ASF Standards · Hospital · Standard 6
Standard 6 — Aftercare & Follow-up
Criteria in this standard
6.1 — Every Discharged Patient Gets a Real Aftercare Plan
6.2 — A Real Mechanism Checks on the Patient After They Leave
6.3 — Patients Can Complain After Leaving, and Complaints Are Actually Read
6.2 — A Real Mechanism Checks on the Patient After They Leave
6.3 — Patients Can Complain After Leaving, and Complaints Are Actually Read
6.1
Every Discharged Patient Gets a Real Aftercare Plan
Non-Negotiable
Every discharged patient receives a documented aftercare plan they can explain back in their own words — not a printed sheet handed over on the way out the door.
In plain terms: Every patient leaving hospital gets a written aftercare plan and can tell you, in their own words, what to do and when to worry.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Discharge is where hospitals lose patients. The handover from ward to home is the least controlled transition in healthcare: the patient is tired, the family is anxious, the nurse is busy, and a sheet of paper is handed over on the way out. Readmission within 30 days is often a discharge failure: a medication misunderstood, a warning sign not recognised, a follow-up not attended. A real aftercare plan is explained, not just given — the patient repeats back what they will do, when to take what, and what symptoms mean 'come back now.' Teach-back at discharge cuts readmissions.
What good looks like
- Every patient receives a documented, patient-specific aftercare plan.
- Patients contacted after discharge can accurately describe their own plan.
- Plans consistently cover medication, warning signs, and who to contact for concerns.
Common failure modes
- Discharge information is a generic printed sheet, identical regardless of the patient's actual situation.
- Patients contacted after discharge cannot describe what they were told.
- Plans are missing key elements like warning signs or contact information for concerns.
Worked example
In practice
A 160-bed hospital with a 30-day readmission rate of 14%.
BeforeDischarge was a printed summary handed over by the ward clerk. The Coordinator phoned 15 recently discharged patients: 6 did not know when their follow-up was; 5 were unsure about medications; 4 could not name a symptom that should prompt return. Three had been readmitted, two for issues the summary had mentioned but the patient had not understood.
ActionA structured discharge conversation was introduced, done by the nurse with the patient and a family member: medications (what, when, why), follow-up (when, where, who), warning signs (three specific symptoms), who to call. A one-page plain-language sheet was completed together. Teach-back: 'Tell me the three things you'll watch for.' Time allocated: 15 minutes per discharge.
AfterThe Monitor phoned ten recent discharges: all could state follow-up date, medications, and at least two warning signs. Readmission rate at six months: 9%. Verified.
If you are starting from zero — do this first
- Phone five patients discharged this week: do they know their follow-up date and warning signs?
- Watch a discharge — is it a conversation or a handover of paper?
- Build a one-page plan: medicines, follow-up, three warning signs, who to call.
- Require teach-back and 15 minutes per discharge.
The most common mistake: Measuring whether the discharge summary was given rather than whether the patient understood it.
Self-assessment questions
1. Does every discharged patient receive a documented aftercare plan specific to their situation? — Not a generic discharge sheet — content specific to this patient's condition and treatment.
Evidence: Discharge plan sample
Evidence: Discharge plan sample
2. Can a recently discharged patient explain their own aftercare plan in their own words? — Tests whether the plan was actually understood, not just handed over.
Evidence: N/A — tested directly, e.g. follow-up call
Evidence: N/A — tested directly, e.g. follow-up call
3. Does the plan cover medication, warning signs, and who to contact if something goes wrong? — A plan missing any of these three leaves a genuine gap in what the patient needs to manage safely at home.
Evidence: Plan content checklist
Evidence: Plan content checklist
Common reasons for a PARTIAL answer
- 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.
- 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.
- Plans are given to the patient but not to an accompanying family member or caregiver, when relevant.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Discharge plan content review | Reviews a sample of discharge plans for patient-specific content covering medication, warning signs, and contact information. |
| ASK | Patient understanding check | Contacts or interviews a recently discharged patient to check whether they can describe their own aftercare plan accurately. |
| OBSERVE | Discharge process observation | Observes how discharge instructions are actually delivered — rushed handover versus a genuine explanation. |
Supervisor tips
- 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.
Evidence base
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.
Train your team: H-06 · Aftercare & Follow-up on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.
6.2
A Real Mechanism Checks on the Patient After They Leave
Non-Negotiable
A genuine, defined mechanism exists to check on the patient after discharge — a scheduled call, a follow-up appointment, or an equivalent real contact — not merely "available on request" if the patient happens to reach back out.
In plain terms: Someone checks on every discharged patient — a phone call, an appointment, a visit — as a routine, not just if the patient calls with a problem.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
The patient who deteriorates at home does not always call. They may not recognise the symptom, may not want to be a bother, may not have the number. A scheduled contact — a nurse's phone call 48 hours after discharge, a follow-up appointment booked before leaving — catches the problem early. It is also the hospital's only source of truth about whether discharge actually worked: the medications were collected, the wound is healing, the patient understood. 'The patient can call us' is not a mechanism; it is an invitation most will not take up.
What good looks like
- A defined, proactive follow-up mechanism is applied consistently to every discharge.
- Follow-up completion is tracked and verifiable, not dependent on individual memory.
- A clear escalation path exists and is used when follow-up reveals a concern.
Common failure modes
- Follow-up happens only if the patient calls back with a problem.
- No tracking exists to confirm follow-up actually happened for a given patient.
- Staff are uncertain what to do if a follow-up call reveals a concerning symptom.
Worked example
In practice
A 130-bed hospital that told patients to 'contact us with any concerns.'
BeforeNo follow-up was arranged unless the doctor requested it. The Coordinator found that 40% of discharged patients had no scheduled contact. Of those who had a follow-up appointment, 25% did not attend and nobody followed up on the non-attendance. A patient with a post-operative wound infection was readmitted 9 days after discharge; she had noticed redness on day 3 but 'didn't want to fuss.'
ActionA discharge nurse was assigned to phone every patient 48–72 hours after discharge using a five-question script: medications collected? Taking them? Any new symptoms? Wound/condition as expected? Follow-up date known? Calls were logged; concerns were escalated the same day. Non-attendance at follow-up triggered a call.
AfterThe Monitor reviewed the call log: 240 calls in one month, 22 concerns escalated, 4 early readmissions prevented per nurse notes. Verified.
If you are starting from zero — do this first
- Count what proportion of discharges have any scheduled follow-up contact.
- Assign one person to phone every discharge at 48 hours with five questions.
- Log every call and every concern.
- Follow up any missed appointment with a call.
The most common mistake: Relying on the patient to call — the ones who need it most are the ones who won't.
Self-assessment questions
1. Is there a defined mechanism to actively check on patients after discharge, not just availability on request? — The facility initiating contact, not merely being reachable if the patient calls first.
Evidence: Follow-up protocol document
Evidence: Follow-up protocol document
2. Does the mechanism apply consistently, not only for cases staff happen to remember? — A follow-up system that depends on individual staff memory is not a reliable system.
Evidence: Follow-up completion log
Evidence: Follow-up completion log
3. Is there a defined escalation if a follow-up contact reveals a concerning symptom or complication? — Detecting a problem during follow-up is only useful if something happens as a result.
Evidence: Escalation protocol
Evidence: Escalation protocol
Common reasons for a PARTIAL answer
- 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.
- 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.
- Follow-up is attempted but not completed if the patient doesn't answer the first call.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Follow-up protocol and log review | Reviews the defined follow-up mechanism and checks completion records against actual recent discharges. |
| OBSERVE | Follow-up contact sample check | Checks whether a sample of recently discharged patients actually received the defined follow-up contact. |
| ASK | Escalation protocol interview | Asks staff what happens if a follow-up contact reveals a concerning symptom. |
Supervisor tips
- 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.
Evidence base
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.
Train your team: H-06 · Aftercare & Follow-up on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.
6.3
Patients Can Complain After Leaving, and Complaints Are Actually Read
Non-Negotiable
A complaint or feedback channel exists that a patient can use after they've left the facility, with evidence that complaints are genuinely read and acted on, not merely collected.
In plain terms: Patients can complain after they have gone home, the complaints are read by someone who can act, and there is evidence that complaints have changed something.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Complaints are free quality data. A patient who complains is telling you where the system failed — and the ones who complain after leaving are the ones with the most perspective. A complaint form in the waiting room is useless to someone at home. There needs to be a phone number, an email, a web form, or a postal address that works from outside — and someone who reads it, responds, and connects it to improvement. The standard's test is evidence: not that complaints are received, but that at least one thing has changed because of one.
What good looks like
- A clear, accessible complaint channel exists for patients after they've left.
- Sampled complaints show genuine responses, not just acknowledgment of receipt.
- At least one documented instance exists of a complaint leading to a real practice change.
Common failure modes
- No channel exists beyond an in-person suggestion box, unusable after discharge.
- Complaints are collected but show no evidence of response.
- Nobody can recall a complaint ever leading to any change in practice.
Worked example
In practice
A 140-bed hospital with a complaints box in the lobby.
BeforeThe only way to complain was the lobby box, emptied monthly. Nothing existed for post-discharge complaints. The box had received 8 complaints in a year; none had a recorded response; none had led to any change. Discharged patients who phoned the switchboard were told to 'write a letter.'
ActionA complaints email and a direct phone line were created and printed on every discharge sheet. A named complaints officer logged each complaint, acknowledged within 5 working days, investigated, and responded within 30. Complaints were reviewed monthly for patterns; each pattern got an action. A 'You said, we did' board was put in the lobby.
AfterThe Monitor reviewed the log: 34 complaints in six months, all acknowledged and responded to; 5 changes made and posted publicly. Interviewed a patient whose complaint about discharge timing had led to a change. Verified.
If you are starting from zero — do this first
- Try to complain about your own hospital from outside — by phone, email, web. How hard is it?
- Put a complaints email and phone number on every discharge sheet.
- Name one person who logs, acknowledges, and responds to every complaint.
- Find one complaint from the last year that could have led to a change — and make it.
The most common mistake: Collecting complaints without responding to them or connecting them to improvement — a complaints box that changes nothing is a decoy.
Self-assessment questions
1. Can a patient submit a complaint or feedback after leaving the facility, not only while present? — A suggestion box in the waiting room alone doesn't meet this — there needs to be a way to reach the facility afterward too.
Evidence: Complaint channel description, e.g. phone/email/form
Evidence: Complaint channel description, e.g. phone/email/form
2. Is there evidence complaints are actually read and result in a response, not just filed? — A collected complaint with no follow-through provides no real value to the patient or the facility.
Evidence: Complaint response record sample
Evidence: Complaint response record sample
3. Have any complaints led to a documented change in practice? — A complaint system that has never once led to a change is worth questioning, not just checking for the existence of a form.
Common reasons for a PARTIAL answer
- 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.
- 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.
- Serious complaints are reviewed and acted on; minor ones accumulate without individual response.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| OBSERVE | Post-discharge channel accessibility check | Verifies a real, accessible way exists for a discharged patient to submit a complaint or feedback. |
| DOCUMENT | Response record review | Reviews a sample of submitted complaints for evidence of an actual response, not just receipt. |
| DOCUMENT | Practice-change history check | Checks for any documented instance where a complaint led to a specific change in facility practice. |
Supervisor tips
- 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.
Evidence base
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.
Train your team: H-06 · Aftercare & Follow-up on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.