Texas Hospital Association Foundation
Critical Access Hospital Quality Improvement Program
2025 Quality Improvement Bootcamp
April 23-25, 2025 (Kerrville, Texas)
April 30-May 2, 2025 (Abilene, Texas)
This program is funded through the Texas State Office of Rural Health
This educational activity is jointly provided by Texas Hospital Association Foundation
and AXIS Medical Education
Critical Access Hospital Quality Improvement Program landing page
Target Audience: This learning opportunity is appropriate for staff at all levels from executive leadership to department directors, mid-level managers and frontline staff who want to gain more insight and knowledge into policies and procedures.
Overview: Keeping patients and care providers safe through reduction in medical errors and patient harm events requires knowledge and action at all levels of the healthcare team. This 2.5-day in-person training aims to provide a review of current performance in Medicare Beneficiary Quality Improvement Project (MBQIP) measures for the state of Texas with identified opportunities for improvement, succession planning, discuss social determinants of health and how to address them in the community, strategic planning and how to manage cross-functional teams. Other topics include the basics aspects of quality improvement, managing and using data, and use of dashboards to engage boards in quality improvement activities. THAF is committed to providing education and resources to assist hospitals to meet the needs of employees to provide quality, patient-centered care.
Agenda and Learning Objectives
Day 1
9:00am Welcome / Introductions
9:30am Basics of Quality
- Define PDCA/PDSA
- Describe basics of quality improvement
- Demonstrate how data drives quality
10:30am Date for Improvement
- Describe the parts of data definitions
- Identify strategies to find and collect data
- Describe methods to analyze and interpret data
- Identify strategies to present meaningful data
11:30am Lunch
12:30am Overcome Resistance to Change
- Identify effective strategies for staff engagement
- Describe potential barriers to staff engagement
- Describe “budget friendly” ways to encourage staff engagement
1:30pm Facilitating Cross Functional Teams
- Define the different roles within a team
- Explain how to establish “ground rules” for optimal team performance
- Explain how varying personalities can impact team performance
- Identify measures to diffuse conflict within a team
2:30pm Break
2:45pm Next Level RCA
- Describe Root Cause Analysis process
- Identity effective communication strategies for interviewing
- Describe barriers to effective communication
- Demonstrate proper interviewing techniques
3:45pm Strategic Planning Part 1
- Define strategic planning
- Describe the importance of having a strategic planning process
4:45pm Wrap up / Questions
Day 2
9:00am Welcome / Questions
9:15am Integrating AI While Keeping Human Component
10:15am Next Level Data
- Describe how dashboards can be utilized in quality improvement and tracking performance measures
- Identify tools used to assist in the creation utilization of dashboards
- Describe reports, graphs, and charts created through dashboards to present organizational data
11:15am Break
11:30am Brainstorming Session (facilitating idea sharing)
12:00pm Lunch
12:45pm Strategic Planning Part II
- Develop mission, vision, values statements
- Identify quality improvement need for organization
- Write strategic plan for QI need as it relates to mission, vision, values
1:45pm Break
2:00pm SDOH – Helping staff ask the questions
- Describe social determinates of health
- Identify possible social determinates of health in the community
- Identify available community resources
3:00pm State of Texas/CAHQI New Measure
- Describe current performance around MBQIP measures in Texas
- Identify new MBQIP measures
- Discuss opportunities for improvement in Critical Access Hospitals
- Outline Quality Improvement priorities for Texas (2024 – 2025)
4:15pm Wrap up / Questions
Day 3
9:00am Welcome / Questions
9:15am Growing Leaders/Succession Plans
- Define succession planning
- Identify ways to pinpoint appropriate candidates
- List ways to implement succession planning
10:30am Break
10:45am Developing a Patient Resource List for SDOH
- Describe social determinates of health
- Identify possible social determinates of health in the community
- Identify available community resources
11:30am Quality Survivor
- Describe challenges to frontline staff in CAHs
- Identify mal-adaptive coping measures
- Identify ways to promote wellness and resiliency among frontline staff
- Describe challenges to quality leaders in CAHs
- Identify barriers associated with quality role
- Identify ways to promote wellness and resiliency among quality leaders
12:15pm Wrap up / Adjourn – Networking Lunch
Please contact Sheila Dolbow ([email protected]) if you need more information.
Sheila Dolbow, MSN, RN, CPHQ, RN Projects Manager, Quality and Patient Safety, Texas Hospital Association Foundation
With over 30 years of nursing experience, Sheila began her career in trauma working in a very busy level I emergency department. She advanced her career from bedside care to the development and management of high-level trauma programs where she developed her expertise in quality improvement. During this time, she also practiced as a forensic nurse both in the acute hospital setting and with the local children’s advocacy center. Prior to joining THA, Sheila served as a Health Science educator with the Liberty Hill School District teaching medical courses so that students wishing to pursue healthcare careers could earn dual credit. Sheila joined THA in 2017 to help improve patient safety through the HIIN program. In her current QPS role, Sheila leads the Critical Access Hospital Quality Improvement (CAHQI) project in collaboration with the State Office of Rural Health. In this role she develops and provides education and technical assistance to critical access hospitals across the state. Sheila also manages the THA Peer Review Network, making assignments for peer review to help hospitals maintain compliance and improve the quality of care provided. She holds a Black Belt in Lean Six Sigma and maintains CPHQ certification.
Nina Costilla, MSN, RN, CPHQ, NEA-BC, RN-BC, RN Project Manager, Quality and Patient Safety, Texas Hospital Association Foundation
Nina obtained both her BSN and MSN from Texas Tech University and began her career as an RN with Texas Health in Dallas. Prior to joining THA she served as an inpatient Nurse Manager for 7 years. Upon joining THA Nina assumed primary responsibility for the HQIC contract deliverables. She also plays a key leadership role with the PSO and contributes to the CAHQI and ASPR programs. Nina’s role and her Green Belt experience allow her to effectively collaborate with quality, patient safety, and risk leaders in THA member hospitals to addresses and improve clinical processes, patient care, and quality outcomes.
ACCREDITED CONTINUING EDUCATION
Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 14.5 contact hours.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.
AXIS Contact Information
For information about the accreditation of this program please contact AXIS at [email protected].