction (SMED) X
o Total productive/preventive/predictive maintenance
(TPM) X
• Workstation Design
o Work cell design/setup X
o Single piece flow (reduction/elimination of batching) X
o Standardized work X X
o Informatics/Automation X
• Sustain
o Key Characteristics for sustainability X (Basic) X (Advanced)
o Implementation Plan X
o Control Plan X
III. Business Operations – Vision and Strategy
• Operational processes vision, mission, strategies,
objectives and targets (goals) X
• Lean principles (programmatic, strategic) X
• Employee empowerment (programmatic, strategic) X
• Operational alignment with organizational vision and
strategy X
IV. Project Design and Communications
o Project Management X
• Product Design and development of products and
services
o Quality function deployment X
o Variety reduction X
o Design for Veteran Centered Care (VCC) X
o Design for environment X
o Failure mode and effects analysis
X (Basic)
X
(Intermediate) X (Advanced)
o Knowledge transfer methods and practices X
• Product market service
o Voice of the Customer X
o Customer specifications and requirements X (Basic) X (Advanced)
o New market development and current market
o Benchmarking X (Basic) X (Advanced)
• Other stakeholders
o Stakeholder engagement methods X
o Stakeholder satisfaction measurement X
o Corrective action system X
o Human Factors Engineering X
V. Return on Investment
• Return on Investment Analysis
o Cost of Poor Quality X (Basic) X (Advanced)
o Soft vs Hard Cost savings X
o Fixed and variable costs X
Appendix II – Performance Criteria and Competencies
Performance Criteria Competencies Practitioner Level (Yellow Belt) Facilitator Level(Green Belt) Program/Strategic
Level (Black Belt)
1. Understand and have access to the Lean “body of knowledge". 1.1 A “body of knowledge” can be accessed and understood. • Access to and understanding of various Lean and Lean methodologies; . • Maintain a personal library, a company library, a computer database or other collection of information. • Contribution to VHA or other Lean Healthcare Knowledge Database 1.2 Taken courses
with a focus on Lean that address the items in the knowledge table
• Successful completion of courses on Lean or Lean and related topics – documentation required • Certified in Lean or Lean • Successful completion of courses on Lean or Lean and related topics – documentation required • Certified in Lean or Lean • Successful completion of courses on Lean or Lean and related topics – documentation required • Certified in Lean or Lean 1.3 Taught courses or short courses on Lean (see the knowledge table) • Taught courses with student evaluation of knowledge of instructor – evaluations required 1.4 Have an education that supports the knowledge that is required for Lean Projects
• Has taken courses
in business, management, mathematics and other disciplines needed to support the work 2. Demonstrate the skills to use Lean knowledge during project assignments 2.1 Demonstrated ability in each area of Lean or Lean listed in skill table. • Demonstrated practitioner level skills in competency-based training • Demonstrated facilitator level skills in competency-based training
• Demonstrated expert level skills in competency-based training
2.2 Demonstration of
the effectiveness of Lean or Lean activities listed in the skills table.
• Demonstrated effectiveness at a practitioner level for Lean or Lean activities in competency-based training • Demonstrated effectiveness at a facilitator level for Lean or Lean activities in competency-based training • Demonstrated effectiveness at an expert level for Lean or Lean activities in competency-based training
2.3 Work experience can be demonstrated for each area of Lean or Lean listed in the skill table.
• References from clients attesting to practitioner level skill in using the methods listed above
• References from clients attesting to facilitator level skills in using the methods listed above
• References from clients attesting to expert level skill in using the methods listed above 3. Demonstrate the attributes for Lean practitioners 3.1 Practice personal attributes necessary for the effective and efficient conduct of Lean or Lean services
• Demonstrated practitioner level attributes in competency-based training • Demonstrated facilitator level attributes in competency-based training • Demonstrated expert level attributes in competency-based training 3.2 Attest to attributes
listed in the table from former clients
• References from clients attesting to practitioner level skill in using the methods listed above
• References from clients attesting to facilitator level skills in using the methods listed above
• References from clients attesting to expert level skill in using the methods listed above
4. Demonstrate important communication skills for Lean practitioners 4.1 Effective communication is practiced • Knowledge of effective communication (verbal, written and listening) is
demonstrated
• Effective communication (verbal, written and listening) is demonstrated within the context of facilitating Lean Teams • Effective communication (verbal, written and listening) is
demonstrated within the context of advancing the strategic direction of the Lean Program
4.2. Interview skills
are used to effectively acquire information required for the Lean or Lean activity • Knowledge of effective interview techniques to acquire valid evidence is demonstrated • Effective interview techniques are used to acquire valid evidence during projects
• Effective interview techniques are used to inform Lean Program strategic direction 4.3 Written comments in Lean or Lean documentation accurately reflect findings, observations and interventions • Effective contribution to reports/presentations is demonstrated • Lean Project findings and results are recorded
accurately, analyzed, prioritized and summarized
• Lean Program findings and results are recorded
accurately, analyzed, prioritized and summarized
4.4 The requirements for information security are understood and applied • Information Security requirements are understood
• Reports and all notes are securely maintained
• Outcomes are not discussed with or distributed to unauthorized personnel
• Reports and all notes are securely maintained
• Outcomes are not discussed with or distributed to unauthorized personnel 4.5 Understand the application of the regulations, industry codes of practice and other considerations that are relevant to the Lean or Lean effort (e.g., environmental, health and safety regulations) • An understanding of how relevant regulations, legal requirements and codes of practice are applied within the organization where the Lean service is being provided
4.6 Understand the
impact of the Lean processes on bargaining unit employees
• Any potential issues
or conflicts with bargaining unit employees are proactively
addressed with union representation 5. Demonstrate the ability to effectively contribute to a Lean Project 5.1 Respond to a request for a Lean or Lean assignment • The services requested are identified and assessed as being within the goals/deliverables of the Lean Program • Appropriate Facilitator, Management Guidance Team and Process Action Team resources are
allocated to support the project
5.2 Create project
charter for the Lean or Lean assignment • Knowledge of components of the Project Charter is demonstrated • Meaningful contribution to the creation of the Project Charter is demonstrated
• The Project Charter is created and effectively utilized as part of the project preparation and project execution
• Project Charters are aligned to meet specific strategic or tactical program goals or deliverables
5.3 Management Guidance Team (MGT) meetings • Knowledge of role of the Management Guidance Team in project development and management is demonstrated • Meaningful contribution to the MGT is demonstrated (if applicable, includes regular attendance at MGT meetings and timely completion of any assigned action items) • Facilitator schedules and conducts 2 MGT Meetings, completes project charter and insures that project action team (PAT) team is appropriate resources and chartered • Management Guidance Teams and other organizational committees are aligned to meet specific strategic or tactical program goals or deliverables 5.5 Conduct PAT Meetings/RPIWs • Knowledge of role of the Process Action Team (PAT) and PAT team members in project execution and implementation is demonstrated • Meaningful contribution to the PAT team is demonstrated (if applicable, includes regular attendance at PAT meetings and timely completion of any assigned action items))
• Conduct RPIW and/or PAT meetings in an effective manner, insure that deliverables are met and
implementation/action plans are executed against in a timely manner
- The facilitator must have knowledge of a range of Lean/Lean tools and methods, employee
engagement methods and demonstrate the ability to determine which would work best under different situations • Resources are appropriately allocated • Barriers to implementation are removed/address in a timely manner
5.6 Address the issue of the resistance to change, sustainability and spread adoption
• Knowledge of the key factors impacting resistance to change, sustainability and spread adoption is demonstrated • Meaningful contribution to the implementation as well as the sustainability and spread adoption of the project is demonstrated (if applicable, includes regular attendance at PAT meetings and timely completion of any assigned action items))
• Prepare
action/implementation plans that will
address the need for change and the actions required to manage/resolve resistance from the internal stakeholders • Effective/Timely escalation of delays in implementation against the action plans
• Regular reporting of progress against goal
• Knowledge of the key factors impacting resistance to change, sustainability and spread adoption is demonstrated • An overview of the business plan and key outcomes, specifically the outcomes required of the current intervention is developed • Resources are appropriately allocated • Barriers to implementation are removed/address in a timely manner 6. Demonstrate the ability to effectively contribute to a facility or VISN based Lean Program 6.1 Develop Effective Program Infrastructure • Lean Board, Management Guidance Teams and other organizational committees are aligned to meet specific strategic or tactical program goals or deliverables 6.2 Develop Effective Project Selection/Prioritization Processes *Lean Project Selection is tied to facility/VISN strategic and tactical planning
Appendix III – Key Personal Attributes
♦ Ethical – fair, truthful, sincere, honest and discreet
♦ Open-minded – willing to consider alternative ideas or points of view; be inquisitive and ask a lot of questions; listens well
♦ Proactive and organized – takes the initiative with issues and is personally organized
♦ Systematic – shows a balanced affiliation for both tasks and people ♦ Logical – makes decisions based on facts and reasoned logic
♦ Decisive – reaches timely conclusions based on logical reasoning and analysis; expedites decisions methodically
♦ Diplomatic – relates to others and shows tact in appropriate situations ♦ Observant – shows the ability to identify both patterns and exceptions in complex situations; actively aware of physical surroundings and activities ♦ Perceptive – instinctively aware of and able to understand situations ♦ Flexible – shows a balanced global and detail focus
♦ Process focused- demonstrates the ability to follow a pre-determined method; sees the interconnections between core product and service processes and the host of supporting processes
♦ People sensitive – is sensitive to and can identify a person’s emotional state
♦ Versatile – adjusts readily to different situations ♦ Tenacious – persistent, focused on achieving results
♦ Self-reliant – acts and functions independently while interacting effectively with different types of people in a range of situations and copes with change ♦ Confident – demonstrates certainty and competency and reacts well to a variety of challenges demonstrating calm and poise in such challenging situations.
Bibliography
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