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

Every patient leaves with a written discharge plan. The plan includes a reconciled medicines list and is sent to the patient and to the next provider.

Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

A patient who leaves without a written plan may not know their medicines, their follow-up or the warning signs. The plan is written before the patient leaves, and the medicines list is reconciled against what the patient was taking on arrival.

The plan is sent to the patient and to the next provider, whether that is a family physician, a community nurse or another hospital. A plan that stays in the file does not protect the patient after the bed is empty.

What good looks like

• A written discharge plan (AFT-PLN-001) for every patient.
• A reconciled medicines list in every plan.
• Confirmation that the plan was sent to the patient and to the next provider.
• Plans checked for completeness before the patient leaves.

Common mistakes

• A discharge plan written after the patient has gone.
• A medicines list copied from admission without reconciliation.
• A plan kept in the file and not sent to the next clinician.
• A plan given only in a language the patient does not read.

How the surveyor verifies this criterion

References

1. WHO (2020). Medication safety in transitions of care. https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
2. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Where a review is needed, the date, place and responsible clinician are set before the patient leaves, and the patient knows them.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

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.

The patient is given the booking details in writing and is told who to contact if the date does not work for them.

What good looks like

• A follow-up booking form (AFT-FRM-001) completed before discharge.
• Date, place and responsible clinician recorded for every review.
• Booking details given to the patient in writing.
• A contact route for changing the appointment.

Common mistakes

• A patient told to "come back in a few weeks" with no date.
• A review booked with no clinician named.
• Booking details given verbally and not recorded.

Questions the surveyor asks

• The date, place and responsible clinician are set before the patient leaves. The surveyor checks each record for the three elements before the discharge time.

How the surveyor verifies this criterion

References

1. WHO (2023). Primary Ear and Hearing Care: Training Manual. https://news.gmj.ge/guideline/primary-ear-and-hearing-care-training-manual/
2. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Patients identified as high risk are contacted within a defined time after discharge. The contact is recorded and any problem is escalated.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

Some patients are at high risk after discharge, such as those living alone or with many conditions. The service defines who is high risk and how soon they are contacted.

Each contact is recorded, and a problem found on the call is escalated to a clinician the same day.

What good looks like

• A defined list of high-risk groups and a defined contact time.
• A post-discharge contact register (AFT-REG-001) kept current.
• Each contact and each escalation recorded with its date.

Common mistakes

• High-risk patients not identified at discharge.
• Calls made but not recorded.
• A problem heard on the call and not passed to a clinician.

Questions the surveyor asks

• Each high-risk patient is contacted within the defined time after discharge. The surveyor checks each record for the contact date against the discharge date.
• Each contact is recorded. The surveyor checks the post-discharge contact register for each contact.

How the surveyor verifies this criterion

References

1. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Each patient receives written warning signs that need urgent help, and a route to get it at any hour.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

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.

The patient repeats back the warning signs and the route, so the team knows the patient understood them.

What good looks like

• Written warning signs and urgent help route (AFT-SOP-002) given to every patient.
• Warning signs and urgent help record (AFT-FRM-002) completed for each patient.
• Out-of-hours route stated in the leaflet.
• Patient repeat-back check recorded.

Common mistakes

• Warning signs given verbally only.
• An out-of-hours route that is not in the leaflet.
• No check that the patient understood.

Questions the surveyor asks

• Each patient is given written warning signs that need urgent help. The surveyor checks each record for the written warning signs given.
• Each patient is given a route to get urgent help at any hour. The surveyor checks each record for the out-of-hours route given.
• The patient confirms they understand the warning signs. The surveyor checks each record for the understanding check.

How the surveyor verifies this criterion

References

1. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services (CG138) (NICE, 2012, last updated 2021).

Unplanned returns within a defined period, and complaints or incidents after discharge, are reviewed. Changes are made where a pattern is found.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

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

A review looks for a pattern, such as the same ward, the same medicine or the same missing plan, and records the change made.

What good looks like

• A readmission and aftercare problem review register (AFT-REG-002) kept current.
• Each unplanned return reviewed within the defined period.
• Patterns identified and a change recorded.

Common mistakes

• Readmissions counted but never reviewed.
• Reviews that do not record a change.
• Complaints and incidents kept in separate logs that no one compares.

Questions the surveyor asks

• Aftercare problems and incidents after discharge are reviewed. The surveyor checks the problem register for each entry and its review.

How the surveyor verifies this criterion

References

1. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

A complaint or feedback route can be used after the patient has left. Complaints are read, answered and acted on, not only collected.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: fitness and wellness.

Guidance

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

Each complaint is read, answered in writing and acted on where action is needed, and the response time is recorded.

What good looks like

• A post-discharge complaints and feedback policy (AFT-POL-001) with routes open after discharge.
• A post-discharge complaint response register (AFT-REG-003) kept current.
• Each complaint answered and each action recorded.

Common mistakes

• A complaint route that requires a visit to the hospital.
• Complaints logged and never answered.
• Answers given without any action recorded.

Questions the surveyor asks

• A complaint or feedback route can be used after the patient has left. The surveyor checks the route for the access options available after discharge.
• Each complaint leads to action where needed. The surveyor checks each complaint for the action recorded.

How the surveyor verifies this criterion

References

1. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 16 (Receiving and acting on complaints) (Care Quality Commission (UK), 2014).
2. Patient experience in adult NHS services (CG138) (NICE, 2012, last updated 2021).