This brief provides a detailed look at outcome measurement issues for State Flex Program (SFP) interventions conducted under Program Area 2: Financial and Operational Improvement (FOI), a mandatory area of SFP activity. It presents a set of short- and intermediate-term FOI measures for common categories of FOI interventions. Given that SFPs tend to focus primarily on output and long-term, high-level outcome measures, these short- and intermediate-term outcome measures provide a bridge between project activities and long-term outcomes within the course of the funding cycle. The brief describes a set of common FOI interventions as well as the theory of change and a set of short- and intermediate term measures for each intervention. Efforts to document the impact of SFP initiatives on Critical Access Hospital (CAH) performance would be supported by:

• Implementing collaborative learning initiatives to provide a unified, structured framework to coordinate SFP FOI activities across the Flex Program funding cycle.
• Reducing the emphasis on outputs and increasing the emphasis on short-, intermediate-, and long-term outcome measures. 
• Structuring SFP requests for proposals to request that contractors identify short-, intermediate-, and long-term outcome measures; baseline data; actionable outcome targets; and a realistic timeline to reach performance targets as part of their work products.

A companion brief provides an inventory of all SFP FOI initiatives and a more detailed analysis of the interventions undertaken by a subset of 14 SFPs.