CHPSO newsletter.

April 2014

In this issue:

Lessons Learned: Complexity of Care Post-Discharge

In the quality and patient safety world, we have a tendency to focus on the complexity of patient care within the hospital setting. However, a classic study by Forster, et al, reminds us that there are many concerns for the complexity of care post-discharge. Nearly 20 percent of patients experience adverse events within three weeks of discharge, about 75 percent of which are preventable. Adverse drug events are the most common post-discharge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity. Additional hazards arise when patients are discharged with test results pending and when the discharge plans include diagnostic workups to be completed as an outpatient, placing patients at risk unless timely and thorough follow-up is ensured. Minimizing post-discharge adverse events has become a priority, as providers try to find ways to reduce preventable hospital readmissions.

Poorly coordinated care transitions are at the root of most adverse events arising after discharge. Lack of direct communication between inpatient and outpatient providers is common, since traditional communication systems (such as the dictated discharge summary) generally fail to reach outpatient providers in a timely fashion and often lack essential information. Patients frequently receive new medications or have medications changed during hospitalizations, yet medication reconciliation at discharge is generally inadequate and not well communicated. This results in the potential for medication discrepancies and adverse drug events—particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.

Even if communication between providers is timely and accurate, and appropriate steps are taken to ensure medication safety, patients and their families still assume a large burden of care after discharge. Accurately assessing patients' abilities to care for themselves after discharge can be difficult and requires a coordinated multidisciplinary effort. Failure to enlist appropriate resources to help with the transition from hospital to home (or another health care setting) may leave patients vulnerable.

Improving transitions in care

Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge:

  • Medication reconciliation: Crosscheck the patient's medications to ensure that no chronic medications are stopped and to ensure the safety of new prescriptions. 
  • Structured discharge communication: Communicate information on medication changes, pending tests and studies, and follow-up needs accurately and promptly to outpatient physicians. 
  • Patient education: Make sure that patients (and their families) understand their diagnosis, their follow-up needs and whom to contact with questions or problems after discharge.


Forster AJ, Murff HJ, Peterson JF, The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Inter Med. 2003;138:161-167.

Kripalani S, LeFevre F, Phillips CO, Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841.

Kripalani S, Jackson AT, Schnipper JL, Dolemena EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314-323.

Medication Reconciliation. AHRQ Patient Safety Network. Located at

CMS Finalizes PSO Reporting Requirements

On March 11, 2014, the Centers for Medicare & Medicaid Services (CMS) issued the final rule implementing a number of provisions of the Affordable Care Act (ACA), including the provision that hospitals must satisfy certain patient safety and quality improvement requirements to contract with a qualified health plan (QHP) through Covered California, the state’s health insurance exchange.

The ACA requires QHPs to contract with hospitals that have more than 50 beds only if they meet certain patient safety standards, including the use of a patient safety evaluation system (PSES) and a comprehensive hospital discharge program. However, the final rule adopts the CMS proposal to phase in these changes over time. In phase one, CMS adopted its proposal to allow a QHP to contract with hospitals that have more than 50 beds only if they are either Medicare-certified (having a Medicare CCN) or are Medicaid-only and have been issued a Medicaid-only CMS certification number, even if they do not use a PSES or meet other ACA patient safety standards. Phase one would begin Jan. 1, 2015, and last two years or until CMS issues further regulation. CMS discusses in the final rule its response to input received through comments on next steps in phase two of implementation.

CHA and the California Hospital Patient Safety Organization (CHPSO) sent comments generally supporting the CMS approach but were hopeful that the agency would move more quickly to address possible alternatives for hospitals to meet the requirements and enhance the capability of PSOs to provide lessons learned to providers. As it stands now, CMS will not issue further standards until it is ready to issue revisions to Health Insurance Exchange market regulations.

More information is available at

Learning Event: PSO Deep Dive™ Part II

Laboratory Testing: Strategies for Error Prevention

CHPSO / ECRI webinar

Register for this event

In April 2013, ECRI issued a call to action to collaborate in an initiative to report laboratory testing events. The result is the third PSO Deep Dive™ analysis identifying laboratory-related events and unsafe conditions, along with risk reduction strategies.

Part II of this series will focus on risk reduction strategies for preventing laboratory testing errors in the pre-analytic phase (specimen labeling) and the post-analytic phase (test results reporting). Please join us to hear examples from:

  • Hardeep Singh, MD MPH - Chief, Health Policy, Quality and Informatics Program at the Houston VA Center for Innovations in Quality, Effectiveness and Safety, and Baylor College of Medicine will discuss strategies in test results communication.
  • Abington Health will share information about their exciting journey towards improving specimen labeling using the Kaizen methodology.

The goals of this presentation include:

  • Summarize the improvement strategies to reduce errors in the total testing process.
  • Review improvement strategies utilized in the pre-analytic and post-analytic phases of the total testing process.

This call is for members only. Registration is required and available at A CHPSO website member account is required. Registrants will receive an email April 18 with participation information. Participants registering on or after April 18 should contact CHPSO for participation information at (916) 552-2600.

CHPSO Welcomes New Team Members

There have been recent changes to the CHPSO staff. Asma Ahmad is our new Administrative Assistant. She studied general business and accounting at American River College and has experience with data management.

Claire Manneh is filling the newly created Project Manager position. She holds a Master of Public Health degree from Dartmouth Medical School and most recently returned as a Fulbright Scholar with the Department of State. She also worked as an operations consultant for IMS Health and a healthcare IT consultant for Accenture, both of Los Angeles. She will be focusing on working with our current membership to develop their PSO infrastructure, orienting new members, and assisting with the development of automated data transfer.

Colorado Hospital Association Partners with CHPSO

The Colorado Hospital Association recently entered into an agreement with the California Hospital Patient Safety Organization (CHPSO) to offer Patient Safety Organization (PSO) services to hospitals and health systems in Colorado.

Prior to selecting CHPSO, Colorado Hospital Association conducted a thorough evaluation of the leading PSOs. Colorado Hospital Association believes CHPSO will provide Colorado hospitals and health systems with unmatched access to the emerging best practices of hundreds of hospitals and in-depth patient safety resources. CHPSO has developed a regional model for PSO membership that brings together health professionals from neighboring facilities to engage in frank, open and legally protected discussions about patient safety and quality issues, based on the premise that the most powerful method for change comes through sharing experiences.

“The Colorado Hospital Association agrees, which is why we endorsed a single PSO,” said Nancy Griffith, Colorado Hospital Association director of quality improvement and patient safety. “Additionally, CHPSO and Colorado Hospital Association are entering a partnership to coordinate CHPSO and Colorado Hospital Association activities to maximize hospital benefit and minimize competing priorities.”

“We welcome Colorado Hospital Association and its member hospitals. CHPSO exists to serve its members and their patients, and welcomes this opportunity to partner with Colorado Hospital Association in this complex but vital task of eliminating preventable patient harm,” said Rory Jaffe, CHPSO executive director.

The Role of Leadership in Shaping Culture

Many American hospitals are characterized by a culture of blame: one that is antithetical to the pursuit of patient safety and high reliability via organizational learning.

Leaders are responsible for shaping organizational culture, even if their own behavior may be a product of the existing culture. In many cases, they may not have the commitment, skill or support to fulfill that responsibility. This may explain much of the variability in results when adopting practices used elsewhere with success. For example, Rotteau and colleagues recently reported dysfunctional behaviors among senior leaders participating in patient safety walk rounds at two major teaching hospitals ( ).

Such observations prove the point made by former MIT professor Edgar Schein in Organizational Culture and Leadership, that leaders do not have a choice about whether or how to communicate. All they can control is how to manage what they do communicate — both verbally and non-verbally. Schein advised that the best way to understand a system is to try to change it. From this perspective, the kind of results reported by Rotteau should not be considered failures unless the leaders fail to learn from their experience and try again.

Schein also noted that the manner in which an organization responds to a crisis, such as a serious reportable patient safety event, tends to reveal the latent and largely unconscious assumptions of the culture. At the same time, the crisis itself offers an opportunity for positive change.

In Schein’s view, a learning organization requires Theory Y management based on the belief that humans are fundamentally self-motivated and need only challenge and direction to achieve excellence, rather than Theory X, which assumes that people are intrinsically lazy and need close supervision and control to be productive. Nevertheless, Americans value individualism, a value that potentially conflicts with the assumption that the best learning organization relationships are cooperative and collaborative. This means that group work for quality is counter-cultural and that leadership will be more likely to generate quality improvement through a pragmatic appeal than through a push to convert individualistic Westerners to communal values.

This brief analysis takes us full circle. The ability to learn from mistakes is essential to progress both individually and collectively. In a learning organization, learning must occur at all levels. Thus, leaders must learn in whatever ways they can, including trial and error, how to be better leaders and foster organizational improvement. Staff must be engaged to learn how to translate their experiences into improvements in patient care. This will not happen if leaders do not consciously address the system of blame of which they are a part.

Coming Next: Requirements for High Reliability

Patient Safety First Regional Meetings in Sacramento and San Francisco

Jenna Fischer, Hospital Council Vice President of Quality Improvement and Patient Safety, invites hospitals to send a team to participate in what promises to be an inspiring day of peer-to-peer networking, knowledge exchange and sharing of experiences to further the important work of patient safety. The 2014 Patient Safety First (PSF) In-Person meetings will be held in three regions in Northern and Central California; Fresno on April 1, Sacramento on May 7 and in San Francisco on June 18.

Guest speakers include Allan Frankel, MD, presenting “Achieving Safe and Reliable Operational Excellence,” Verna Gibbs, MD, will speak on “Retained Sponges, Towels, SMIs, and UDFs: Understanding Failure Modes Generates Behavior Change” and Larry Veltmann, MD, on “Too Many Caesareans? Statistics, Safety and Strategies.” Each meeting will also include local hospital presentations.

For more information about the PSF Regional Meetings, please contact Jenna Fischer,, 925-746-5106 or visit:

Infection Viral Video Project

Rego Digital Studios is looking for a Northern California hospital that would like to participate in a viral video on infection. Filming would be the first week of May.

Given the recent news stories about hospital infections, this video could serve to address patient concerns and empower caregivers. The hospital that participates can choose whether to be named in the video or not. It will take a ½ day to film the video and some conversations beforehand to plan.

Rego Digital frequently films in hospital settings and is very sensitive to patient care and confidentiality. We are happy to film in a physician office space that looks like hospital space or film into the evening.

The video will be set and lip synched by staff to the Gloria Gaynor song “I Will Survive” but will be re-recorded with the new lyrics addressing infection control.

Hospitals interested in participating in the video should contact Karie Rego-Kozak.

Learning Event: HQI 2014 Inaugural Annual Meeting

Join the Hospital Quality Institute (HQI) November 6 & 7 in Huntington Beach, CA, as we discover, learn, engage and commit to advance and accelerate patient safety and quality improvement. National experts will join California experts to share knowledge, experience, and resources to advance transformation through Vision to Action, Evidence to Practice, Outcome to Income, and Patient to Partner.

More information is available at Registration will open later this month.

Influence what happens.

Let us know what you would like to see at the conference by completing a short survey.


The California Hospital Patient Safety Organization is one of the largest Patient Safety Organizations in the nation, serving hospitals in the Western United States. CHPSO confidentially collects and analyzes patient safety data, develops and shares best practices, and helps individual hospitals accelerate safety improvement. More than 300 institutions have joined in this quest to eliminate preventable patient harm. CHPSO collaborates with hospital associations to ensure an integrated approach. It also maintains close alliances with other statewide PSOs, quality and safety agencies, research institutes and think tanks. As a result, members gain unprecedented access to the collective intelligence of patient safety experts and innovators. For more information, visit

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