Rural Health Policy Hospital Application Form

Rural Hospital Performance Improvement (RHPI) Project
Delta Region
Application Form for Hospital Participation

Please complete this form and return to the RHPI Project to be considered for consultation services specific to small, rural hospitals in the Delta Region. For inquiries regarding the RHPI projects, please contact Bethany Adams.

Bethany Adams
Delta RHPI Program Manager
Mountain States Group
1607 W. Jefferson St
Boise, ID 83702-5111

Questions? Call Bethany at 904.553.0081
badams@mtnstatesgroup.org

To submit your application, see Alternative Ways to Submit Your Application at the bottom of this web page.

Your request for consultation will be reviewed and a follow-up telephone call will be conducted to discuss the request.

Hospital Name:
Address:
City, State ZIP:
County / Parish:
Telephone Number:
Fax Number:
Hospital Administrator / CEO:
Telephone Number:
Fax Number:
E-mail:
Board Chair / President:
Telephone Number:
Fax Number:
E-mail:
Number of Beds:
Annual Net Revenues:
Annual Expenses:

Please note the services provided at your facility by inserting summary volume levels:

	Days		Procedures		Visits
Inpatient Acute		OP Surgery		PT, OT, ST
Obstetrics		Radiology		Provider-Based Clinic
Swing Bed - SNF		CT Scan		Independent Clinic
Swing Bed - NF		Ultrasound		Home Health
Distinct Part SNF/NF		Lab (not as contract)		Other (specify)

Hospital Fiscal Year:

CAH

Year Converted to CAH:

Describe strategic challenges and how needs were identified. Include data, if available. Attach additional pages if needed.

Technical assistance can be provided to meet a wide range of needs. The following is a sampling of needs that could be met through consultation. Please review and provide further description of the needs.

	Billings and collections
	Board leadership development
	Community engagement, development and involvement
	Conflict management
	Cost reporting
	Customer service
	Data collection
	Fiscal and overhead management, business office functions, fiscal policy, operating expenses
	Fundraising
	Information systems
	Marketing
	Practice management
	Quality improvement
	Record keeping
	Scope of services assessment
	Service line development
	Staff performance evaluations
	Staff satisfaction assessments
	Staff capacity
	Strategic planning
	Please describe additional needs.

Please describe what you expect from the consultation. How do you expect the consultation to help you?

If you previously participated in the RHPI project, did you implement consultant recommendations?

Signed by (if submitting electronically, please type in name and dates)

Hospital Administrator / CEO
Date
Board of Director Chairperson / Trustee Chairperson / President*
Date

* The purpose of this is to ensure that the Chairperson / President of the hospital's board of directors or trustees are informed that the hospital is submitting this application. The hospital is encouraged to submit this application as soon as possible, so if it is not possible to obtain the signature at the time the application is complete, please submit and the project can work with you to ensure board support.

Alternative Ways to Submit Your Application

1. Email to badams@mtnstatesgroup.org

2. Fax to 208-331-0267.

3. Mail to:

Bethany Adams
Program Manager
Mountain States Group
RHPI Project
1607 West Jefferson Street
Boise, Idaho 83702-5111

Back to Application Information