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Washington State Department of Health

Top Flex Activities

Program Area: Support for Quality Improvement

Support in this area includes:

  • Quality improvement (QI) leadership training and technical assistance guided by critical access hospitals (CAH)
  • QI training including basics for new directors, Medicare Beneficiary Quality Improvement Project (MBQIP) information, how to use the data being collected to identify what is important and what to do about it
  • Certified Professional in Healthcare Quality (CPHQ), Certified Diabetes Educator (CDE) and Certified Infection Control (CIC) study materials and exam fees for staff at CAHs in conjunction with QI Leadership forums put on in collaboration with Washington State Hospital Association (WSHA)
  • Supporting CAH participation in reporting MBQIP and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures to QualityNet and the Centers for Medicare & Medicaid Services (CMS) Abstraction and Reporting Tool (CART) through virtual and in-person technical assistance
  • Education and training webinars for Antibiotic Stewardship requirements through collaboration with the Healthcare Associated Infections Program at WSHA
  • Offering guidance and support for quality improvement projects performed within the CAHs
  • Funding and technical assistance for the quality health improvement program, through QHi as a subcontractor

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

In 2017, the Washington Flex Program conducted over 200 hours of technical assistance for the CAHs in regards to MBQIP reporting, quality improvement projects and interpreting submitted data for their hospitals. The Flex QI Coordinator developed a new emergency department transfer communication (EDTC) abstraction tool to assist first-time reporters in abstracting the EDTC measures for the MBQIP program.

Currently, Washington Flex is working with CAHs to identify one or a cluster of measures from the MBQIP program to conduct a small quality improvement project around. In 2018, Washington Flex plans to offer multiple two-day MBQIP workshops and distribute a QI staff resource file for new QI staff. In addition, Washington Flex will begin using the QHi portal to create data report cards encouraging CAHs to report, interpret, and use their data on a regular basis. Washington Flex is trying to encourage movement from simply reporting data to utilizing data to improve patient outcomes, hospital operations and overall success of CAH facilities.

Program Area: Support for Financial and Operational Improvement

The Washington Flex Program continues to provide support to 13 financially distressed CAHs through Chief Executive Officer (CEO) participation in the Washington Rural Health Access Preservation (WRHAP) Pilot. This workgroup is comprised of two other state agencies and the 13 CAHs. The workgroup's mission is to assist these CAHs on the brink of closure with preparing for value-based purchasing and alternative payment models. The WRHAP Pilot was created when state law ESHB 2450 was passed unanimously by the Washington State Legislature and signed into law by the Governor in April 2017. Funds were appropriated by the Washington Legislature for two fiscal years and are divided back to the 13 CAHS into two components via management assistance and Medicaid services.

Methods to implement behavioral health and care coordination services, as well as telemedicine support, are currently being developed through the ESHB 2450 funding source. 

In collaboration with WSHA, a Chief Financial Officer (CFO) Financial Summit is in development and will take place in early spring. Topics were selected for the agenda through a survey sent out to each of the CAH CFOs for their input.

The Washington Flex Program funded a year of QHi portal access for all 39 CAHs. Previously, only the CAHs associated with the two rural health hospital networks had access through their memberships, leaving out 14 hospitals who were not eligible. With this new contract, all hospitals are able to post both QI and financial measures.

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

This past year, nine CAHs successfully completed their first year of a population health project. These projects are a means for CAHs to develop skills and knowledge that build capacity for the new incentives for care and payment. The initial goal was to provide an opportunity for CAHs to assess the social determinants of health in their community based on data review, select a project that could improve population health, and strategize and collaborate with community partners to ensure the success of the project. There has been much excitement around how the projects have developed collaborative relationships with community partners to ensure their success.

Washington Flex is now funding the second year of the project. The second year goal will be to continue project engagement with community partners and track progress by developing measurable goals and targets. Some of the population health goals and topics include:

  • Improve dental health access
  • Early detection and effective treatment of depression
  • Implement collaborative integrated care to improve behavioral and mental health care
  • Provide high-quality care to rural residents by developing a Social Work Extender Program
  • Develop a housing strategy for homeless and lower income patients
  • Reduce and prevent diabetes, obesity and heart disease

Working with the state Rural Emergency Medical Services (EMS) section at the Washington State Department of Health (DOH), the Flex team identified that volunteer EMS workers were often unable to complete their testing due to the cost of the National Registry test. With Flex funds, the state was able to purchase EMS, emergency medical technician (EMT), and Advanced EMT (AEMT) vouchers that rural EMS agencies can apply for. This supports Washington Flex's goal of increasing volunteer EMS personnel in rural communities. 

Please provide information about Collaboration/Shared Services

Washington Flex is supporting the statewide development of a new Stroke Triage Tool initiated in each county through the EMS Regional Councils and local county stroke teams. This will include the development of revised county level protocols. The tool is being introduced in two launches on each side of the state and will include EMS teams as well as prevention, post-acute (home health, rehabilitation in a skilled nursing facility), primary care and other local community resources.

Washington Flex supports the annual Northwest Rural Health Conference by providing program development as well as scholarships to local teams from the state's CAHs and EMS agencies to attend. For the first time last year, the state put rural EMS in the milieu with the CAHs and facilitated discussions about the coordination between settings and established more intentional partnerships between CAHs and EMS. This approach was well-received and helped set a new record for conference attendance. The Washington Flex program is currently planning the next regional conference for March 2018 and will again offer EMS topics to the conference planning team.

Program Area: Support for Integration of Innovative Health Care Models

The Washington Flex Program continues to support the integration of innovative health care models through participation in the WRHAP group and through funding the second year of the population health projects for nine CAHs. In addition, Washington Flex is working with Washington Technology Solutions (WaTech) to develop EMS volunteer recruitment videos. 

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

Washington Flex actively participates in the Washington Rural Health Access Preservation workgroup which includes 13 CAHs, the Washington State Hospital Association, the Department of Health, the Health Care Authority and a national expert in value-based purchasing.

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

The Washington Flex Program funds state networks in developing the use of the QHi reporting portal among their CAH members. This allows both QI and financial data to be entered and extracted, stimulating conversation around improvements as they compare their performance with other CAHs in their group. Many improvement projects have been initiated by this comparison and conversation. The WSHA provides an online monthly QI Leaders forum, bringing in topics of relevance and speakers. This a well-attended forum of great value to CAH QI staff.

  • Washington Rural Health Collaborative: Twelve CAHs working on clinical quality improvement, financial improvement and accountable care organization (ACO) development. All but one CAH is on the west side of the state
  • Northwest Rural Health Network: This network includes 14 CAHs and one rural sole community hospital. The network has worked primarily on health information technology (HIT) and care coordination. The network has a CFO group that meets regularly and are looking at developing an ACO. Specifically, the goals include:
    • Improve the quality and delivery of both behavioral and primary care health services in four rural counties in eastern Washington
    • Strengthen the rural health care system by establishing local public-private partnership organizations in four rural counties in eastern Washington
    • Expand impact with shared best practices and results
  • Public Hospital Joint Operating Board: This board is comprised of 18 hospitals that have an agreement to negotiate joint contracts with health insurers. This group is working on preparing for value-based contracting

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

The Washington Flex Program is working with their Quality Innovation Network (QIN), Association for Professionals in Infection Control and Epidemiology (APIC) and the WSDH Healthcare Acquired Infection Section to develop a new Infection Preventionist (IP) training and professional development program designed specifically for CAHs.

Within the WSDH Office of Rural Health, there is collaboration among the federal Small Rural Hospital Improvement Grant Program (SHIP), State Office of Rural Health (SORH), the Stroke Program, Workforce and J1 Visa program, EMS and Trauma services.

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.

Washington Flex would be happy to share the new EDTC abstraction tool that was developed in the Washington Flex Program.

The QHi portal has also been a great value to Washington's CAHs. 

Program Statistics

Type of Organization State Government
Staffing 2.0 FTEs
Number of CAHs 39
Website URL Organization Website

Flex Program Staff

Pat Justis
State Office Director, Washington
(360) 236-2805

Specialty Areas / Background

Patient-Centered Medical Home Collaboratives both statewide and regional, expertise in quality improvement, primary care pratice transformation, patient safety, patient and employee experience.

State Office Director since August 2014

Lindy Vincent
Flex Coordinator, Washington

Flex Coordinator since March 2016

Danielle Kunkel
Flex Quality Improvement Coordinator, Washington
(360) 236-4863

Flex Quality Improvement Coordinator since August 2016

Bonnie Burlingham
State Office of Rural Health Grant Manager, Washington
(360) 236-2819

Specialty Areas / Background

  • Public and rural health
  • Rural health clinics (RHCs)
  • Strategic planning

Grant Manager since September 2013 

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.