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Georgia State Office of Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

Medicare Beneficiary Quality Improvement Project (MBQIP) activities are focused on the four different quality domains. Building and maintaining the participation of all critical access hospitals (CAHs) in MBQIP through these sets of quality measurement and reporting activities are required.

The Georgia FlexProgram utilizes a subcontractor to implement MBQIP activities. The MBQIP subcontractor provides access to performance measurement system software that helps hospitals collect, report and analyze clinical quality data. Real-time reporting provides immediate feedback on performance for hospital quality improvement opportunities. CAHs have access to ongoing technical assistance for data collection and reporting to the Hospital Compare website. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey tool is provided via a web-based survey. Additional online resources such as survey guidance, tips, and standard and customizable marketing templates are also provided. Post-survey technical assistance includes the use of dashboards, graphics, prioritized questions and dimensions as well as next steps.

Georgia Flex utilizes the Institute for Healthcare Improvement (IHI) “Breakthrough Collaborative” model for technical support for CAH implementation of core components of the Rural Hospital Antibiotic Stewardship program. 

Please share a success story about reporting quality data or using quality data to help CAHs in your state improve patient care.

All 30 Georgia CAHs have committed to reporting the full set of MBQIP measures. 

Program Area: Support for Financial and Operational Improvement

The Georgia Flex Program utilizes a subcontractor to implement the Financial and Operational Program Area. In this third year of the Flex Program, the contractor will focus on measuring current practice and the impact of technical assistance. Activities include:

  • Financial and operational in-depth assessment(s) and action planning with CAH-based skilled nursing facilities (SNF), rural health clinics (RHC) and/or physician practices
  • Re-assessment of the financial and operational status by means of in-depth analysis, including a review of the latest filed Medicare cost report. Standardized financial and operational indicators are reported and compared to the baseline.
  • Performing comprehensive re-assessments and analyses of reporting practices for Medicare reimbursement
  • Provision of on-site leadership consultative visits to provide hospital-specific recommendations based on evidenced-based best practices
  • Providing education/training and technical support for operational improvements through Lean. Support for Lean Six Sigma Green Belt Certification will be offered to CAH improvement teams

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

A subcontractor will implement the second phase of the Population Health project and focus on conducting a regional population health management needs assessment analysis for each community/county for sixteen targeted CAHs. Key activities include:

  • Develop Community Health Profiles to report on some of the factors that influence the health of individuals and populations in the CAH service area. Each profile to include:
    • Population-level data on several variables such as income, housing, education and child development
    • Health indicators such as life expectancy, birth rates, standardized mortality ratios and on how health services are used
    • Burden of chronic disease
    • Access to care
    • Patterns of health care utilization
  • Survey each CAH’s population health readiness using the Population Health Readiness Assessment tool

CAHs which participated in the previous year’s needs assessment analysis will be recruited to engage in an in-depth strategic analysis and project implementation.

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

The Georgia Flex Program has focused efforts on improved financial management linked with clinical quality improvement. Using themes within value-based purchasing, Georgia Flex has introduced CAHs to the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System, utilization of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) and care coordination to reduced potentially preventable readmissions. 

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

Georgia Flex plans to launch an initiative to promote a Chief Executive Officer (CEO) network for operational improvement during fiscal year (FY) 2017.

Please share any resources or tools that you found useful in your state Flex Program's work this past year that you would recommend to your Flex Program colleagues.

The Population Health Readiness Assessment tool.

Program Statistics

Type of Organization State Government
Staffing 2.0 FTEs
Number of CAHs 30
Website URL None provided

Flex Program Staff

Patsy Whaley
State Office Director, Georgia
(229) 401-3081

Specialty Areas / Background

Patsy has more than 35 years of health care experience including administration of critical access hospital (CAH) and prospective payment system (PPS) hospitals, health information management and quality improvement.

State Office Director since August 2015

Lisa Carhuff
Flex Coordinator, Georgia
(229) 401-3092

Flex Coordinator since June 2015

Dawn Waldrip
Program Operations Specialist, Georgia

Program Operations Specialist since January 2016

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.