Clinical Collaboration in Texas Hospitals

With nearly 100 years of combined experience working in and with hospitals, the Texas Hospital Association Foundation’s Clinical Initiatives team helps hospital members meet and exceed the highest standards of quality and patient safety.


In 2010, the Texas Hospital Association Foundation launched its Patient Safety Institute to advance the adoption of strategies that enhance quality and patient safety in Texas hospitals. This newly formed group came to fruition five years after the Patient Safety and Quality Improvement Act and two months after the passage of the Affordable Care Act, both of which placed a renewed emphasis on improving patient outcomes while reducing unnecessary costs.

In eleven years, the Patient Safety Institute has metamorphosed into the Clinical Initiatives team. They’re a collaborative group of registered nurses, a clinical data analyst and a program specialist who work together with THA members to implement evidence-based practices that improve patient safety.

“Our goal is to be our members’ go-to resource for anything related to quality and patient safety,” says Karen Kendrick, RN, MSN, vice president of clinical initiatives and quality. “When I was working as a nursing and quality leader in hospitals, I had no idea the Texas Hospital Association had resources to help me with my programs. We have worked hard to create resources in direct response to our members’ requests or needs.”

Clinical Collaborative Wins

The Clinical Initiatives team partners with numerous outside agencies and organizations to help implement innovative practices into health care delivery while offering a forum for hospitals and health care systems to share best practices and solutions.

Critical Access Hospital Quality Improvement Program

A Critical Access Hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services. They created the designation in the Balanced Budget Act of 1997 when rural hospital closures became more prominent. In order to keep essential services in rural communities, the CAH designation reduces the financial vulnerability of rural hospitals.

The financial viability of CAHs is also dependent on their ability to improve quality outcomes.

In 2014, the Clinical Initiatives team partnered with the Texas A&M Health Science Center Rural and Community Health Institute and the Texas Department of Agriculture’s State Office of Rural Health to form the Critical Access Hospital Quality Improvement Program (CAHQI). Through the CAHQI program, CAHs have access to assistance with various aspects of their quality improvement activities, including program planning, data submission and best practice development.

There are 88 CAHs in Texas, nearly all of which are active participants in the CAHQI program.

“The level of engagement and participation we get with our Critical Access Hospitals in the CAHQI program is extraordinary,” says Kendrick. “We’ve developed very strong relationships with these organizations and get a lot of satisfaction seeing their quality initiatives grow and flourish.”

Patient Safety Organization

The Patient Safety and Quality Improvement Act of 2005 authorized the creation of Patient Safety Organizations (PSOs) to provide a confidential environment for shared learning about actual safety events that have occurred in member facilities. Learning from each other, PSO members can proactively assess and update their own processes to help improve patient safety and health care quality.

The THA PSO is federally certified under the U.S. Department of Health and Human Services through the Agency for Healthcare Research and Quality and works with member hospitals as they work to improve quality and patient safety. The PSO provides member access to expert consultation and regulatory updates and networking with clinical peers in other health care organizations.

Currently, there are 102 health care facilities that are part of THA’s PSO, ranging in size from small CAHs to large health care systems.

“The breadth of experience and knowledge is immense when members of the PSO have the opportunity to gather and confer about various quality and patient safety issues,” says Kendrick.

Participants in the PSO can take part in quarterly safe table meetings where clinicians confidentially report on adverse events, analysis of risk and ideas for process improvement.

“Most of the times, things don’t happen at just one hospital,” says Nina Costilla, RN, MSN, clinical projects manager at THA. “Usually, many hospitals struggle with the same issues. The PSO provides these hospitals with the opportunity to share how they’re dealing with the issue or innovative ideas they might have to address the issue in a safe and secure environment.”

Peer Review Network

The latest initiative launched by the Clinical Initiatives team is its Peer Review Network (PRN), which provides timely, cost-efficient medical peer reviews for Texas hospitals.

“Our Peer Review Network came at the request of our board members who indicated that medical peer reviews were challenging, and they hoped we could find a solution, and I believe we did,” says Kendrick.

THA’s PRN utilizes a secure, cloud-based program that maintains reviewer anonymity and keeps patient data secure, unlike other peer review programs that may require participants to mail confidential patient information. Participating health care organizations also have unlimited utilization of the program for their internal review process.

“We just launched this program, but so far the feedback has been very positive,” says Kendrick. “I think everyone appreciates how simple it is and how it will allow peer reviews to be more consistent with the same platform, same format and the same scoring methodology.”

Support During the Pandemic

No one has experienced the hardship of a pandemic more fully than frontline health care workers.

As the primary contact for member hospitals’ clinical staff, the Clinical Initiatives team provided much-needed guidance and support to meet the needs of clinicians navigating the evolving pandemic and its effects on patient care.

In addition to their clinical responsibilities, which were already exacerbated by the pandemic, state and federal agencies also tasked health care workers with data collection to ensure regulatory compliance.

The Clinical Initiatives team was quick to jump in and facilitate communication between the state and federal governments and hospitals, ensuring that expectations were understood and met, particularly pertaining to data compliance. Kendrick acted as a data liaison, working with Texas DSHS and the U.S. Health Resources and Services Administration to make sure Texas hospitals understood the data reporting processes. Texas hospitals quickly achieved and maintained a 98-100% compliance on data reporting.

In April 2020, $100M was given to hospital associations for distribution as part of the Coronavirus Preparedness and Response Supplemental Appropriations Act through the Office of the Assistant Secretary for Preparedness and Response (ASPR). An additional $250M, allocated as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act was awarded in May 2020.

As a result, Texas hospitals received $11.4M in combined grant funding from the CARES Act and ASPR. The Clinical Initiatives team helped disburse the funds to hospitals and communicating the expectations, stipulation and guidance around receiving the funds.

“We were responsible for facilitating the grant funding process and helping our members receive those funds, utilize those funds and supply the documentation to ensure they are in compliance with the program,” says Kendrick.

The government allocated a small portion of the ASPR funding for educational offerings on infection prevention. The Clinical Initiatives team used that funding to produce a monthly Lunch and Learn series and to launch a free seven-part preparation course for the Certification in Infection Control exam.

“This grant has been especially helpful for our rural hospitals as they often don’t have easy access to this training, and it’s something we’ll be able to offer for at least two more years,” says Kendrick.

Beyond providing support and guidance to members, the Clinical Initiatives team regularly checks in on their colleagues on the frontlines to ensure THA remains aware of their needs.

“We try to be a sounding board for our clinical colleagues within member hospitals and check-in, see how they’re doing and find out if there’s any additional way we can help,” says Dolbow.

Future Endeavors

2020 proved to be an epoch that will forever change health care delivery. Telemedicine, health care equity and, more recently, staff retention and burnout are all top-of-mind when considering what health care must look like moving forward.

“We are always on the lookout for new programs that we can offer members,” says Kendrick. “We are particularly interested in programs that mitigate workplace violence, promote health equity, patient family engagement and social determinants of health.”

Many of the Clinical Initiative team’s current priorities are shaped by member hospitals’ priorities. The team is always receptive for new opportunities to help Texas hospitals meet and exceed the highest standards of quality and patient safety.

“If one of our members have a need or request, we are more than happy to assist them. If we don’t have the expertise in-house, we’ll connect them with someone who can help or another member who has been successful,” says Kendrick.

For now, the team is “eager to be back on the road” to meet with members again in person. They look forward to consulting on quality improvement projects and continue to provide support and guidance to a workforce that’s still strained under the pressure of a pandemic.

Leading Frontline Leaders

The Clinical Initiatives team has three registered nurses on staff. With combined expertise in nursing, quality and education, they are uniquely positioned to consult clinical colleagues in all facets of quality improvement.


Karen Kendrick, RN, MSN spent over 30 years in the nursing profession, 13 of which were spent in quality improvement at the hospital or system level. She attributes her propensity for quality improvement to her experience as an adept turnaround quality improvement professional in small hospitals and large health care systems in several states.

“Being able to relate to various health care settings is important because you appreciate the challenges and opportunities in Critical Access Hospitals and in large systems,” says Kendrick. “Going in and doing interim work really teaches you how to do a quick deep-dive into a quality program, identify opportunities for improvement and put those processes in place.”


Nina Costilla, RN, MSN has been a nurse for 13 years in progressively larger leadership roles within Med-Surg units. During that time, she was a preceptor, charge nurse, supervisor and finally a nurse manager of a 24-bed Med-Surg unit with 50 employees.

“Being a nurse manager meant I was in charge of everything from human resources to budget to quality, and I noticed that the relationship between clinical staff and quality and risk can be contentious,” says Costilla. “I think it’s important we bridge that gap.”

“Bringing the perspective of a nurse manager to the Clinical Initiatives team helps me look at our programs through the lens of a frontline leader and assess how helpful our resources are to them.”


Sheila Dolbow, RN, BSN has a background in trauma and forensic nursing. She began her nursing career 28 years ago as a bedside nurse in a level one trauma center and worked her way up to developing and managing high-level trauma programs. She credits her attention to detail and ability to break down complex ideas to educate others to her background in forensic nursing and teaching.

“When you work in a trauma care setting, you realize the delivery of trauma care is scrutinized more than any other service in a hospital,” says Dolbow. “You become used to having a very robust quality improvement program that’s directly associated with the trauma service line.”


Augmenting the team’s clinical expertise, Judi Trout serves as the clinical data analyst to analyze and interpret trends within patient quality and safety data and implement data standards. Judi has 21 years of experience working in and with hospitals to support clinical data acquisition and submission, while ensuring data integrity. Her ability to analyze and display data in a meaningful way is a critical component of the team’s process improvement strategies.