PSO Deep Dive™ #4
Care Coordination at Discharge

CHPSO members have the opportunity to participate in a “Deep Dive” collaborative which will help organizations learn from care coordination events and, more importantly, help prevent similar events from reaching others. Thanks to the federal Patient Safety and Quality Improvement Act (Patient Safety Act), members of PSOs may report near misses and incidents through a voluntary and confidential mechanism.

Care coordination is a shared responsibility among multiple providers. Care provided after an inpatient admission or discharge from the ED is the focus of this Deep Dive. Beyond the scope of this study is inpatient care coordination between hospital nursing units and departments. The Agency for Healthcare Research and Quality further defines Care coordination as:

“…deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient”


Patient care that is not carefully coordinated and communicated, may trigger other safety events and result in patient harm. To that end we are asking members to please submit at least ten care coordination events from June 10 to July 31, 2014.

Kick-off presentations demonstrating how to submit the events will be offered via web conference on June 10th at 10 a.m. (Pacific) and repeated again on June 17th at 8 a.m. (Pacific). Email for the kick-off presentation participation information.

Data submitted will be used to deeply analyze all care coordination events. CHPSO will provide access to reports, PowerPoint slides, tools, etc., as material is made available. Results will also be presented in a CHPSO / ECRI webinar.

For additional information, please contact Claire Manneh via email or at (916) 552-7683.