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University of Nevada, Reno School of Medicine

Top Flex Activities

CAH Quality Improvement

The Nevada Flex Program and its principal program subcontractor, the Nevada Rural Hospital Partners (NRHP), have succeeded in engaging all Nevada critical access hospitals (CAHs) in Medicare Beneficiary Quality Improvement Project (MBQIP) participation and reporting for the Fiscal Year (FY) 2020-2021 budget period requirements.

During the current fiscal period, in addition to individual technical assistance provided to each CAH, the Nevada Flex Program supported four quarterly meetings with the Quality Improvement (QI) Network and Infection Control Work Group (ICWG). Activities undertaken by the QI Network and ICWG have been focusing on facilitating CAHs’ participation in MBQIP reporting and improvement in core measures. Data visualization charts are produced to analyze performance during QI Network and ICWG quarterly meetings. CAHs work together as a group on QI improvement by selecting individual measures and allowing for the sharing of ideas and best practices. The charts are provided for each hospital to utilize internally for their own quality improvement activities. Once a year, the ICWG meets with the Risk Manager Work Group (RMWG) and the Quality Improvement (QI) Network so the Infection Preventionists, Risk Managers, and Quality Directors can work together on common issues. Since March, due to the COVID-19 pandemic, all travel has been canceled and all meetings have been held virtually.

To improve the appropriate use of antibiotics and to extend specialty care to patients with chronic, costly, and complex medical illnesses, the Nevada Flex Program facilitates Nevada CAHs’ medical staff participation in Project ECHO (Expansion for Community Healthcare Outcomes) Nevada clinics. Project ECHO Nevada provides numerous clinics on various topics where university-based faculty specialists connect with primary care providers in rural and under-served areas of Nevada via videoconference meetings. Project ECHO Nevada has been responsive to the rural hospital needs for COVID-19 pandemic education and training. Since March 2020, Project ECHO Nevada has been providing necessary COVID-19 clinics. 

CAH Operational and Financial Improvement

The Nevada Flex Program and NRHP implemented a wide range of technical assistance to support rural hospital financial and operational performance improvement. In FY 2020-2021, the Nevada Flex Program has provided education and training opportunities for Nevada’s CAHs on the Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Funds, the Paycheck Protection Program, the Families First Coronavirus Response Act, the Coronavirus Relief Funds, Medicare Accelerated and Advanced Payments, billing and coding guidance, the COVID-19 emergency waivers and emergency declarations, and more. All thirteen CAHs in Nevada participated in training and education opportunities on financial improvement during the pandemic. In April, CAH Chief Financial Officers and other Flex Performance Improvement Network members started meeting monthly and communicate on near-daily calls.

In FY 2020-2021, the Nevada Flex Program targeted the specific needs of member hospitals during the COVID-19 pandemic. With strained supply channels, the demand for personal protective equipment (PPE) outpaced the available supply, as did that of ventilators, respirators, and cleaning and disinfectant products. The Nevada Flex Program worked to vet available products and to consolidate orders between CAHs to meet manufacturer minimum order quantities. Likewise, the necessary lab equipment and related supplies needed for COVID-19 testing were in short supply and as new products became available, it was difficult for CAHs to ascertain the equipment that fit the needs of the hospitals. Accordingly, the Nevada Flex Program created a cross-departmental product review committee comprised of vested stakeholders to meet this challenge.

CAH Population Health Improvement

For the past two decades, the Nevada Flex Program has supported a variety of technical assistance to further rural population health management, including the production and dissemination of eight editions of the Nevada Rural and Frontier Health Data Book and four editions of the Health Care Careers in Nevada guide for rural middle-school and high-school students.

Nevada Office of Rural Health and Urban Health Departments facilitated four quarterly meetings with the Nevada Association of Local Health Officers. The purpose of these meeting was to work with each county to determine rural public health resources that could be used in the expansion and development of rural public health. At this time, the primarily focus has been on the COVID-19 response and expanding ability of rural counties to address public health threats.

Rural Emergency Medical Services (EMS) Improvement

Flex funding contributed to the EMS integration and development in rural communities served by Nevada CAHs. Due to the COVID-19 pandemic, the Annual Rural Nevada EMS Conference was held in September virtually. 

During FY 2019, the Nevada Flex Program conducted a statewide rural EMS needs assessment to determine the specific needs of rural EMS personnel and agency concerns in the areas of EMS education, billing/reimbursement, recruitment, and retention. The survey results were analyzed in FY 2020. The Rural EMS Personnel Survey results showed a need in support of acquiring continuing education credits locally. The Nevada EMS State Office agreed to approve continuing education credits for EMS personnel attending the Rural Trauma Team Development Course (RTTDC). The Nevada Flex Program supports RTTDC course delivery in CAHs. The course is provided in CAHs and it is free of charge to participants. It saves EMS personnel the time and expense of traveling to an urban area to receive continuing education credits. The goal of this course is to improve patient outcomes by facilitating interactive learning between rural hospital trauma teams, local EMS agencies, and local law enforcement about effective communication and appropriate patient care.

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

The Nevada Flex Program has been to supporting quarterly meetings for the state’s CAHs to develop and implement network-based strategies to facilitate the transition to value-based care and improved population health management, including:

  • The Nevada Rural Hospital Quality Improvement (QI) Network, which focuses on MBQIP measures such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), inpatient and outpatient, and Emergency Department Transfer Communication (EDTC) measures. This group also meets in conjunction with the Risk Manager Work Group, which emphasizes initiatives that improve patient safety. Once a year, Directors of Nursing are invited to this meeting to focus on important clinical.
  • The Infection Control Work Group, which facilitates the development and implementation of infection prevention and antibiotic stewardship programs and capacity in Nevada CAHs.
  • The Process Improvement (PI) Network, which focuses performance improvement assessment and interventions to any requesting Nevada CAH: Revenue Cycle Management (RCM); readiness assessments; gap analysis of current policies and procedures; assistance with the use of benchmarking core financial performance indicators; and hospital staff training on the use of RCM and other performance improvement tools.

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

The Nevada Flex Program has been collaborating with colleagues in Arizona, California, Hawaii, New Mexico, Utah, and other western states to support CAHs' chief executive officers (CEOs) and members of the PI and QI Networks participation in the annual Western Region Flex Conference. 

Please describe how your state Flex Program is reaching out to non-traditional partners to support its work.

The Nevada Flex Program is partnering on two projects with Renown Health in Reno, Nevada. The first project is to provide a Rural Trauma Team Development Course onsite at CAHs. Participants include the hospital’s medical staff, local law enforcement, and local Emergency Medical Services (EMS). The second project is on data analysis for the outmigration of rural patients for treatment.

The Nevada Flex Program supports University of Nevada, Reno School of Medicine second-year medical students in rural clinic outreach to migrant workers by coordinating work relationship between CAHs and medical students.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization University
Staffing (FTE) 2.66
Website Organization Website 
Number of CAHs 13

Flex Program Staff

Gerald Ackerman
State Office Director, Nevada
(775) 738-1525

Assistant Dean, Rural Health; Director, Office of Rural Health; Director, Nevada AHEC Program.

John Packham
Associate Dean, Office of Statewide Initiatives, Nevada
(775) 784-1235
Laima Etchegoyhen
Flex Coordinator, Nevada
(775) 682-8471

Outreach and Technical Assistance Coordinator since January 2018

Becky Bayley
Director of Strategic Initiatives, Nevada
(775) 827-4770
Mary Tabor Griswold, PhD
Director, Health Workforce Research, Nevada
(775) 682-8475

Specialty Areas / Background

  • Health services research
  • Geographic information system (GIS) research and mapping
  • Health workforce
  • Health economics
Blayne Osborn
Flex Staff, Nevada
(775) 827-4770

Research Analyst, Nevada Rural Hospital Partners

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, $1,560,000 (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.