Discharge Alerts: Standard Operating Procedure Feb-2024 v3.0 Due for review Sep-24 Introduction This document is designed to standardize the operational procedure for all North Central London (NCL) Hospitals Discharge Systems when an
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Presentation Transcript
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Discharge Alerts: Standard Operating Procedure Feb-2024 v3.0
Due for review Sep-24<br>
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Introduction This document is designed to standardize the operational procedure for all North Central London (NCL) Hospitals Discharge Systems when an incident or near miss occurs on discharge from hospital.
It contains the following sections:
Introduction
Why do we need discharge alerts?
Roles and Responsibilities
Discharge Alert Process
Stage 1: Notification, screening and investigation
Stage 2: Reporting
Ownership of this document sits with the North Central London Discharge Operational Leadership Group.<br>
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Why do we need an NCL discharge alert SOP? To help implement discharge best practice across all NCL hospitals (Community/Acute) and Community settings; and will aim to do this in the following ways:
A standardised process for managing discharges alerts in NCL which aligns with partner organisations. These are designed to minimise the reoccurrence of failed discharges and to be used as a learning tool.
New clear NCL Discharge Alert Form used by all NCL acute and community hospitals & community settings.
Clear oversight of the number of patients who have experienced reported issues with their discharges.
Centralisation of referrals to enable a single point of contact within the ICB for referrer/community services.
Reduction in occurrences of reported issues.
Learning and improving patient’s experience of Discharge to Assess pathways both locally and system wide
Improving patients’ outcomes and safety.<br>
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Roles and Responsibilities<br>
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Discharge Alert Process Stage 1: Notification, screening and investigation 8. Quarterly report shared with NCL Operational Lead Group (at quarterly meeting) Stage 2: Reporting 9. Insights synthesised for system learning<br>
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1. Error identified (and the post discharge escalation process) Any issues regarding a discharge should be raised immediately to prevent a failed discharge, and we encourage all teams to work proactively to resolve any issues, then report it as a discharge alert.
Typical errors include:
Lack of medications
Inappropriate equipment
District nursing issue
Contact details for post discharge escalation are found in the appendix for this document (last slide). Stage 1: Notification, screening and investigation<br>
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2-3. Raising an alert and sending it The NCL Discharge Alert form should be completed on the same day as the issue was identified and sent to the responsible organisation. The Discharge Alert form lists where it should be sent for each Trust (the ToCH for most Trusts except UCLH, where it should be sent to them directly). Stage 1: Notification, screening and investigation What if the issue is resolved?
For the first couple of months of implementing the SOP, all issues post discharge should be reported as a discharge alert even if resolved. We are conscious of the potential workload of this,but need to understand the volume of work associated with it – and want to ensure that we are learning as much as possible so we can prevent further issues from happening.
We will review three months after launch to understand how we can continue to capture the learning, but reduce the impact on workload.<br>
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4. Screening alerts The first step once a discharge alert has been received is to screen it to ensure that it is a discharge alert and not something that needs to be handled via a different pathway.
Discharge alerts should be handled in accordance with the Trust’s patient safety policy, which should align to the Patient Safety Incident Response Framework. The discharge alert could also be a complaint or safeguarding, and as such should follow the relevant processes. However if it is discharge related, it should also be considered a discharge alert. Stage 1: Notification, screening and investigation<br>
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5. Raising a datix and investigating Once received by the organisation with responsibility, a datix should be logged and an investigation into the error should occur. This is the final step of stage 1. The outcome of the investigation is logged and reported on under stage 2 – reporting.
Escalation
If response to alert is not reported within 20 days the hub will use the usual escalation routes outlined in the escalation policy to chase the outcome of the investigation.
Delays in reporting will be included in the quarterly reports. Stage 1: Notification, screening and investigation<br>
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6 Reporting to the referrer Once the investigation is complete, the responsible organisation should send a report on the alerted datix with the outcome of the investigation and relevant learnings for system partners.
The referrers may have raised the alert on their own system to help them track it, and need the outcome Stage 2: Reporting<br>
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7 – 8 The quarterly report Once a quarter, a report summarising the discharge alerts and learnings should be sent to the NCL Discharge Operational Leadership Group for the quarterly reporting meeting (to be the first meeting of the second month of the quarter.
Each trust should share its report according to their relevant policies, and insights from each trust should be synthesised for system learning.
A reporting template will be circulated each quarter, with the following fields: Stage 2: Reporting 8. Quarterly report shared with NCL Operational Lead Group (at quarterly meeting) 9. Insights synthesised for system learning<br>
