Standard 42: Aftercare, Follow-Up and Post-Discharge Safety

Why it matters. A patient who leaves hospital without a written plan may not know their medicines, their follow-up or the warning signs. A written discharge plan, passed to the next clinician, keeps care safe after the bed is empty.

Sample. Review discharge records for 20 patients discharged in the last 3 months.

1. Every discharged patient has a written discharge plan.

Method. Check each discharge record for the written plan.

Evidence to show. Discharge and aftercare planning (HOS-SOP-010, existing, reused).

Pass when. Every sampled patient has a written discharge plan.

2. The medicines list is reconciled at discharge.

Method. Check each record for the reconciliation entry against the admission list.

Evidence to show. Medicines reconciliation form (HOS-FRM-006, existing, reused).

Pass when. Every sampled discharge has a reconciled medicines list.

3. The plan is sent to the patient and the next provider.

Method. Check each record for the dates the plan was sent to each.

Evidence to show. Discharge aftercare plan (HOS-FRM-008, existing, reused).

Pass when. Every plan is sent to the patient and the next provider.

Immediate fail (any one means the criterion is not met)

• A patient discharged with no written plan and a medicines list never reconciled.

Why it matters. A follow-up visit that is not booked before the patient leaves is often forgotten. Setting the date, place and clinician before discharge makes the follow-up happen.

Sample. Review discharge records for 20 patients who needed a review after discharge.

1. The date, place and responsible clinician are set before the patient leaves.

Method. Check each record for the three elements before the discharge time.

Evidence to show. Follow-up booking before discharge (AFT-FRM-001).

Pass when. Every sampled review has the three elements set before discharge.

2. The patient is told the date, place and clinician.

Method. Check each record for the patient’s confirmation of the details.

Evidence to show. Post-discharge follow-up (HOS-SOP-011, existing, reused).

Pass when. Every sampled patient confirms the details.

3. The booked review takes place or is followed up if missed.

Method. Check the follow-up register for each booking and its outcome.

Evidence to show. Post-discharge follow-up register (HOS-REG-003, existing, reused).

Pass when. Every booking is attended or followed up.

Immediate fail (any one means the criterion is not met)

• A patient told to come back for a review with no date, place or clinician named.

Why it matters. Some patients are at high risk after discharge, such as those living alone or with many conditions. A call within a set time catches problems before they become emergencies.

Sample. Review contact records for all patients identified as high risk in the last 6 months.

1. Each high-risk patient is contacted within the defined time after discharge.

Method. Check each record for the contact date against the discharge date.

Evidence to show. High-risk patient contact after discharge (AFT-SOP-001).

Pass when. Every high-risk patient is contacted within the defined time.

2. Each contact is recorded.

Method. Check the post-discharge contact register for each contact.

Evidence to show. Post-discharge contact register (AFT-REG-001).

Pass when. Every contact is recorded.

3. Any problem found is escalated.

Method. Check each contact with a problem for the escalation record.

Evidence to show. Post-discharge follow-up register (HOS-REG-003, existing, reused).

Pass when. Every problem found is escalated.

Immediate fail (any one means the criterion is not met)

• A high-risk patient discharged, not contacted, and no one notices for weeks.

Why it matters. Patients who do not know which symptoms need urgent help may wait too long. Written warning signs, with a route to get help, let them act in time.

Sample. Review discharge leaflets and records for 20 patients discharged in the last 3 months.

1. Each patient is given written warning signs that need urgent help.

Method. Check each record for the written warning signs given.

Evidence to show. Written warning signs and urgent help route (AFT-SOP-002).

Pass when. Every sampled patient has written warning signs.

2. Each patient is given a route to get urgent help at any hour.

Method. Check each record for the out-of-hours route given.

Evidence to show. Warning signs and urgent help record (AFT-FRM-002).

Pass when. Every sampled patient has an out-of-hours route recorded.

3. The patient confirms they understand the warning signs.

Method. Check each record for the understanding check.

Evidence to show. Warning signs and urgent help record (AFT-FRM-002).

Pass when. Every sampled patient confirms understanding.

Immediate fail (any one means the criterion is not met)

• A patient discharged with no warning signs and no way to reach help at night.

Why it matters. Patients who come back soon after discharge, or who complain afterwards, show where aftercare is failing. Reviewing those cases is how the service improves.

Sample. Review the readmission register and the complaint and incident records for the last 12 months.

1. Each unplanned return within the defined period is reviewed.

Method. Check the readmission register for each return and its review.

Evidence to show. Unplanned admission review register (DAY-REG-002, existing, reused).

Pass when. Every unplanned return is reviewed.

2. Aftercare problems and incidents after discharge are reviewed.

Method. Check the problem register for each entry and its review.

Evidence to show. Readmission and aftercare problem review register (AFT-REG-002).

Pass when. Every aftercare problem is reviewed.

3. A pattern found leads to a change in practice.

Method. Check each pattern for the change made and its date.

Evidence to show. Unplanned admission review (DAY-SOP-003, existing, reused).

Pass when. Every pattern has a recorded change in practice.

Immediate fail (any one means the criterion is not met)

• Ten patients readmitted within a week of discharge, with no review.

Why it matters. A patient who leaves may still have a complaint, and may find it hard to raise it from home. A complaint route that works after discharge, and answers are given, keeps the service accountable.

Sample. Review post-discharge complaints and feedback for the last 12 months, including response times.

1. A complaint or feedback route can be used after the patient has left.

Method. Check the route for the access options available after discharge.

Evidence to show. Post-discharge complaints and feedback (AFT-POL-001).

Pass when. The route is available after discharge.

2. Each complaint is read and answered.

Method. Check each complaint for the response date.

Evidence to show. Complaints and feedback (INC-POL-002, existing, reused).

Pass when. Every complaint is answered.

3. Each complaint leads to action where needed.

Method. Check each complaint for the action recorded.

Evidence to show. Post-discharge complaint response register (AFT-REG-003).

Pass when. Every complaint that needs action has action recorded.

Immediate fail (any one means the criterion is not met)

• A complaint after discharge logged and never answered.