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EVENT REGISTRATION FORM Please submit completed form(s) to Silviya Mihaylova at [email protected]. For a joint group invoice, please complete a registration form for each registrant and submit them together. Registrations are due Friday, November 6th.

Fields in bold are required. Prefix (Mr., Mrs., Ms.) Preferred Name (Will show on badge) Formal Name (First, Middle Initial, Last Name) Suffix (MD, PhD, RN, Sr., Jr.) Job Title Company Business Address E-mail Business Phone Mobile EVENT REGISTRATION ☐$900 Human Capital Investment Conference and Gail L. Warden Leadership Excellence Award Reception & Dinner ☐$500 Gail L. Warden Leadership Excellence Award Reception & Dinner ☐$450 Human Capital Investment Conference Special Rates: LENS and Council Members receive free admission to the Human Capital Investment Conference. A limited number of registrations for $275 per event are available for up to three team members from presenting organizations, government employees, and full-time university faculty members and $100 per event for current NCAF-member administrative fellows. These rates are available on a first-come, first-served basis.

As an individual attending the Award dinner, I prefer to be seated with: ______Please indicate if you have a dietary restriction: ☐ Vegetarian ☐Gluten Free ☐Vegan

National Center for Healthcare Leadership  1700 W. Van Buren Street, Suite 126B, Chicago, IL 60612  Phone: 312.563-6630  Fax: 312.563-6631 PAYMENT INFORMATION The Total Amount due is $ ______(Please make checks payable to NCHL or provide credit card information below) Payment method: ☐ Check (enclosed) ☐ PO #______☐Invoice Me ☐ Invoice Group contact (name & email address) ______Credit Card: ☐Visa ☐MasterCard ☐American Express ☐Discover Name on Card: ______Card #: ______Security Code:______Exp. Date:______Billing Address & Zip Code: ______

Registration Policy: There is a $150 processing fee for cancellations made prior to two weeks before the event. Registered attendees who fail to cancel prior to this period or fail to attend the event will be liable for the full fee. Registrations may be transferred to another colleague at no additional charge.

National Center for Healthcare Leadership  1700 W. Van Buren Street, Suite 126B, Chicago, IL 60612  Phone: 312.563-6630  Fax: 312.563-6631 LEADERSHIP EXCELLENCE NETWORKS (LENS) & COUNCIL MEMBERS ONLY To see a list of LENS and Council Members, please visit our website http://bitly.com/LENSCouncils. LENS WORKSHOPS - Tuesday, November 17th 8:00-10:30 AM (please select one)

☐Succession Planning: Creating Successful Transitions for Physician Leaders Doug Knutson, MD, System Vice President Talent Management, Academic Affairs, OhioHealth Judy Herendeen, System Director, Physician Leadership Development, OhioHealth

How can you foster successful selection and transition for your physician leadership roles? There has been much discussion about developing physician leaders as an important organizational priority. Hear how OhioHealth has evolved its longstanding Leadership Academy to take the first steps in creating a physician leader succession planning program. The program includes a formalized talent review, calibration session, and collaborative development planning sessions with physician leader cohorts. This interactive session will cover two iterations of their talent review, best practices for physician succession planning, and some lessons learned from their trials and tribulations creating this program.

☐What Matters in Patient Experience: A Case for a New Mindset in Healthcare Jason Wolf, PhD, President, Beryl Institute Potential LENS Participant

Where is your organization in its patient experience efforts and what can we learn from the latest data? Join The Beryl Institute to hear more about its biennial benchmarking study on the state of patient and family experience. Their white paper on the benchmarking study, including global data, is scheduled to be released in the next few months, just in time for our November Conference. In this interactive dialogue, participants will engage in a collective conversation on what matters in patient experience excellence today. The session will provide an overview of patient experience trends and findings, market trends driving healthcare today, and current global data that reinforce critical and positive trends in the new healthcare mindset.