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Hawaii Department of Health, Office of Primary Care & Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

Medicare Beneficiary Quality Improvement Project (MBQIP) Participation and Training

Hawaii brings the critical access hospitals (CAHs) together quarterly for updates on MBQIP, to provide training on quality improvement and to evaluate measures used in MBQIP. This is a full day activity and includes the CAHs that have shown improvement in their measures as trainers on what changes they have implemented. 

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Training

All of Hawaii’s CAHs participate in HCAHPS. The Hawaii Office of Primary Care and Rural Health (OPCRH) provides training to the CAHs on what HCAHPS is, what it measures and how to put processes in place to ensure that they receive high HCAHPS survey scores. Quarterly, the Hawaii Flex Program reviews the HCAHPS scores and identifies areas for improvement with each of the CAHs.

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

Because Hawaii Flex brings together other partners in our quarterly meetings, this has helped spur the Hawaii CAHs to start developing antimicrobial stewardship programs before they were required under MBQIP. The Hawaii Flex Program has also received broad participation from the CAHs in the Hospital Improvement Innovation Network (HIIN) for Hawaii, where they have improved on healthcare-associated infections (HAI).

Program Area: Support for Financial and Operational Improvement

Financial and Operational Benchmarking Collaborative

Hawaii has a quarterly meeting that is aimed at improving finances and operations in the CAHs. The CAHs are measured using 10 common metrics to gauge performance improvement, such as gross days in accounts receivable, average daily census for acute, skilled nursing facility (SNF) and observation and days in accounts payable. Training focuses on implementing strategies for improvement.

Leadership Development and Strategies for Change

Hawaii is in the process of developing a network for leadership training using Studer principles. This started with a quarterly training of interested CAHs, but has evolved into a focused training with three CAHs that are to serve as evidence-based learning centers and will provide additional training to the other CAHs in the state.

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

Community Health Plan

The Hawaii OPCRH devotes a part of its funding to developing collaborative initiatives in rural communities working towards an integrated system of health care. A lot of this is currently focused on getting existing providers to better collaborate to meet the spectrum of health needs of the community, but also involves working with non-traditional partners to get at the underlying determinants of health. As most of these initiatives involve trying to get improved community health outcomes, public health data for the community are used as one of the measures, though these tend to change more slowly over time. In the interim, the OPCRH uses process measures as a means of measuring the overall advancement of moving towards healthier communities. Currently, the OPCRH will be receiving training in the Tool for Health and Resilience In Vulnerable Environments (THRIVE) and providing training to communities in the tool. The OPCRH also is working closely with rural Blue Zone communities.

Community Health Needs Assessments 

The Hawaii OPCRH has staff trained in performing community health needs assessments (CHNAs) and help CAHs and rural communities to conduct needs assessments and follow-up meetings. The OPCRH also works with communities to help develop plans and processes to meet identified needs. The community and facilities come up with the areas they wish to improve and work with the OPCRH to develop measures for success when requested.

Community Paramedicine Pilot

The Hawaii OPCRH is working with the Hawaii Emergency Medical Services (EMS) Branch to develop a community paramedicine pilot for implementation in rural areas. It is currently at the development stage and determining the needs to be addressed in the pilot communities and how they will be measured.

Hawaii Trauma Network

All of the CAHs are part of the Hawaii Trauma Network as support facilities. The OPCRH sits on the Hawaii Trauma Network Advisory Committee to provide perspective on small rural hospitals and to ensure that CAHs are fully engaged with the Trauma Network. CAHs' participation in their regional trauma councils is monitored as it is a requirement for CAHs to receive support funds from the trauma system. All CAHs have gone through the Rural Trauma Team Development Course (RTTDC), though several would like to go through it again due to staff turnover since the last time they participated. The CAHs have also provided information concerning the emergency department transfer communications tool to the Hawaii Trauma Network as it was developing a checklist for trauma transfers.

Please provide information about Collaboration/Shared Services

The community paramedicine project is in collaboration with the state EMS branch in order to better provide services to rural communities and to better utilize those with training in paramedicine. The THRIVE initiative has really taken off due to collaboration with the Hawaii Public Health Institute, which has been able to expand the number of communities reached using the THRIVE methodology.

Program Area: Support for Integration of Innovative Health Care Models

Hawaii is supporting a Project ECHO with clinics around endocrinology, geriatrics, behavioral health, Alzheimer's and dementia. The ORHPC is developing and will release a clinic on incorporating behavioral health in the primary care setting. The Hawaii Flex Program uses part of its funds to help develop such clinics, which are taught to the rural areas via video-telecommunications software. Hawaii is in its early stages of doing Project ECHO and has had a good turnout from the Project ECHO clinics it offers, and those clinics have scored very well on participant feedback.

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

The Hawaii Flex Program continues to work closely with the state quality improvement organization (QIO) and hospital association to provide education and support to better measure and move towards a value-based method of care. All CAHs are a part of the latest HIIN effort and several CAHs have revisited their strategic plans with an eye towards developing in an environment of value-based care. OPCRH has also been providing information concerning participation in accountable care organizations (ACOs) to the CAHs and is looking to develop a workgroup towards developing/joining an ACO.

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

Hawaii has a quality improvement network and a financial network that meets quarterly to evaluate measures, opportunities for improvement and participate in training for improvement. These meetings also allow the hospitals to ask questions and share areas of difficulty. Hawaii also has a leadership network that provides training to three hospitals on Studer principles and seeks to develop the participating hospitals into Centers of Excellence that can provide training to other facilities that currently are not participating in the network.

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

The biggest enhancement has been an increased understanding of the Centers for Medicare & Medicaid Services (CMS) Abstraction and Reporting Tool (CART) by the Flex staff. This has been an important development in understanding the issues that CAHs encounter in reporting their data and knowing how to better help them and provide better referrals when issues arise. The OPCRH has also been developing a resource repository to better develop consistent community reports.

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.

Toby Freier, from New Ulm Medical Center in New Ulm, Minnesota, is a fantastic speaker on population health from a CAH perspective. His presentations moved the needle on the ACO discussion by the CAHs in our state that we have had difficulty in getting the CAHs to engage in previously.

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


Program Statistics

Type of Organization State Government
Staffing 1.3 FTEs
Number of CAHs 9
Website URL Organization Website

Flex Program Staff

R. Scott Daniels
Flex Coordinator, Hawaii
(808) 961-9460

Specialty Areas / Background

  • Health information technology
  • Public policy
  • Performance measurement

Flex Coordinator since September 2005 

Gregg Kishaba
Rural Health Coordinator, Hawaii
(808) 586-5446
Allison Mikuni
Primary Care Office Manager, Hawaii
(808) 733-8364

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.