Critical Access Hospital Quality Improvement Program (CAH-QI)

Policy and Procedure Virtual Learning Series

UPDATED DATES!

November 6, 2024 (12p – 1p CT)

November 13, 2024 (12p – 1p CT)

November 20, 2024 (12p – 1p CT)

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

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: Administrators, departmental leaders and mid-level managers in healthcare have a responsibility to maintain safe, consistent care through the development and use of strong, meaningful policies, procedures, and operational plans. It is also the responsibility of frontline staff to know their organizational policies and procedures and understand the importance of adhering to them. This virtual series educational offering is designed to provide in-depth education and training on the development, implementation, vetting, and adherence to best practice of these hospital policies, procedures, and operational plans, including how to locate and utilize peer reviewed sources to support the policy and procedure work.

Agenda and Learning Objectives

November 6, 2024:  Policy vs. Procedure vs. plan – Knowing the difference and understanding the compliance and legal purpose of each

• Define policy, procedure, and plan
• Identify key differences between policy, procedure, and plan
• Describe key attributes of policies and procedures that encourage compliance
• Explain the legal importance and ramifications of policy and procedure documents

November 13, 2024: Steps to Creating Policy – Planning, Analyzing, Researching, Writing

• Discuss key components of policies, procedures, and plans
• Identify qualities of effective policies, procedures, and plans
• Identify key differences between well written and poorly written policies, procedures, and plans
• Outline the steps of policy and procedure development: planning, analysis, research, writing
• Demonstrate appropriate policy and procedure writing style and skills

November 20, 2024: Process to Develop, Review, and Approve Policy – Supporting documents and vetting shared policies

• Describe the value of consistency and the importance of following standards within the organization
• Identify strategies to overcome resistance to standardization and encourage sustainable use of policies and procedures
• Define peer reviewed research
• Identify appropriate documents that support a policy or procedure
• Demonstrate proper use of citations for supporting documents

Speakers:

Sheila Dolbow, MSN, RN, CFN, 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.

Karen Kendrick, MSN, RN, VP of Quality & 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.

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 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 3.0 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, CPHQ, NEA-BC, RN-BC 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:

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:  

Upon successful completion of the online form, your statement of completion will be presented to you to print.

Attend/participate in the educational activity and review all course materials. 

Complete the CE Attestation/Evaluation form online by 11:59 pm ET on December 20,2024. 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.