Aftercare & Follow-up

MANDATORY

3 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

Discharge communication quality is consistently identified in patient safety literature as a determinant of post-discharge complications and readmission, distinct from the clinical quality of care received during admission.

Discharge is the moment responsibility for a patient's care transfers from the hospital to the patient themselves, often at exactly the point they're most fatigued, medicated, or overwhelmed to absorb complex instructions. A plan that isn't actually understood provides none of its intended protection, however thorough it looks on paper.

1 Plans are individualised for complex cases but generic for routine discharges.

Perceived complexity often determines effort, even though routine-seeming discharges still carry real risk.

2 The plan is thorough but delivered in the last rushed minutes before the patient leaves.

Content quality doesn't matter if the delivery moment doesn't allow genuine understanding.

3 Plans are given to the patient but not to an accompanying family member or caregiver, when relevant.

A patient who is unwell or medicated may rely heavily on whoever is caring for them at home.

Week 1 Review a sample of recent discharge plans for genuine patient-specific content.

Week 2 Build discharge plan delivery into the schedule with real time allocated, not squeezed into a rushed final moment.

Week 3 Train discharging staff to check patient understanding directly before the patient leaves.

Ongoing Spot-check patient understanding through follow-up contact after discharge.

Contact a discharged patient directly if possible, rather than relying on the plan document alone.

The document proves content existed; the patient's recall proves it was actually understood.

Observe an actual discharge if the timing allows.

Rushed, last-minute delivery is a common, specific failure pattern worth seeing directly.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

Structured post-discharge follow-up contact is associated with earlier identification of complications and reduced avoidable readmission in health services literature, distinct from the quality of the discharge plan itself.

Placing the entire burden of follow-up on a patient who has just been discharged, often unwell and unfamiliar with warning signs, means the people most at risk of a missed complication are also the ones least likely to reliably initiate contact. A system that reaches out, rather than waiting to be reached, closes that gap.

1 Follow-up happens reliably for high-risk discharges but inconsistently for routine ones.

Perceived risk level often determines effort, though routine discharges still carry genuine risk of missed complications.

2 A follow-up call is made but doesn't ask specific enough questions to catch a real problem.

A generic "how are you feeling" check may miss a specific warning sign a targeted question would catch.

3 Follow-up is attempted but not completed if the patient doesn't answer the first call.

A single missed attempt without a retry protocol can leave the highest-risk, hardest-to-reach patients uncovered.

Week 1 Review recent discharges for evidence of actual follow-up contact, not just a policy that one should occur.

Week 2 Define a specific follow-up mechanism, timing, and content — what questions get asked.

Week 3 Build a simple tracking log so follow-up completion is verifiable, not assumed.

Ongoing Review the escalation protocol periodically, particularly for cases where a real concern was caught.

Ask for a completion log, not a description of the intended process.

A tracked, verifiable record is the only real evidence the mechanism functions consistently.

Ask about retry attempts for patients who don't answer the first follow-up call.

The hardest-to-reach patients are sometimes also the highest-risk ones.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

Patient complaint systems with demonstrated action on findings are identified in patient safety literature as a distinct quality signal from complaint volume alone — the presence of a channel says little without evidence it functions.

A complaint channel only available while the patient is physically present misses exactly the concerns that surface once someone has had time to reflect on their experience, or once a delayed complication reveals a problem with the care they received. And a channel that collects complaints without demonstrable follow-through teaches patients their feedback doesn't matter, discouraging exactly the reporting that helps a facility improve.

1 A channel exists but isn't clearly communicated to patients before they leave.

Availability that patients don't know about functions similarly to no availability at all.

2 Complaints receive an acknowledgment but not a substantive response addressing the actual concern.

A form-letter acknowledgment can satisfy the letter of "responding" while providing no real value.

3 Serious complaints are reviewed and acted on; minor ones accumulate without individual response.

Triage by severity is reasonable, but complaints below a certain threshold shouldn't disappear entirely.

Week 1 Review current complaint channel accessibility, particularly for discharged patients.

Week 2 Ensure the channel is clearly communicated as part of the discharge process.

Week 3 Establish a defined response process and timeframe for submitted complaints.

Ongoing Track and periodically review whether complaints are leading to real practice changes.

Ask how a discharged patient would actually find and use the complaint channel.

Theoretical availability and genuine patient-facing accessibility aren't always the same.

Ask for a specific example of a complaint that changed something.

A real example, or its honest absence, reveals more than a description of the general process.