Georgia State Flex Profile

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 program utilizes a subcontractor to implement the MBQIP program. The program additionally provides education and training to assist CAH Quality Improvement (QI) staff in their QI program development and continuous quality improvement methods and tools. Starting with the basics, this course is designed to provide a foundation for the QI leader to develop an effective improvement team within their CAH. 

The program 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. The CAHs have access to ongoing technical assistance for data collection and reporting to the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey tool is provided via web-based survey as well as additional online resources such as survey guidance, tips, and standard and customizable marketing templates. Post-survey technical assistance is provided via dashboards, graphics, prioritized questions and dimensions as well as next steps.

Please share a success story about reporting quality data or using quality data to help Critical Access Hospitals (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: 

Georgia’s CAHs are in crisis. Within the last two years, four CAHs have closed their doors. Evidence points to the risk that several more are on the brink of closure. The Georgia Flex Program utilizes a subcontractor to implement the Financial and Operational Program Area. A cohort of 14 CAHs has been identified to participate in the Flex Financial and Operational Assessment. The program includes:

  • Performing comprehensive assessments and analyses of reporting practices for Medicare reimbursement
  • Preparing hospital-specific recommendations based on evidenced-based best practices
  • Developing action plans with hospital management teams to implement best practice recommendations
  • Providing education or training and technical support for operational improvements through Lean or other process improvement activities, workshops and direct consultations to CAHs

In addition, the sub-grantee will conduct 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.

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

Population health will be a focus for Georgia Flex this grant cycle. A subcontractor will implement the project and focus initially on conducting a regional population health management needs assessment analysis for each community/county in which fourteen targeted 501c (3) CAHs provide services. Key activities will 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 readiness utilizing the Population Health Readiness Assessment tool
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 the program has introduced CAHs to CMS Star ratings, utilization of PEPPER reports and care coordination to reduced potentially preventable readmissions. 

From the last Flex Program year, please describe a best practice you would like to share with other states: 

The program 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. The CAHs have access to ongoing technical assistance for data collection and reporting to the CMS Hospital Compare website.

Program Statistics

What type of organization is your Flex office housed in?: 
State Government
What is the number of full time employees (FTE) in your Flex office?: 
2.00
How many CAHs are in your state?: 
30
Do you have any hospitals interested in converting to CAH status?: 
No

Additional Information

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
229-401-3090

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.