Standard 35: Aftercare, Follow-Up and Post-Discharge Safety (Version 11)

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.

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.

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.

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. 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.

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 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.