Critical Access Hospital Quality Improvement Program (CAH-QI)

 More

Critical Access is a hospital designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS)

Surviving health care reform is a significant challenge for the 91 Critical Access Hospitals in Texas. Several CAHs nationwide have had to close their doors in recent years due to the changing health care environment, and the survival of these facilities will depend highly on their ability to improve quality outcomes. The Texas Hospital Association Foundation’s CAHQI initiative works in partnership with the Texas A&M Health Science Center Rural and Community Health Institute and is funded by the Texas Department of Agriculture’s State Office of Rural Health.

Current Learning Opportunities:
2024 CNO Nurse Leader Bootcamp

August 1-2, 2024 in Austin, Texas at the THA conference room.

12 nursing CNEs will be offered.

See more

Understanding Changes to MBQIP – Meeting Series

Series of online meetings beginning June 18, 2024 to discuss all upcoming changes for 2025 MBQIP reporting.

See more

MBQIP Flex Frontline First – Webinar Series

Weekly webinar beginning July 24, 2024.

1 nursing CNE per webinar with max total of 5.

See more


Additional CAHQI Resources:

BOOTCAMP Resources: Check out the presentations from our 2024 Bootcamp as well previous years: 2022 and 2023.

FRONTLINE FIRST 2022:  Education series designed to meet the educational needs of frontline staff in critical access hospitals across Texas. Brought to you by THAF and AXIS Medical Education


Understanding Changes to MBQIP – Meeting Series

Series of meetings to discuss all upcoming changes for 2025 MBQIP reporting

Meetings begin on June 18, 2024 12:00PM – 1:00PM; recurring meeting held every two weeks; last meeting to be held on August 27, 2024

June 18, 2024 Recording: HERE Presentation: HERE

July 2, 2024 Recording: HERE Presentation: HERE

July 16, 2024 Recording: HERE Presentation: HERE


Frontline First Webinar Series

This series of 5 webinars will take place each Wednesday beginning July 24, 2024. Webinars will be at 12 noon E.S.T. providing a great opportunity to grab some lunch and join us for a quick learning opportunity. The topics of each webinar with a brief description are listed below. 1 nursing CNE for each webinar with 5 Max for entire series in partnership with AXIS Medical Education.

Target Audience: This activity has been designed to meet the educational needs of frontline staff in critical access hospitals across Texas. The information is appropriate for all hospital staff to include nurses, nurse aids/PCTs, radiology technicians, pharmacy technicians, laboratory staff, housekeeping, or any other staff member who is involved in the patient care process or environment.

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 series of five 1 hour virtual learning sessions will provide frontline staff with education and training on social determinants of health, health literacy, quality improvement basics, impact of healthcare mistakes on patients and staff, trauma informed care, and workplace violence. THAF is committed to providing education and resources to assist hospitals to meet the needs of employees to provide quality, patient-centered care.

July 24th – Social Determinants of Health / Health Literacy – Let’s talk about social determinants of health common to the rural community, how you can identify them, and how we can make a difference!

  • Describe social determinates of health
  • Define health literacy
  • Identify social determinates of health in the community
  • List three ways frontline staff can improve health literacy
  • Identify available community resources

July 31st – Quality Improvement (It Takes a Village) – Quality improvement is EVERYONE’s job! Here we will cover the basics of quality improvement, the vital role that frontline staff play in the success of quality improvement activities, and how you can make a difference in your own organization.

  • Describe basic concepts of quality improvement
  • Describe use of data for quality improvement activities
  • Describe role of frontline staff in quality improvement processes

Aug 7th – Healthcare Mistakes and Their Impact – It is important in healthcare to recognize issues before mistakes happen. But what about when they do? We will discuss the impact of healthcare mistakes on your organization and your community and things you can do to help reduce the risk of patient harm events in your organization.

  • Describe how a medical error can impact a healthcare facility
  • Describe how a medical error can impact individual employees
  • Identify ways to assess for system issues that increase risk of error
  • Describe measures facilities can take to reduce risk of error

August 14th – Trauma Informed Care – It’s about taking care of the whole patient! We will provide information on what trauma informed care is and how it can impact not only patient outcomes but staff as well.

  • Define trauma informed care
  • Identify factors that impact psychological safety in the workplace
  • Describe strategies for providing trauma informed care
  • Describe strategies to develop workplace culture of providing trauma informed care

August 21st – Workplace Violence – With new legislation taking effect September 1, 2024 it is important that staff understand their role in reducing violence in the workplace.

  • Define workplace violence
  • Identify various types of workplace violence
  • Describe impact of workplace violence on staff resilience
  • Describe new state legislation requirements related to workplace violence

Speakers/Contributors:

Sheila Dolbow, MSN, RN, CFN, CPHQ, Clinical Projects Manager, Quality and Patient Safety, Texas Hospital Association Foundation

Prior to joining THA, Sheila served as a Health Science educator with the Liberty Hill School District.  She also has extensive experience with forensic nursing and as a Trauma Coordinator.  In her Clinical Initiatives role, Sheila leads the Critical Access Hospital Quality Improvement (CAHQI) project in collaboration with the State Office of Rural Health. In this role she provides education and technical assistance to critical access hospitals across the state. Sheila has also taken on the management of the external peer review portion of the THA Peer Review Network, making assignments for peer review to help hospitals maintain compliance and improve the quality of care provided.

Nina Costilla, MSN, RN, CPHQ, NEA-BC, RN-BC, Clinical Projects 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.

Karen Kendrick, MSN, RN, CPHQ, VP Quality and Patient Safety, Texas Hospital Association Foundation

A Registered Nurse since 1989, Karen began her healthcare career as a bedside medical/surgical nurse, advancing to a management role within three years. After leading clinical care departments for 16 years, she transitioned to Quality and Patient Safety leadership. Prior to joining THA Karen served in both permanent and transitional/interim leadership roles in hospitals of varying types/sizes in six different states. Karen joined THA as the Director of Clinical Initiatives with primary responsibility for the recruitment, launching, and implementation of the HIIN program. Over the next three years she also led three cohorts for the ICU Safety project and the STRIVE program. In 2018 Karen assumed leadership of the PSO and supported the department during the leadership transition period, assuming the role of VP for the department in 2019.

ACCREDITED CONTINUING EDUCATION

Accreditation Statement

Image Not Found

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association Foundation. 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 a maximum of 5.0 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].

Disclosure of Relevant Financial Relationships

AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, peer reviewers, and other individuals who are in a position to control the content of this activity to disclose all personal financial relationships they may have in the past 24 months with ineligible companies. An ineligible entity is any organization whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant financial relationships are identified and mitigated prior to initiation of the planning phase for an activity. 

AXIS has mitigated and disclosed to learners all relevant financial relationships disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty, Sheila Dolbow, MSN, RN, Karen Kendrick, MSN, RN, and Nina Costilla, MSN, RN reported no relevant financial relationships or relationships they have with ineligible companies of any amount during the past 24 months.

The following directors, planners, managers, reviewers, and relevant staff reported no financial relationships they have with any ineligible company of any amount during the past 24 months:

Name of Director, Planner, Manager, Reviewer, Staff
Karen Kendrick, MSN, RN
Nina Costilla, MSN, RN, CPHQ, NEA-BC, RN-BC
Sheila Dolbow, BSN, RN, CFN, CPHQ
Holly M.Hampe, DSc., RN, MHA, MRM, CPHQ
Dee Morgillo, MEd., MT(ASCP), CHCP

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:  

  • Attend/participate in the educational activity and review all course materials. 
  • The Attestation/Evaluation/Certificate portal will activate on 8/21/24 at 1:00 pm CT.  Complete the CE Attestation/Evaluation/Certificate portal online by 11:59 pm ET on 9/21/24. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CE credit for this event.
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.

2024 CNO Nurse Leader Bootcamp

Target Audience: This activity has been designed to meet the educational and training needs of nurses who have transitioned into executive and senior leadership roles in critical access and rural hospital settings.

Nurse leaders in the rural sector can face unique challenges. Many times they find themselves in the executive role without having a lot of nursing experience. They often do not have access to other nurse executives to mentor them and help them fully develop in these leadership roles. As part of the Flex program administered through the State Office of Rural Health, Texas Hospital Association is pleased to welcome back our guest speaker Dr. Joyce Batcheller for our 2nd CNO Nurse Leader Workshop! Over the course of two days, nurse leaders will gain valuable insight from Dr. Batcheller on topics such as:

  • How to have a successful transition
  • Building a high performing team
  • Work force issues
  • Managing resources
  • What THA has to offer
  • Clifton StrengthsFinder
  • Civility Reframing to Address Bullying and Violence
  • Workforce Planning
  • Speed Consulting
  • Action Plan Development

Participants will receive a copy of Strengths Finder 2.0 with access to complete the Clifton Strengths assessment to identify their top five leadership strengths. This education opportunity is appropriate for those who have taken on the role of Nurse Executive in the critical access or rural hospital setting and is intended to provide information and strategies to support the smooth transition into this role from that of department manager or staff nurse. This year the workshop will take place on August 1-2, 2024 in Austin, Texas at the THA conference room. A light breakfast and lunch will be provided each day thanks to our sponsor Qualivis and 12 nursing CNEs will be offered in partnership with AXIS Medical Education.

Presenter Bio:

Joyce Batcheller, DNP, RN, NEA-BC, FAONL, FAAN – Dr. Joyce Batcheller is President, The Nurses Legacy Institute and founder of the Chief Nursing Officer (CNO) Institute which was developed for new and aspiring to be CNOs and The Chief Nursing Officer Executive Retreat which has been developed for experienced CNOs. Dr. Batcheller holds the position of adjunct professor for Texas Tech University Health Sciences Center School of Nursing in Lubbock, Texas and currently is serving as the President, Texas Nurses Association.

Dr. Batcheller has served as the Vice President and chair of the International Association of Leadership Science in Nursing (ALSN) and host of a radio show “All about Nursing”. Dr. Batcheller is an innovative healthcare leader known for her ability to transform nursing and improve patient outcomes. She inspires nurses and other healthcare professionals to reach their full potential. One of Dr. Batcheller’s unique talents is her ability to create a compelling vision to engage, empower, and stimulate innovation among her peers. Dr. Batcheller has also specialized in on-boarding and enculturation of new CNOs.

Having served for 19 years as chief nursing officer of Central Texas’ largest healthcare system, overseeing more than 3,700 nurses and 90 clinical locations including 11 hospitals, four of which became Magnet-designated and five Pathway to Excellence-designated during her tenure.

She was a member of the 2013 class of Leadership America, selected as a Robert Wood Johnson Foundation Executive Nurse Fellow in 2005 and has held various leadership roles at the national and state level. She is a Fellow of the American Academy of Nursing and the American Organization of Nursing leadership (AONL).  

Food and materials sponsored by:

ACCREDITED CONTINUING EDUCATION

Image Not Found

Accreditation Statement: In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association Foundation. 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 a maximum of 12 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].

Disclosure of Relevant Financial Relationships

AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, peer reviewers, and other individuals who are in a position to control the content of this activity to disclose all personal financial relationships they may have in the past 24 months with ineligible companies. An ineligible entity is any organization whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant financial relationships are identified and mitigated prior to initiation of the planning phase for an activity. 

AXIS has mitigated and disclosed to learners all relevant financial relationships disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty, Joyce Batcheller, DNP, RN, NEA-BC, FAONL, FAAN and Sheila Dolbow, MSN, RN, reported no relevant financial relationships or relationships they have with ineligible companies of any amount during the past 24 months.

The following directors, planners, managers, reviewers, and relevant staff reported no financial relationships they have with any ineligible company of any amount during the past 24 months:

Name of Director, Planner, Manager, Reviewer, Staff
Karen Kendrick, MSN, RN
Nina Costilla, MSN, RN, CPHQ, NEA-BC, RN-BC
Sheila Dolbow, BSN, RN, CFN, CPHQ
Holly M.Hampe, DSc., RN, MHA, MRM, CPHQ
Dee Morgillo, MEd., MT(ASCP), CHCP

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:  

  • Attend/participate in the educational activity and review all course materials. 
  • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on the dates listed below. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CE credit for this event.
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.
Activity DatePortal Expiration Date
August 1 and 2, 2024June 3, 2024

Further Reading:

THA’s Comments on CMS Proposed Rule on Conditions of Participation (CoP) for Rural Emergency Hospitals and Critical Access Hospital CoP Updates

Interested in other opportunities and resources from the THAF QPS Programs? Click HERE for more information.


This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H54RH26521, Medicare Rural Hospital Flexibility Grant Program, $901,523 (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.