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Arizona Center for Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

The Arizona Flex Program provides training and education to Arizona’s critical access hospitals (CAHs) on the Medicare Beneficiary Quality Improvement Project (MBQIP) by monitoring and evaluating data, creating and disseminating reports to CAH leadership and reviewing best practices so that Arizona can get to and sustain 100% MBQIP reporting. Activities include:

  • monthly webinars with the Arizona CAH Quality Network;
  • onsite technical assistance site visits to educate and assist CAHs in MBQIP;
  • monthly MBQIP reminders and tips;
  • customized reports with hospital scorecards on the MBQIP domains;
  • and a quality listserve to support CAHS and share best practices.

Program Area: Support for Financial and Operational Improvement

The Arizona Flex Program has retained a consultant to conduct financial and operational assessments at two CAHs for fiscal year (FY) 2018 based on their low to negative margins, which were determined by an in-depth review of the hospitals’ operations and finances. The consultant will submit a report based on findings and discuss results of the benchmark analyses, best practices and provide recommendations. The expected long-term result is to improve financial and operational metrics. CAH Chief Financial Officers (CFOs) will share the process, results, lessons learned, and best practices to all CAH leadership. Measurement of this activity may take up to two years to show impact. Results are being tracked using the annual Flex Monitoring Team (FMT) CAH Financial Indicator Reports (CAHFIR).

Program Area: Support for Population Health Management and Emergency Medical Services Integration

In FY 2016, the Arizona Flex Program identified an activity focused on analyzing the CAHs’ community health needs assessments (CHNAs) to identify common issues and priorities to address. Several CAHs are currently in the process of updating their 3-year plans, while other CHNAs are still current. The Arizona Flex Program will use the review to help the CAHs measure impact of their respective community-wide efforts. The Arizona Flex Program will focus on building CAH capacity in the area of CHNAs and community health-focused interventions.

Co-convened statewide Trauma Program Managers quarterly face-to-face meetings - this collaboration extends to a very active listserv to share best practices among all trauma programs in Arizona.

Please provide information about Collaboration/Shared Services

The Arizona Flex Program continues to collaborate with the Arizona Department of Health Services (ADHS) Bureau of Emergency Medical Service (EMS) and Trauma System and the 40 trauma centers (Level I, III and IV) in the state. The Arizona Trauma Managers Work Group has been meeting regularly for over seven years and continues to meet face-to-face on a quarterly basis, rotating through trauma center sites around the state. Over 100 people actively participate in a Trauma Program Manager listserv that is managed and maintained by Arizona Flex to share ideas, policies, best practices, etc.

One significant outcome of this work group has been the design and distribution of a Trauma Injury Prevention Survey, in response to the need to better understand the current status of injury prevention programs in Arizona's trauma centers. Efforts started in January 2016 with the formation of a Survey Development Committee. The survey was distributed during the summer and fall, with analysis completed by spring 2017. Based on survey results the state’s trauma centers, ADHS and other partners will determine suitable objectives and initiatives for a possible statewide injury prevention project.

Please provide information about any efforts to assist CAHs/communities and partner organizations in the transition to value-based care.

Information is shared with CAHs through webinars and the state rural health conference.

Please provide information about network activities in your state to support Flex Program activities.

The Arizona Flex Program runs a variety of networks, including a ones focused on leadership, quality, Trauma Program Managers, and a base hospital work group.

All of the above networks have proven to be extremely valuable for the CAHs to network and share information. Most of the networks meet face-to-face and/or by webinar. Some networks are set up as a listserv to communicate messages or issues in a fast productive way.

Please provide information about cross-state collaborations you may be working on related to the Flex Program.

Since 2013, the Arizona Flex Program has worked with the Bureau of EMS and Trauma System (BEMSTS) on implementing a statewide trauma performance improvement initiative focused on:

Reducing Level III/IV Emergency Department (ED) dwell times to Level I Trauma Centers

  •  Reducing transfers after admissions
  •  Reducing deaths outside of trauma centers
  •  Increasing trauma billing efficiency

Involved, too, are Arizona’s Trauma I Centers which have taken turns to host a one-day face-to-face meeting of trauma program managers around the state. These meetings address the Arizona trauma plan priorities – continuing the PI efforts, strengthening injury prevention, supporting utilization of the trauma registry and providing necessary resources on trauma billing. Forty people from around the state have participated, which demonstrates the continued importance of this statewide initiative. In February 2015, the Arizona Flex Program distributed an EMS needs assessment to better articulate EMS priority needs to BEMSTS and EMS agencies located in a CAH community. BEMSTS identified three priority areas: (1) conducting an EMS needs assessment, (2) offering EMS leadership training courses, and (3) supporting EMS financial and operational performance. Only four out of the 15 EMS agencies located in a CAH community responded to the request. Priorities identified included: need for recruitment and retention, strategic planning, and an EMS needs assessment.

Please describe how your state Flex Program has enhanced its use of data in the past year.

The Arizona Flex Program creates reports using MBQIP data and customizes reports for each CAH to use in their quality council meetings and board meetings. These reports are created using PowerPoint so the CAHs can customize them if they prefer.

The Arizona Flex Program makes sure that all CAHs have access to the Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS). In addition, the Arizona Flex Program has created a scaled-down version of the CAHFIR.

Do you have any hospitals interested in converting to CAH status?:


Program Statistics

Type of Organization University
Staffing 5.0 FTEs
Number of CAHs 15
Website URL Organization Website

Flex Program Staff

Daniel Derksen, MD
Director, Center for Rural Health, Arizona
(520) 626-3085

Specialty Areas / Background

Director of the Center for Rural Health (CRH), Walter H. Pearce Endowed Chair and Professor, Director of the Community, Environment and Policy Division at the University of Arizona’s Mel and Enid Zuckerman College of Public Health. As CRH Director, he oversees the State Office of Rural Health, the Rural Hospital Flexibility Program (Flex), and the Small Rural Hospital Improvement Program (SHIP). He chaired the American Academy of Family Physicians Commission on Governmental Advocacy in 2013-14. He served on the American Hospital Association’s Governing Council Section on Rural or Small Hospitals, and on the Arizona Hospital and Healthcare Association Small Rural Hospital Constituency Group.

State Office Director since July 2013

Jill Bullock
Flex Coordinator, Arizona
(520) 626-3722

Specialty Areas / Background

  • Network development
  • Physician outreach
  • Healthcare program navigation and Medicaid eligibility 

 Coordinator of Rural Health Services since September 2011

Joyce Hospodar
Manager, Health Systems Development, Arizona
(520) 626-2432

Specialty Areas / Background

  • Health services research including quality improvement and health systems development
  • Health planning
  • Network development

Health Systems Development Manager since 2001

Bryna Koch
Special Projects Coordinator/Internal Evaluation, Arizona
(520) 626-6253

Specialty Areas / Background

  • Evaluation
  • Evaluation capacity building at the local, state and national levels

Special Projects Coordinator/Internal Evaluation since August 2016

Melissa Quezada
Program Coordinator, Arizona

Flex Support Staff since October 2017

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.