INTEGRATED DISCHARGE PLANNING · define correct management of integrated discharge planning. Part 4...

INTEGRATED

DISCHARGE

PLANNING

Code of

Practice

for

Health Service ExecutiveCode of Practice for

Integrated Discharge Planning

Part 1: Background

HSE Code of Practice for Integrated Discharge Planning. Version 1.0. September 2008 .

This is a controlled document and may be subject to change at any time

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R ead er I n f o r m at i o n

Directorate: Health Service Executive (HSE)

T itl e: HSE C ode of P ractice f or I ntegrated D ischarge P lanning

Docum en t P urp os e: Standards & R ecommended P ractices— P art 1

Author: HSE N ational I ntegrated D ischarge P lanning Steering C ommit-

tee

P ub l ication Date: Septemb er 2 0 0 8

T arg et Aud ien ce: A ll relevant healthcare providers

Des crip tion : T he C ode of P ractice is a guide to the standards of practice re-

quired in the management of integrated discharge planning in

the HSE, b ased on current legal requirements and prof essional

b est practice

S up ers ed ed Docs : A ll previous local and national documents relating to integrated

discharge planning

R ev iew Date: Septemb er 2 0 0 9

C on tact Detail s : W inif red R y an,

N ational Hospitals O f f ice,

Q uality , R isk and C ustomer C are D irectorate,

M id- W estern R egional Hospital (N enagh)

N enagh,

C o. T ipperary ,

I reland.

E m ail : winif red.ry an@ hse.ie

W eb : www.hse.ie

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HSE Code of Practice for Integrated Discharge Planning. V ersion 1.0. November 2008.

This is a controlled document and may be subject to change at any time.2

Fiona Quinn,

Winter Initiative,

HSE,

31/33 Catherine Street.

Limerick,

Ireland.

Email : [email protected]

Web: www.hse.ie



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F o r ew o r d

Foreword

The Code of Practice has been produced by the National Integrated Discharge Planning

Steering Committee as a guide to the required standards of practice in the management of

integrated discharge planning in the HSE and in any facility providing services on behalf of the

HSE.

The Code of Practice was drafted by members of the National Integrated Discharge Planning

Steering Committee and was prepared by utilising published guidance from expert bodies, and

existing best practice guidance and standards. Information has also been drawn from various

expert groups and reference sources. A national consultation process on the draft Code was

undertaken and feedback, where appropriate, was incorporated into the final version of the

Code. Work on the Code also benefited greatly from the input of Liz Lees, Consultant Nurse

( Acute M edicine) R G N, Dip N, B Sc ( hons) , Dip HSM , M Sc.

The Code provides:

1. A framework for consistent, coherent management of integrated discharge planning in

the Health Service Executive.

2. A reference point against which continual improvement and consultation can take

place.

The Code applies to healthcare facilities providing services on behalf of the Health Service

Executive under S.3 9 of the Health Act 20 0 4 . It is allied to work being undertaken on the

Transformation Programme—Develop integrated services across all stages of the care journey.

This is an evolving document because standards and practices in relation to integrated

discharge planning will change over time, particularly in the context of emerging primary care

teams and networks. It will therefore be subject to regular review and updated as necessary.

Part 1 - Background

HSE Code of Practice for Integrated Discharge Planning. Version 1.0. November 2008.

This is a controlled document and may be subject to change at any time. 3



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Contents

The document has been prepared in five main parts. There is an overall table of contents

following the foreword. E ach part of the document also has its own contents page, which

provides a detailed breakdown of all the sections and subsections in that part of the document.

Part 1 Backgrou nd T h i s p art p rov i de s t h e f ou ndat i on f or al l s t andards and re com m e nde d

p ract i ce s de t ai l e d i n t h e re m ai nde r of t h e docu m e nt .

Part 2 S tandards T he standards for integrated discharge planning are describ ed in this

section.

Part 3 Recommended

Practices

T his part identifies the recommended practices that are intended to

define correct management of integrated discharge planning.

Part 4 A u dit T ool T he au dit tool relates to the standards for integrated discharge planning

in the H ealth S erv ice E x ecu tiv e.

Part 5 A dditional Re-

sou rces & A p-

pendices

T his part inclu des a glossary , list of ab b rev iations and a reference list.

A ppendices inclu de the memb ership of the N ational I ntegrated D is-

charge Planning S teering C ommittee.

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Contents

ContentsF orew ord

P a rt 1

B a c k g rou nd P a g e

1. Introducti on 10

2 . H ow h e a l th ca re org a ni s a ti ons ca n i m p rov e th e i r di s ch a rg e p ra cti ce 13

3 . D e v e l op m e nt of th e H S E Inte g ra te d di s ch a rg e p l a nni ng C ode of P ra cti ce 15

P a rt 2

S ta nd a rd s

1. C om m uni ca ti on a nd cons ul ta ti on 6

2 . O rg a ni s a ti ona l s tructure a nd a ccounta b i l i ty 8

3 . M a na g e m e nt a nd k e y p e rs onne l 10

4 . E duca ti on a nd tra i ni ng 11

5 . O p e ra ti ona l p ol i ci e s a nd p roce dure s 13

6 . Inte g ra te d di s ch a rg e p l a nni ng p roce s s 15

7 . A udi t a nd m oni tori ng 2 1

8 . K e y p e rf orm a nce i ndi ca tors 2 3

Part 1 - Background



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Contents

Part 3

R e c o m m e n d e d p rac ti c e s Pag e

1. Communication with patients/families/carers 7

2 . M ultidisciplinary team 11

3. Nurse (or HSCP/Other) facilitated discharge 14

4. Key task s pre-admission 18

5 . Key task s on admission 2 2

6 . Key task s during in-patient stay 2 6

7. Key task s 2 4 hours b efore discharge 2 9

8. Key task s day of discharge 31

9 . F ollow-up post-discharge and evaluation 33

10 . Self-discharge/discharge against medical advice 35

11. People who are homeless/living in temporary /insecure accommodation 37

12 . Planning discharge from hospital for people with dementia 38

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Contents

Part 4

A u d i t to o l

1. Introduction 5

2. G uide l ine s f or using th e audit tool 6

3 . R isk l e ve l cate g orie s 15

4 . S tandards f or inte g rate d disch arg e p l anning 16

5 . Q ual ity im p rove m e nt action p l an 18

6 . S tandard scoring sum m ary sh e e t 19

7 . Auditors’ note s 20

Part 5 A d d i ti o n al re s o u rc e s an d ap p e n d i c e s

1. R e f e re nce s

2. Abbre viations

Ap p e ndix 1: M e m be rsh ip of national inte g rate d disch arg e p l anning ste e ring com m itte e

Appendix 2: List of key stakeholder groups

Part 1 - Background



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91

93

94

95

1. Discharge Checklist

2. Key Tasks

A ppendix 1: M em bership of N ational Integrated Discharge Planning Steering Com m ittee

A ppendix 2: List of key stakeholder groups

3. Patient Inform ation Brochure

4. References

5. A bbreviations



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Contents

Contents – Bac k ground P age

1 . I ntroduc ti on 1 0

1.1 Integrated discharge planning

1.2 W ho le sy stem s appro ach

1.3 C o m m o n A ssessm ent P ro cess and C o m m o n S u m m ary A ssessm ent R eco rd

1.4 T he principles o f integrated discharge planning

1.5 F acilitating b est practice

1.6 W hat is the b enef it?

2 . H ow h eal th c are organi sati ons c an i m p rov e th ei r di sc h arge p rac ti c e 1 3

2 .1 M anagem ent su ppo rt

2 .2 C linical leadership

2 .3 Inf o rm atio n sharing

2 .4 E du catio n and training

2 .5 C hange m anagem ent and o rganisatio nal learning

3 . D ev el op m ent of I ntegrated D i sc h arge P l anni ng Code of P rac ti c e 1 5

3 .1 Intro du ctio n

3 .2 D ef initio n

Part 1 - Background



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Introduction

1 Introduction

1. 1 Inte g ra te d dis ch a rg e p l a nning

Patients being discharged from hospital should receive a seamless transition from one

stage of care to the next. A coordinated and patient centred approach to planning for

discharge can lead to increased satisfaction with healthcare services, reduced length of

stay and prevention of unplanned readmissions.

A patient centred approach to integrated discharge planning occurs when hospitals,

general practitioners (G Ps) and other Primary, Community and Continuing Care

(PCCC) providers coordinate care for the patient from the hospital to the community.

E ffective integrated discharge planning supports the continuity of healthcare, between

the healthcare setting and the community, based on the individual needs of the

patient. I t is described as “ the critical link between treatment received in hospital by

the patient and post- discharge care provided in the community” ...N S W D epartment of

H ealth (2 0 0 6 ).

1. 2 W h ol e s y s te m s a p p roa ch

O ur services cannot work in isolation from each other. E ffective multi- agency and

multi- disciplinary working is essential to manage the patient’ s j ourney from pre-

admission through hospital discharge to the community. T o achieve a truly patient

centered approach to integrated discharge planning, all stakeholders must accept their

inter- dependency and must work together to ensure that there are no gaps in services

or duplication of efforts. F or example, this approach may involve individuals or teams

working innovatively to enable the j oined up delivery of services that support

individual needs and the transition to an appropriate setting.

Achieving a whole systems approach req uires the enhancement and development of

relationships, built upon effective communication and cooperation, between primary,

community and continuing care (PCCC), hospitals, transport services and the relevant

voluntary sectors.

E ffective integrated discharge planning relies on knowledge of available healthcare

services, partnerships between organisations and a clear understanding of respective

roles. T he increased emphasis on a whole systems approach challenges us to

coordinate services across organisational boundaries in order to deliver seamless and

appropriate services for patients.

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Introduction

1.3 Common Assessment Process and Common Summary Assessment

R ecord

In December 2006, following a Government decision, the Minister for Health &

Children announced plans for a significant change in how long term residential care is

provided and paid for. U nder the new legislation, the HSE has statutory responsibility

to ensure that people with demonstrated need will be able to access state funding for

long term residential care. To effectively implement this scheme a number of processes

have been implemented by the HSE as follows:

Common Assessment Process ( CAP) and Common Summary Assessment

R ecord ( CSAR ) .

Integrated Care Pathways— eq uitable access to Home Care & L ong Stay Care

( Public & Private) .

1.4 T he principles of integ rated discharg e planning

Integrated discharge planning is considered as a process, not an event. The

process will encompass key elements: written discharge information, provision

of a discharge plan and an estimated length of stay.

Supporting this process, integrated discharge planning systems should include:

i. The allocation of responsibilities across healthcare services ( which

involves defining roles and identifying and reviewing communication

channels) .

ii. Well-defined discharge policies, procedures and activities.

iii. Discharge documentation that accompanies the patient throughout the

episode of care.

iv. Provision for stakeholder feedback and response to that feedback.

v. Methods for managing impediments to good discharge practice.

A documented discharg e plan should commence at or before admission to

hospital. The discharge plan should be subj ect to ongoing assessment

throughout the hospital stay to take account of changes in patient and carer

health and social status.

The assessment and discharge process must be person centred. The patients’

interests and wishes should be taken into account when considering future care

options. This should involve ongoing consultation with the patient and his/her

family/carer/advocate.

Integrated discharge planning is the responsibility of all healthcare providers

in partnership with the patient/carer/family. A staff member should be

identified as being responsible for ensuring that all aspects of integrated

discharge planning have been addressed by the time of discharge.

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Introduction

A multi-disciplinary and multi-agency approach is the most appropriate one

for the development and implementation of discharge plans. T o achieve best

practice the multi-disciplinary teams should work together collaboratively and

in a planned and integrated manner. In addition to hospital and community

staff, it is important that integrated discharge planning includes the transport

services and voluntary/ non-statutory partners.

Effective integrated discharge planning should be co nsistent for all patients

receiving care in the healthcare system.

T he ability to discharge effectively is dependent on the av ailab ility o f a range o f

serv ices to meet ongoing or longer-term care needs. T hus the discharge plan

should take account of any additional resources required to effect the discharge

and work towards a resolution.

1 . 5 F acilitating b est practice

F acilitating best practice involves the following steps:

1 . P atient assessment that is thorough and covers pathological, physiological,

psychological, social and cultural needs (including the patients’ home(s) and

social circumstances).

2 . P lanning that the patient, carer, nurse, doctor and other appropriate members

of the multidisciplinary team conduct together. T he documentation of this

discharge plan is filed in the patient healthcare record and regularly revised.

3 . T he plan’s implementatio n, which involves patient and carer education,

referrals to hospital-based and P C C C services, and communication with P C C C

service providers and general practitioners (G P s).

4. T he f o llo w -up of patients after discharge, to evaluate the effectiveness of the

planned interventions and ensure continuity of care.

1 . 6 W h at is th e b enef it?

G etting discharge right benefits everyone:

P atients want information about their treatment, how long they are likely to

stay in hospital and when they can ex pect to be discharged. T his helps the

patient to access services when they need them, have their needs identified and

have care delivered in a setting appropriate to their needs.

Improved pre-planning of patient care will result in less stress for staf f and a

better working environment.

H ealth care f acilities will be enabled to employ their valuable resources to

max imum effect.

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Ho w h eal t h c ar e o r gan i s at i o n s c an s u c c es s f u l l y i m p r o v e t h ei r d i s c h ar ge p r ac t i c e

2 How healthcare organisations can successfully improve their

d ischarge practice

2. 1 M anagement support

Management should support the change and review new integrated discharge

planning policies and procedures for integration into day to day patient care.

Management should provide ongoing support of work practice change by

involving all relevant healthcare staff and encouraging them to learn from

examples of success.

2. 2 C linical lead ership

S uccessful improvement of integrated discharge planning involves the

championing and clinical leadership of improved patient care processes.

The hospital consultant has continuing clinical and professional

responsibility for patients under his/ her care and each member of the multi-

disciplinary team has a k ey leadership role to play with regard to their area of

expertise within the team.

2. 3 I nformation sharing

Effective communication between hospitals, GPs, PCCC, voluntary and private

service providers is essential to ensure a coordinated patient j ourney from pre-

admission through to discharge. To ensure q uality and timely communication, there

should be a uniform approach to information management across the public sector in

acute and the PCCC sectors. This may involve:

Conducting multi-disciplinary and multi-agency forums to discuss integrated

discharge planning issues.

Conducting formal education sessions for particular groups or services.

Educating hospital and PCCC staff about the healthcare services available in

the region.

W ork ing together to develop local service directories. These directories may

include contacts, service descriptions and process information. They may also

contain referral forms and a description of the eligibility criteria for each

service.

Ensuring local service directories are accessible to staff and up-to-date, and

encouraging staff to use them.

I dentifying information needed to help staff communicate with other

healthcare providers.

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Ho w h eal t h c ar e o r gan i s at i o n s c an s u c c es s f u l l y i m p r o v e t h ei r d i s c h ar ge p r ac t i c e

Considering privacy and confidentiality issues when implementing

information systems.

Developing patient information with patients/families/carers to ensure that

it is relevant, legible and understandable.

2.4 Education and training

Staff should be informed and educated about any changes in integrated

discharge planning practice.

Staff should be given the k nowledge, sk ills and tools to identify and

implement real improvement in integrated discharge planning.

Training needs analysis should be conducted as part of staff induction

programmes and ongoing integrated discharge planning training needs

should be identified.

2.5 C h ange m anage m e nt and organis ational l e arning

A ll staff involved in the integrated discharge planning process should

participate in the improvement effort.

P atients should also be involved in changing work practice that directly or

indirectly improves patient care.

The organisation should evaluate whether change improves patient care,

reduces delays, reduces duplication and increases patient and staff

satisfaction.

The organisation should generate a culture that is comfortable with change

and seek s continuous improvement in integrated discharge planning.

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Development of the Integrated Discharge Planning Code of Practice

3 Development of Integrated Discharge Planning Code of

Practice

3. 1 Introdu ction

The Code of Practice was developed as follows:

Extensive literature search.

Consideration of the opinion of experts knowledgeable in the subj ect.

Consideration of the available current best practice, both in Ireland and

internationally, that may impact on integrated discharge planning.

Organisation of a series of national workshops to discuss integrated discharge

planning with key stakeholder groups.

Development of draft standards and recommended practices that were

distributed for consultation to key stakeholders.

Incorporation of feedback, where appropriate, into the final version of the

Code.

3. 2 Definition

The Integrated Discharge Planning Standards present a standardised approach to

integrated discharge planning in the Health Service Executive ( HSE) , from pre-

admission to post-discharge. The aim of the Standards is to enhance patient safety and

improve continuity of care from the hospital to the home and community. The

Standards will be used to direct and evaluate integrated discharge planning practices in

the HSE.

S tandards = Organisational structures and processes needed to identify, assess and

manage specified risks in relation to integrated discharge planning.

Each standard has a title, which summarises the area on which that standard

focuses.

This is followed by the standard statement, which explains the level of

performance to be achieved.

The rationale section provides the reasons why the standard is considered to be

important.

The standard statement is expanded in the section headed criteria, where it

states what needs to be achieved for the standard to be reached.

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Development of the Integrated Discharge Planning Code of Practice

Recommended Practices = recommendations concerning best practice in relation to

integrated discharge planning.

The Recommended Practices are intended to define correct management of integrated

discharge planning. They are also intended to serve as the basis for policy and

procedure development in integrated discharge planning in acute hospitals and local

health offices.

Each recommended practice has an introdu ction, which summarises the area

on which the recommended practice focuses.

This is followed by the recommended practice scope, which explains the

obj ective of the recommended practice and why it is considered to be

important.

The contents section outlines the contents of the recommended practice.

This is expanded in the section headed procedu re, where it states how each

recommended practice can be achieved.

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Part 2: Standards

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This is a controlled document and may be subject to change at any time.

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Part 2

Par t 2

S t an d ar d s

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Contents

Cont e nt s – S t andar ds P ag e

1 . Com m u ni c at i on and c ons u l t at i on 6

1.1 Standard Statement

1.2 R ati o nal e

1.3 C ri teri a

2 . O r g ani s at i onal s t r u c t u r e and ac c ou nt ab i l i t y 8

2 .1 Standard Statement

2 .2 R ati o nal e

2 .3 C ri teri a

3 . M anag e m e nt and k e y p e r s onne l 1 0


3 .2 R ati o nal e

3 .3 C ri teri a

4 . E du c at i on and t r ai ni ng 1 1


4 .2 R ati o nal e

4 .3 C ri teri a

5 . O p e r at i onal p ol i c i e s and p r oc e du r e s 1 3


5 .2 R ati o nal e

5 .3 C ri teri a

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6 . I n t egrat ed d i s c h arge p l an n i n g p ro c es s 1 5


6.2 R ati o nal e

6.3 C ri teri a

7 . A u d i t an d m o n i t o ri n g 2 1


7 .2 R ati o nal e

7 .3 C ri teri a

8 . K ey p erf o rm an c e i n d i c at o rs 2 3


8 .2 R ati o nal e

8 .3 C ri teri a

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Communication and consultation

1 Communicat ion and cons ult at ion

1. 1 S t at e me nt

Appropriate and effective mechanisms shall be in place for communication and

consultation on matters relating to integrated discharge planning, with key

stakeholders within and outside the organisation.

1. 2 R at ionale

Interactive, timely ex change of information with key stakeholders creates an

empowering infrastructure and environment. These are important factors for enabling

the integrated discharge planning process and for continually improving and

enhancing performance over the continuum of care.

1. 3 Cr it e r ia

1 . The organisation shall develop a set of shared values, behavioural guidelines and

quality principles in support of the H ealth S ervice E x ecutive C ode of Practice for

Integrated Discharge Planning that are reflected in job descriptions and vision

statements.

2 . H ealthcare workers and patients shall be given an opportunity to provide feedback

on these values, guidelines and quality principles.

3 . These values, guidelines and quality principles shall be reflected in each

departments’ business plans.

4. The organisation shall develop and implement a practical methodology for sharing

best practice in relation to integrated discharge planning, both internally and with

key stakeholders.

5. The organisation shall inform their staff, local healthcare providers and patients

about the H ealth S ervice E x ecutive C ode of Practice for Integrated Discharge

Planning.

6 . E ducational material shall be provided using a variety of different media as

required.

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Communication and consultation

7. H ealthcare providers and k ey stak eholders shall b e encouraged to use customer

f eedb ack mechanisms to help inf orm service improvement and learning.

8. The organisation shall have in place a f ormal sy stem f or recording and analy sing

customer f eedb ack in relation to integrated discharge planning.

9. The organisation shall have in place a programme to reduce customer complaints

in relation to integrated discharge planning.

10. R elevant inf ormation f rom recording and analy sing customer f eedb ack in relation

to integrated discharge planning shall b e used to continuously improve the service.

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O r gan i s at i o n al s t r u c t u r e an d ac c o u n t ab i l i t y

2 Organisational structure and accountability

2.1 S tandard S tatem ent

Responsibility for integrated discharge planning shall be clearly defined and there shall

be clear lines of accountability throughout the organisation.

2.2 Rationale

The CEO/ Manager (i.e. hospital CEO/ manager or local health office manager)

through the senior management team, is responsible for ensuring that there are

effectiv e arrangements for integrated discharge planning.

2.3 C riteria

1 . I ndiv idual responsibility for integrated discharge planning shall be defined

throughout the organisation and there shall be clear lines of accountability leading

up to the most senior manager of the organisation.

2 . The scope of responsibility shall include the competence of contractors where the

organisation buys in serv ices and professional liability where the organisation buys

in or sells serv ices to other organisations.

3. I ntegrated discharge planning shall be a standard item on the agenda of the

appropriate committee in the organisation. The D ischarge Co-ordinator (or

designated indiv idual) shall submit regular reports on management of integrated

discharge planning to the committee.

4 . A monthly report on the effectiv eness of integrated discharge planning shall be

submitted to the appropriate committee for rev iew. This committee, which shall

include in its membership the CEO/ Manager or CEO/ Manager nominee, shall

present the report (with suggestions, where appropriate) to the management team.

5. Each organisation shall identify a discharge co-ordinator (or designated

manager...see note overleaf). The duties of the designated person shall not be

confined to any one aspect of the integrated discharge planning function but shall

encompass all integrated discharge planning processes wherev er they occur within

the organisation.

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Each organisation shall identify discharge co-ordinators (or a designated

m anager... see note overleaf ). The duties of the designated person shall not be

confined to any one aspect of the integrated discharge planning function but shall

encom pass all integrated discharge planning processes wherever they occur within

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O r gan i s at i o n al s t r u c t u r e an d ac c o u n t ab i l i t y

6. The discharge co-ordinator (or designated individual) shall have responsibility and

authority for developing and monitoring policies, continuous q uality

improvement and/ or strategies for integrated discharge planning for approval by

the or appropriate committee.

7. The discharge co-ordinator (or designated individual) shall attend appropriate

meetings and conferences, local and national, relevant to integrated discharge

planning, to increase their knowledge and improve their ability to undertake the

role.

8. The discharge co-ordinator (or designated individual) shall undertake the

dissemination of information relating to integrated discharge planning, where

relevant, to all key stakeholders, both within the organisation and externally.

9. The discharge co-ordinator (or designated individual) shall work with clinicians

and departmental/ line managers to develop and improve the systematic approach

to integrated discharge planning.

10. The discharge co-ordinator (or designated individual) shall be responsible for

ensuring that the integrated discharge planning audit activity under the

responsibility of each head of department has been completed.

11. Each individual delivering care along the care continuum (this includes staff at

ward level and staff in PCCC services) shall be made aware of their responsibility

in relation to integrated discharge planning.

Note: S maller organisations may decide that the role of the discharge co-ordinator is

best performed as part of the duties of a discharge co-ordinator in a larger

organisation in the network/ PCCC region. W hat is important is that:

The CEO/ Manager takes active responsibility for integrated discharge planning.

The reporting pathways are clearly defined.

The resources devoted to integrated discharge planning are adeq uate.

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Management and key personnel

3 Management and key personnel


Appropriately qualified key personnel shall be in place to ensure that integrated

discharge planning is provided safely, efficiently and cost- effectively.

3.2 R ati o nal e

T o ensure a high quality and safe, integrated discharge planning process.

3.3 C ri teri a

K ey persons and responsibilities shall be as follows:

1. T he CEO/Manager ( i.e. hospital CEO /manager or local health office manager)

shall put in place arrangements to ensure effective and efficient management of


2 . A discharge co-ordinator ( or designated individual) shall be identified, shall have

formally defined responsibilities in accordance with these Standards and shall be

provided with the necessary resources and authority to discharge these

responsibilities.

3. T he discharge co-ordinator ( or designated individual) shall have an appropriate

combination of experience and qualifications to undertake his/her role.

4. T he discharge co- ordinator ( or designated individual) shall work with designated

N u rses ( or H S CP s/Others) for integrated discharge planning and shall ensure that

these personnel have been trained to the necessary standard of competence.

5 . H eal thcare p rof essional s shall have appropriate training on the principles of

integrated discharge planning and shall have a good knowledge of the Health

Service Executive Code of Practice for Integrated Discharge Planning.

6 . Appropriate I CT ex p ertise and support shall be available for integrated discharge

planning.

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E d u c at i o n an d t r ai n i n g

4 Education and training

4.1 S tandard S tatem ent

Education and Training in relevant aspects of integrated discharge planning shall be

provided to all new and existing staff members (both permanent and temporary).

4.2 Rational e

All clinical and administrative staff should have a general knowledge of the principles

of integrated discharge planning.

4.3 C riteria

1 . I n addition to g eneral induction training th ere s h al l b e a s tructured integ rated

dis ch arg e p l anning f oundation training p rog ram m e f or rel ev ant m anag ers and s taf f

com m ens urate w ith th eir w ork activ ity / res p ons ib il ity to incl ude th e f ol l ow ing :

i. Communication with patients/families/carers in relation to integrated

discharge planning.

ii. Multidisciplinary team.

iii. Nurse (or HS CP/Other) facilitated discharge.

iv. K ey tasks before admission.

v. K ey tasks on admission.

vi. K ey tasks during admission.

vii. K ey tasks 2 4 hours before discharge.

viii. K ey tasks on day of discharge.

ix. F ollow- up post discharge and evaluation.

x. S elf- discharge/discharge against medical advice.

xi. I nformation technology training specific to the integrated discharge planning

function.

2 . I nduction training in integrated discharge planning shall be provided to each staff

member (where relevant) and shall be documented in the individuals training record.

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E d u c at i o n an d t r ai n i n g

3. Staff from acute and PCCC services shall participate in joint training sessions. Such

sessions shall have a common focus and shall include a focus on person centred care

across the continuum of care.

4 . Acute and PCCC services shall work in partnership to provide training opportunities

which shall increase staff understanding of the role that their services play in the

continuum of care, and the sk ills req uired.

5. T here shall be a continuing programme of training (internal organisation training on

HSE Code of Practice for I ntegrated Discharge Planning) and education (external

professional education) for staff on integrated discharge planning. Departmental

records of staff attendance at further training in integrated discharge planning shall be

k ept.

6 . T raining shall be supported with adeq uate resources and facilities.

7 . Competencies in integrated discharge planning across the organisation shall be

assessed and records shall be k ept.

8. A formal appraisal system shall be in place to monitor staff performance and to

identify individual training needs.

9. T he organisation shall undertak e an annual training needs analysis for integrated

discharge planning and shall develop a training plan to support the needs identified.

Note: I ntegrated discharge planning principles and processes shall be incorporated into

undergraduate and postgraduate clinical education for all disciplines.

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Operational policies and procedures

5 Operational policies and procedures f or integrated discharge

planning

5.1 S tand ar d S tatem ent

Written policies, procedures and guidelines for the integrated discharge planning

process shall be based on the Health Service Executive Recommended Practices for Integrated

D ischarge Planning ( Part 3 ) , shall be available, implemented and shall reflect relevant

legislation and published professional guidance.

5.2 Ratio nale

Formal documented control of integrated discharge planning within a quality

management system is necessary to monitor each aspect of the patient j ourney in order

to demonstrate compliance with current legislation and guidance. This will reduce

risks to patients, staff and the organisation and will ensure person centred care across

the patient pathway.

5.3 C r iter ia

1. The organisation shall have documented policies, procedures and guidelines for all

of the key elements of the integrated discharge planning process as outlined in the

recommended practices sections of the HS E Code of Practice for I ntegrated

D ischarge Planning. These policies, procedures and guidelines (where assessed as

relevant), shall include:

i. Communication with patients/families/carers in relation to integrated

discharge planning.

ii. M ultidisciplinary team working.

iii. Nurse (or HS CP/Other) facilitated discharge.

iv. K ey tasks pre- admission.

v. K ey tasks on admission.

vi. K ey tasks during in- patient stay.

vii. K ey tasks 2 4 hours before discharge.

viii. K ey tasks on day of discharge.

ix . Follow- up post discharge and evaluation.

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Operational policies and procedures

x. Self-discharge/discharge against medical advice.

xi. M edication management.

xii. P rocedures with dealing for vulnerable patient groups, e.g. people who are

homeless/living in temporary accommodation and people with dementia.

xiii. IT training.

2. All policies and procedures associated with integrated discharge planning shall

comply with current legislation, H ealth Service E xecutive guidance and published

professional guidance.

3. The appropriate committee shall approve policies, procedures and guidelines for

integrated discharge planning in the organisation.

4. There shall be a system to ensure each department or service has access to a

current copy of the approved integrated discharge planning policies, procedures

and guidelines pertinent to its activities.

5 . All relevant staff shall be req uired to read the integrated discharge planning

policies and procedures relevant to their area of work and to sign a statement to

indicate that they have read, understood and will comply with same.

6 . All policies and procedures associated with integrated discharge planning shall be

controlled documents (showing date of issue and revision number) to ensure that

current versions are available to all who need to use them.

7 . M aster copies shall be kept in a secure location in accordance with good records

management practices.

8. Obsolete documents shall be removed from all points of use and dealt with, in line

with good records management practices.

9. A biennial review of all policies, procedures and documents associated with

integrated discharge planning shall be undertaken to check their relevance and

issue status.

10. A document management system for the control and management of integrated

discharge planning policies and procedures shall be available within the

organisation.

11. All electronic data shall be stored securely, backed up and audited regularly.

12. Access to data/records shall be restricted to authorised named persons and

specified information shall be maintained in line with relevant legislation.

13. Staff shall have access to the Intranet as appropriate.

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Procedures for dealing with vulnerable patient groups, e.g. people who are

hom eless/living in tem porary accom m odation and people with dem entia.

ICT training.



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Integrated discharge planning process

6 Integrated discharge planning process

6. 1 S tandard S tatement

Integrated discharge planning shall include the patient and as appropriate, the family/

carer in the development and implementation of the patient’s discharge plan and shall

ensure that steps are taken to address necessary linkages with other healthcare

providers in order to ensure a seamless transition from one stage of care to the nex t.

6. 2 R ationale

T o ensure that every patient discharged from a Health S ervice Ex ecutive (HS E)

healthcare facility and from those facilities providing services on behalf of the HS E, is

transitioned safely to the community with appropriate arrangements for their

continuing care.

6. 3 C riteria

Assessment

1. Pre-admission assessments shall be conducted for patients who have planned

admissions to hospital.

2. Patient assessment regarding potential for delayed discharge shall begin either

prior to admission or at first presentation to the hospital.

3. Patient assessment shall continue throughout the patient’s hospital stay.

4. S tandardised, up-to-date, patient healthcare records shall be readily accessible at

pre-admission and throughout the patient’s stay in hospital.

5. T he healthcare facility shall have in place defined agreements regarding access

(including prioritisation of access) and response times for both internal and

ex ternal diagnostic services.

Note: The Common Summary Assessment Record (CSAR) should be utilised, where appropriate.

R ef erral

6. Referral shall be made to the other members of the multi-disciplinary team as

appropriate (this includes referral to PCCC services) and this shall be documented

in a timely manner.

7. Referral shall be made to the diagnostic services by the appropriate personnel and

this shall be documented as appropriate.

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8. Receipt of referrals shall be documented on a integrated discharge planning

track ing form in the patient’ s healthcare record within 24 hours of receiv ing the

referral. N ote: this includes referral from hospital to P C C C serv ices.

Nurse (or HS CP/Other) facilitated discharge

9. The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge

shall be agreed with admitting clinician in conjunction with the multi-disciplinary

team.

10 . W ithin one hour of patient admission to the ward, an appropriate and competent

Nurse (or HSCP/Other) from the ward shall be identified and assigned to actively

manage the patient pathway of care.

11. The healthcare record shall indicate that it is a Nurse (or HSCP/Other) facilitated

discharge and the name of the Nurse (or HSCP/Other) shall be documented.

12. The Nurse (or HSCP/Other) shall be up to date on all aspects of the patient care

pathway, particularly focusing on the current medical and nursing condition and

discharge plan.

Estimated length of stay

13. Each patient shall have an estimated length of stay.

14. The estimated length of stay shall be identified by the admitting consultant in

conjunction with the multi-disciplinary team, during pre-assessment, on the post-

tak e ward round or within 24 hours of admission to hospital and shall be

documented in the patient’s healthcare record.

15 . The estimated length of stay shall be based on the anticipated time needed for

tests and interventions to be carried out and for the patient to be clinically stable

and fit for discharge. Note: the actual length of stay is dependent on the patient’s

condition and circumstances.

16. The estimated length of stay shall be discussed and agreed with the patient/family

and carers.

17 . The estimated length of stay shall be proactively managed against the treatment

plan (usually by ward staff) on a daily basis and changes shall be communicated to

the patient/carer.

18 . A ny changes to the estimated length of stay shall be communicated to the PCCC

services, as appropriate.

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Treatment plan

19. Each patient shall have a medical treatment plan.

20. The medical treatment plan shall be discussed and agreed with the patient/family

and carers.

21. The medical treatment plan shall be documented in the patient’s healthcare

record.

D i s c h arg e plan

22. I ntegrated discharge planning shall commence at pre-admission or on admission

and shall include information about the patients’ pre-admission abilities in

relation to potential discharge issues.

Trans po rt arrang ements

23. Transport arrangements shall be confirmed 24 hours before discharge.

C o mmu ni c ati o n

24 . Peri-operative services or pre-admission clinics shall communicate planned

admissions to PCCC service providers before admission.

25 . The hospital shall notify PCCC service providers of unplanned admissions at the

time of hospitalisation, as appropriate.

26. When aware of a patient’s admission, PCCC service providers shall contact the

hospital department ( as appropriate) to discuss premorbid health status to ensure

continuity of care while the patient is in hospital.

27. The hospital shall advise PCCC service providers, as appropriate, of the planned

discharge date as soon as possible, and at least two days prior to patient discharge

( for patients who are in-patients for five days or longer) to enable them to plan the

necessary post-hospital service commencement.

28. Two-way communication between the hospital and the GP and other PCCC

service providers, as appropriate, shall be arranged to ensure such services are

available and in place for the patient to use when needed post discharge.

29. The discharge check list shall be completed twenty four hours before discharge to

ensure all of the above activities have been carried out.

30. The family/carers, GP and other PCCC service providers shall be contacted at

least the day before discharge to confirm that the patient is being discharged and

to ensure that services are activated or re-activated, as appropriate.

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31. At the time of leaving the hospital, each patient shall be provided with an

information pack containing relevant information such as patient/carer plan, a

medication record, and information.

32. Information and education shall be provided to the patient and the family/carer

in the appropriate language, verbally and in written form relating to:

i. The anticipated course of treatment and estimated length of stay.

ii. O ngoing health management.

iii. An appropriate post- discharge contact to answer q ueries and address

concerns.

iv. M edications.

v. The use of aids and eq uipment.

vi. F ollow- up appointments.

vii. PCCC based service appointments.

viii. Possible complications and warning signs.

ix . W hen normal activities can be resumed.

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Transfer and discharge communication

33. The transfer or discharge communication shall include information under the

following headings:

Organisation Name.

Patient identification information.

Responsible clinician name and contact details.

Ward or department or specialty issuing the discharge document ( including

contact details) .

Patient’s registered GP details/referring clinician if different.

Patient’s PH N details.

D iagnoses on discharge ( including problem list) .

Patient alerts/allergies.

I nfection status ( as appropriate) .

Presenting problem/complaint ( include current diagnoses) .

Procedures and investigations.

Results of investigations.

Relevant findings on sy stems review, ex amination findings and summary of

management care plan.

F unctional state ( self- care/baseline mobility /walk ing aids and appliances)

on discharge.

Medications and diets including nutritional supplements and relevant

information on administration of medicines.

The name, signature, grade and contact details of the member of staff who

has completed the transfer/discharge communication.

D ischarge plan.

The name, signature, grade and contact details of the member of staff who

has completed the discharge plan.

The name and title of the receiving clinician in the case of a transfer.

34 . Transfer/discharge communications shall be multi- disciplinary where multi-

disciplinary care is to be continued.

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35. A copy of the transfer/discharge communication which is completed before

discharge shall be sent to the patient, the patients GP, PHN and other healthcare

providers (e.g. Nursing Home) and a further copy shall be retained in the

healthcare record.

36. T ransfer/discharge communication shall be authorised by the relevant responsible

healthcare professionals (including contact details) .

37. A copy of the Common S ummary Assessment R ecord (CS AR ) shall be included,

where appropriate.

38. Where a decision to recommend the patient for long-term residential care has

been made, it shall be documented in the healthcare record that the patient was

informed within fifteen days of that decision being made.

Time of discharge

39. E ach patient discharge shall be effected (i.e. hospital bed becomes available for

patient use) by 1 2 noon on the day of discharge. T his includes completion of all

necessary discharge procedures, documentation of the time of discharge in the

healthcare record and communication with patients, carers and other healthcare

providers (where relevant) .

F ol l ow- u p of discharge pl an

4 0 . Contact shall be made with all referred patients within three days post discharge

(either via telephone and/or contact with the GP and other PCCC service

providers) to find out if the problems identified as requiring intervention post-

discharge were adequately addressed and to deal with any new problems.

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A u d i t an d m o n i t o r i n g

7 Audit and monitoring

7.1 S tandard S tatement

Audits shall be carried out to ensure that the local policies and procedures for

integrated discharge planning conform to the required Standards and that the

processes undertaken conform to the policies and procedures. The audit results shall

be used to identify opportunities for improvement.

7.2 Rational e

Audit is necessary to provide evidence that the system of integrated discharge planning

in place is effective.

7.3 C riteria

1. Audit of integrated discharge planning shall include:

i. Accountability arrangements.

ii. Staff knowledge, expertise and resources.

iii. P rocesses, including risk management arrangements.

iv. P olicies, procedures and guidelines.

2. Each relevant head of department shall be responsible for preparing a written

agreed programme which shall ensure that all aspects of integrated discharge

planning within their department are audited at least once a year.

3. Each relevant head of department shall be responsible for ensuring that the audit

is conducted in accordance with this programme.

4. Each relevant head of department is responsible for ensuring that any deficiencies

identified during audit are reported and discussed with line management [and the

discharge co-ordinator (or designated individual)] and for verifying the efficacy of

remedial actions undertaken.

5. The discharge co-ordinator (or designated individual) shall be responsible for

ensuring that the audit activity, under the responsibility of each relevant head of

department has been completed.

6. The appropriate committee shall be responsible for the implementation and

monitoring of a integrated discharge planning audit and monitoring programme

in each organisation.

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Each relevant head of department is responsible for ensuring that any deficiencies

identified during audit are reported and discussed with line management and the

discharge co-ordinator (or designated individual) and for verifying the efficacy of

remedial actions undertaken.



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A u d i t an d m o n i t o r i n g

7. Audit results shall be fed back to the discharge co-ordinator (or designated

individual) , the appropriate committee, relevant staff and the organisation

management team.

8. Audit results shall be included in the appropriate annual report.

9. Audit results shall be used to help inform and improve integrated discharge

planning practices.

10. The audits shall be carried out by appropriately trained auditors.

11. The senior management team shall submit an annual assurance statement on

audit findings for consideration and approval by the Network Manager/Assistant

National Director Primary Community and Continuing Care (PCCC) .

12. The Network Manager/Assistant National Director PCCC shall submit annual

assurance statements on audit findings to the Director of the National H ospitals

O ffice/Director of Primary, Community and Continuing Care.

13 . E x ternal national audits of integrated discharge planning shall be carried out as

appropriate under the direction of the Assistant National Directors of Quality,

R isk and Customer Care.

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The audits shall be carried out by appropriate personnel trained in the audit tool.

14. The audit should form part of a cycle of continuous improvement and re-auditing

going forward.



Page 23

Key p er f o r m an c e i n d i c at o r s

8 Key perf ormance indicators

8.1 S tandard S tatement

Key performance indicators that are capable of show ing improvements in the efficacy

of integrated discharge planning in the organisation shall be used.

8.2 Rationale

Key performance indicators are designed to demonstrate improvement in the

performance of integrated discharge planning services over time.

8.3 C riteria

Assessment

1. Patient assessment shall begin either prior to admission or at f irst presentation to

the hospital.

Ref erral

2. Receipt of referrals shall be documented on a integrated discharge planning

tracking form in the patient’s healthcare record w ithin 24 hou rs of receiv ing the

ref erral. N ote: this includes referral from hospital to PC C C services.

N u rse ( or H S C P / O ther)

3 . W ithin one hou r of patient admission to the w ard, an appropriate and

competent N urse ( or H S C P/ Other) shall be identified and assigned to actively

manage the patient pathw ay of care.

4. This N urse ( or H S C P/ Other) shall be up to date on all aspects of the patient care

pathw ay, particularly focusing on the current medical and nursing condition and

discharge plan.

E stimated leng th of stay

5 . E ach patient shall have an estimated length of stay.

6. The patient’s estimated length of stay shall be identified du ring pre- assessment,

on the post- tak e w ard rou nd or w ithin 24 hou rs of admission to hospital and

shall be documented in the healthcare record.

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Nurses (or HSCPs/Others)

Within one hour of patient admission to the ward, appropriate and

com petent N urses (or H SCPs/O thers) shall be identified and assigned to actively

m anage the patient pathway of care.

These N urses (or H SCPs/O thers) shall be up to date on all aspects of the patient car

pathway, particularly focusing on the current m edical and nursing condition and

discharge plan.

Each patient shall have a docum ented length of stay.



Page 24

Key p er f o r m an c e i n d i c at o r s

7. The estimated length of stay shall be discussed and agreed with the patient/family

and carers.

T reatment plan

8 . E ach patient shall have a medical treatment plan.

T ranspo rt arrangements

9 . Transport arrangements shall be confirmed 2 4 ho urs b efo re discharge.

C o mmunicatio n

10. The hospital shall advise PCCC service providers, as appropriate, of the planned

discharge date as soon as possible, and at least two days prio r to patient discharge

( fo r patients who are in- patients fo r fiv e days o r lo nger) to enable them to plan

the necessary post- hospital service commencement.

T ransfer/D ischarge co mmunicatio n

11. A copy of the transfer/discharge communication which is completed b efo re

discharge shall be given to the patient and sent to the patients GP, PHN and other

healthcare providers (e.g. Nursing Home) and a further copy shall be retained in

the healthcare record.

T ime o f discharge

12. E ach patient discharge shall be effected (i.e. hospital bed becomes available for

patient use) by 1 2 no o n on the day of discharge. This includes completion of all



providers (where relevant).

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A copy of the transfer/discharge communication which is completed before

discharge shall be given to the patient and sent to the patient’s GP, PHN and other

healthcare providers (e.g. Nursing Home) and a further copy shall be retained in

the healthcare record.

Each patient discharge shall be effected (i.e. hospital bed becomes available for

patient use) no later than 12 noon on the day of discharge. This includes completion

of all necessary discharge procedures, documentation of the time of discharge in the



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Part 3: Recommended Practices

41




T itl e: HSE C ode of P ractice for Decontamination of Reusable Invasive

Medical Devices

Docum en t P urp os e: Standards & Recommended P ractices

Author: Decontamination of Reusable Invasive Medical Devices Steering

C ommittee

P ub l ication Date: July 2007

T arg et Aud ien ce: A ll staff in the HSE who work in C entral Decontamination

Units, Endoscopy Units, Dental Services and other relevant staff

with responsibility for decontamination of reusable invasive

medical devices


quired in the decontamination of reusable invasive medical de-

vices in C entral Decontamination Units, Endoscopy Units and

Dental Services, based on current legal requirements and profes-

sional best practice

S up ers ed ed Docs : N A

R ev iew Date: July 2009

C on tact Detail s : W inifred Ryan,

N ational Hospitals O ffice,

Q uality, Risk and C ustomer C are Directorate,

Mid-W estern Regional Hospital (N enagh)

N enagh,

C o. T ipperary,

Ireland.

E m ail : [email protected]

W eb : www.hse.ie


T itl e: HSE C ode of P ractice for Discharge P lanning

Docum en t P urp os e: Standards & Recommended P ractices— P art 3

Author: HSE N ational Discharge P lanning Steering C ommittee

P ub l ication Date: A pril 2008

T arg et Aud ien ce: A ll relevant staff in the HSE


quired in the management of discharge planning in the HSE,

based on current legal requirements and professional best prac-

tice

S up ers ed ed Docs : ?

R ev iew Date: A pril 2009

C on tact Detail s : W inifred Ryan,

N ational Hospitals O ffice,

Q uality, Risk and C ustomer C are Directorate,

Mid-W estern Regional Hospital (N enagh)

N enagh,

C o. T ipperary,

Ireland.

E m ail : [email protected]

W eb : www.hse.ie

Page 3

Par t 3

P art 3

R ecom m en d ed P ractices

f or in teg rated d is charg e p l an n in g

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HSE Code of Practice for Integrated Disch arge Planning. Version 1.0. September 2008 .


Page 4

Contents

Contents – Pa r t 3

Pa g e

1 Com m u ni c a ti on w i th p a ti ents/ f a m i l i es/ c a r er s 7

1.1 Introduction

1.2 S cop e

1.3 C onte nts

1.4 P roce dure

2 M u l ti - di sc i p l i na r y tea m 11

2 .1 Introduction

2 .2 S cop e

2 .3 C onte nts

2 .4 P roce dure

3 N u r se ( or HS CP/ O th er ) f a c i l i ta ted di sc h a r g e 14

3 .1 Introduction

3 .2 S cop e

3 .3 C onte nts

3 .4 P roce dure

4 K ey ta sk s p r e- a dm i ssi on 18

4 .1 Introduction

4 .2 S cop e

4 .3 C onte nts

4 .4 P roce dure

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Contents

Page

5 K ey t as k s o n ad m i s s i o n 2 2

5.1 Introduction

5.2 S cop e

5.3 C onte nts

5.4 P roce dure

6 K ey t as k s d u r i n g i n - p at i en t s t ay 2 6

6 .1 Introduction

6 .2 S cop e

6 .3 C onte nts

6 .4 P roce dure

7 K ey t as k s 2 4 h o u r s b ef o r e d i s c h ar ge 2 9

7 .1 Introduction

7 .2 S cop e

7 .3 C onte nts

7 .4 P roce dure

8 K ey t as k s o n d ay o f d i s c h ar ge 3 1

8 .1 Introduction

8 .2 S cop e

8 .3 C onte nts

8 .4 P roce dure

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Contents

Page

9 F o l l o w - u p p o s t d i s c h ar ge an d ev al u at i o n 3 3

9.1 Introduction

9.2 S cope

9.3 Contents

9.4 P rocedure

1 0 S el f - d i s c h ar ge/ d i s c h ar ge agai n s t m ed i c al ad v i c e 3 5

10.1 Introduction

10.2 S cope

10.3 Contents

10.4 P rocedure

1 1 Peo p l e w h o ar e h o m el es s / l i v i n g i n t em p o r ar y / i n s ec u r e ac c o m m o d at i o n 3 7

11.1 Introduction

11.2 S cope

11.3 Contents

11.4 P rocedure

1 2 Pl an n i n g d i s c h ar ge f r o m h o s p i t al f o r p eo p l e w i t h d em en t i a 3 8

12.1 Introduction

12.2 S cope

12.3 Contents

12.4 P rocedure

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Communication with patients/families/carers

1 Communicat ion wit h pat ie nt s /car e r s /f amilie s

1. 1 I nt r oduct ion

Patients , fam il ies and carers who are ful l y engaged at al l s tages of the adm is s ion to,

length of stay in and discharge from hospital can better understand what is happening

and what outcomes are ex pected. For patients who are discharged home, education

about self-management can reduce re-presentations and readmissions to hospital. Part

of this education should deal with medication management, since re-presentation to

hospital is often associated with medication mismanagement.

1.2 Scope

The obj ective of this procedure is to provide guidelines in relation to integrated

discharge planning and communication with patients, families and carers.

1.3 C on t en t s

Section One: Estimated length of stay

Section Two: D ischarge plan

Section Three: I nformation pack

Section Four: I ndividualising information

Section Five: Medication management

Section Six : Feedback

1.4 Procedure

Sect i on O n e: E s t i m a t ed l en g t h of s t a y

The estimated length of stay should be identified as soon as possible (at pre-

admission or on admission) and discussed with patients, families and carers.

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Section Two: Discharge plan

The discharge plan should be developed with the patient/ family/ carer in

order to ex plore options for the patient’s care post hospitalisation, including

family members, voluntary services and other healthcare providers.

The discharge plan should be discussed with the patient/ family/ carers to

ensure that they understand the plan, medication management regime and so

on.

The C ommon Assessment Process ( C AP) and C ommon S ummary

Assessment R ecord ( C S AR ) shall be ex plained to the patient/ family, where

appropriate.

Section Three: I nf orm ation pack

An information pack should be developed in which to keep all information

brochures and sheets for the patient/ family/ carer.

Patient information should be developed with patients/ families/ carers, to

ensure that it is relevant, legible and understandable.

Patients and carers should be involved in determining what information

should be provided.

The inf orm ation pack may include the following:

i. The names and telephone numbers of hospital/ PC C C contacts in the

event that the patient has questions following discharge.

ii. Details about the patient’s medical condition.

iii. Details about the patient’s health management, including activity and

diet advice.

iv. Details about ongoing investigations, including any special instructions.

v. The date, time and location of the appointments for any investigations,

where possible.

vi. Medication management information, including instructions on

administration, the management of side- effects, and storage.

vii. Details about follow- up appointments, including the name and address of

the healthcare provider, the date and time of the appointment and the

reason for the appointment.

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Section Four: Individualising information

The Nurse (or HSCP/Other) who is facilitating discharge should find out

what is important to the patient/carer and what are their concerns.

Medical terms should be clearly explained.

I nformation, either written or verbal, should be timely, repeated and checked

out to ensure patients and carers understand that information.

The Nurse (or HSCP/Other) who is facilitating discharge should check that

the patient/carer understands the diagnosis, the reason for particular

treatments and how to perform or use treatments.

The Nurse (or HSCP/Other) who is facilitating discharge should check

whether the patient/carer understands what follow-up is required and why

this is required.

The Nurse (or HSCP/Other) who is facilitating discharge should confirm

that the healthcare facility and the patient/carer have a shared understanding

of the problem and the plan of action.

The Nurse (or HSCP/Other) who is facilitating discharge should confirm

that the patient/carer agrees with the plan of action.

Members of the multidisciplinary team should give the patient/carer and

family members an opportunity to ask questions.

The needs of patients with poor vision, cognitive deficits, cultural and

language barriers should be considered.

The method of education which is best suited for a specific patient

population or individual should be assessed.

Section Five: M edication management

A complete medication management history, including over-the-counter and

complementary medicines should be taken.

Contraindications, allergic reactions and interactions between medications

should be checked.

The pre-admission medication management list should be reconciled with the

list of medication prescribed on the hospital drug chart and any anomalies

resolved.

D osing should be simplified where possible.

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Patients (families/carers) should be provided with verbal and written

information including:

i. Medicine contents.

ii. H ow to take the medicine.

iii. A ctions of the medicine.

iv. Benefits, adverse effects and side effects of the medicine.

The medication management details listed on the discharge summary/

communication, the discharge prescription and the patient information

should be cross checked for accuracy.

Patients (families/carers) should be taught to monitor their medication use.

Patients (families/carers) should be taught self-monitoring skills (for ex ample

peak flow measurement, blood glucose readings, blood pressure).

Patients (families/carers) should be helped to learn how to obtain their test

results (for ex ample, drug levels, blood glucose tests, clotting times).

Patients (families/carers) should be provided with medication management

charts.

C ounselling and family/carer therapy should be provided for complex

medication management regimes (for ex ample, insulin, antidepressants,

biologicals).

Education regarding self-management should be documented in the patients

healthcare record.

Section Six : F eedb a ck

Healthcare services should learn ab out the effectiveness of their integrated

discharge planning b y ob taining patient/ family/ carer feedb ack on the q uality

of discharge processes in the acute hospital and P C C C settings.

T his information should b e used to give feedb ack to staff ( particularly positive

reinforcement of activities that meet patient and carer needs) and to identify

how to improve integrated discharge planning practices.

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Education regarding self-management should be documented in the patient’s

healthcare record.



Page 11

M u l t i d i s c i p l i n ar y t eam

2 M ul t i di s ci pl i na ry T ea m

2.1 I nt roduct i on

Multidisciplinary teams are groups of professionals from different disciplines, who

work together to provide comprehensive patient assessment and treatment. The

benefits of effective multidisciplinary team work ing include timely and effective patient

discharge, increased patient confidence, continuity of q uality care, enhanced

communication and partnership regarding resource management. The patient, their

carer and family must be viewed as essential members of this multidisciplinary team.

2.2 Scope

The obj ective of this procedure is to provide guidelines in relation to the

multidisciplinary team and integrated discharge planning.

2.3 C ont ent s

Section One: Membership

Section Two: Roles and responsibilities

Section Three: Documentation and the healthcare record

Section Four: Team meetings

Section Five: Case conferences

2.4 Procedure

Sect i on O ne: M emb ers h i p

Regular multi-disciplinary forums across the hospital and local health office

should be established to ensure admission, discharge and transfer of care are

planned appropriately.

The multidisciplinary team should consist of any number of people who are

involved in patient care, including hospital, primary and P CCC services staff.

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The multidisciplinary team should consist of any number of people who are

involved in patient care, including hospital and PCCC services staff.



Page 12


Section Two: Roles and responsibilities

The responsibilities of the multi-disciplinary team in taking a more pro-active

approach to discharges should be clarified.

Responsibilities should be agreed around the following:

i. Who can identify and document the estimated length of stay?

ii. Who can review the patient?

iii. H ow multi-disciplinary decisions are made about when the patient is

clinically stable and fit for discharge or safe to transfer?

Staff in the acute hospital services should be informed and educated about

P C C C services and vice versa.

Section Th ree: D ocu m entation and th e h ealth care record

The estimated length of stay should be documented in the patient’ s

healthcare record.

The treatment plan should be documented in the healthcare record, reviewed

daily and updated in response to changing needs.

The discharge plan should be documented in the healthcare record, reviewed

daily and updated in response to changing needs.

Relevant internal referrals ( diagnostics, health & social care professionals,

specialist nursing services, liaison services, etc) should be made to the various

members of the multidisciplinary team and this should be documented as

appropriate.

The C ommon Summary A ssessment Record ( C SA R) should be completed,

where appropriate.

Receipts of referrals should be documented on an integrated discharge

planning tracking form in the patient’ s healthcare record within 2 4 hours of

receiving the referral.

The patient’ s healthcare record should be kept up to date and legibly signed

by each member of the multi-disciplinary team.

P rogress should be documented as intervention commences.

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The patient’s healthcare reco rd should be kept up to date and legibly signed

by each member of the multi-disciplinary team involved in the patient’s discharge.



Page 13


Section Four: Team meetings

The multidisc iplinary team should meet to further plan patient c are, set goals

and adjust timeframes for discharge, where necessary.

Family members and carers should be encouraged to attend multi-disciplinary

team meetings where appropriate. O therwise they should be k ept informed

of-up-to date integrated discharge planning arrangements. This information

should be documented.

Multi-disciplinary review team meetings should be planned, where

appropriate, to ensure continuity of patient care.

Section Five: Case conferences

Where there are complex needs or significant input of services req uired by

the multi-disciplinary team/PCCC services, a case conference may well be

appropriate and should be considered.

Typically, this should involve all/any k ey personnel from each service to

establish the needs of the client and how best they may be delivered.

The case conference should also include patients, families and carers as

appropriate.

Note: The Common Assessment Process (CAP) and Common Summary Assessment Record

(CSAR) shoul d b e undertak en f or those p ati ents w ho w i l l req ui re access to l ong term

resi denti al care.

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N u r s e ( o r H S C P/ O t h er ) f ac i l i t at ed d i s c h ar ge

3 Nurse (or HSCP/Ot her) f acilit at ed discharg e

3.1 I nt roduct ion

Many patients will require healthcare services from a number of different disciplines

including medicine, nursing and health and social care professionals. Effective

integrated discharge planning will thus need to reflect a full understanding of the

patient’s medical condition and the resources that the patient can access on discharge

from the hospital. Research indicates that assigning responsibility to a named

individual for coordinating progress through the system results in improved and timely


3.2 Scope

The obj ective of this procedure is to provide guidance in relation to Nurse (or HSCP/

Other) facilitated discharge.

3.3 Cont ent s

Section One: General principles

Section Two: Criteria for the Nurse (or HSCP/Other) to undertak e discharge

Section Three: Education and training

Section F our: D ischarge framework

Section F ive: I nforming patients

Section Six : L egal liability

3.4 Procedure

Sect ion One: G eneral principles

The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge

should be agreed by the admitting consultant in conj unction with the multi-

disciplinary team.

Within one hour of patient admission to the ward, an appropriate and

competent Nurse (or HSCP/Other) from the ward should be identified and

assigned to actively manage the patient pathway of care.

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This Nurse (or HSCP/Other) should be up to date on all aspects of the

patient care pathway, particularly focusing on the current medical and

nursing condition and discharge plan.

The healthcare record should indicate that it is a Nurse (or HSCP/Other)

facilitated discharge and the name of the Nurse (or HSCP/Other) should be

documented.

If the patient is transferred to another ward or healthcare facility, the Nurse

(or HSCP/Other) who is facilitating discharge should provide a formal

transfer of responsibility to the Nurse (or HSCP/Other) who is facilitating

discharge in that ward or healthcare facility.

If the Nurse (or HSCP/Other) who is facilitating discharge is off duty, a

second named team member should provide cover to ensure continuity of

care planning.

The Nurse (or HSCP/Other) who is facilitating discharge should source and

co-ordinate client information and links with families, carers, primary care

teams and voluntary agencies where appropriate.

This two-way process of information sharing should be standardised and

formalised.

The format of this communication should be agreed locally (e.g. e-mail or fax)

and these details should be readily available.

Section Two: Criteria for Nurse (or HSCP/Other) to undertake discharge

The ability to advocate on behalf of the patient and family/carer.

The ability to educate patients, family/carer and other staff.

A dvanced clinical knowledge in the speciality area.

Well-developed communication and negotiation skills.

The ability to work as a member of the multidisciplinary team.

Detailed knowledge of what services are available and to whom.

The ability to assess and make critical decisions regarding discharge.

The support of their manager/director of nursing/lead clinician to confirm

that:

i. Their post is one in which they will have the need and opportunity to

initiate and authorise discharge.

ii. Local protocols and patient criteria have been developed, agreed and are

in operation

iii. They will have access to, and the support of, the multi-disciplinary clinical

team.

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If the patient is transferred to another ward or healthcare facility, the Nurses

(or HSCPs/Others) who are facilitating the transfer or discharge should provide

a formal transfer of responsibility to the Nurses (or HSCPs/Others) who are

facilitating discharge in that ward or healthcare facility.

If the Nurse (or HSCP/Other) who is facilitating discharge is off duty, an

other named team member should provide cover to ensure continuity of

care planning.

The Nurses (or HSCPs/Others) who are facilitating discharge should source

and co-ordinate client information and links with families, carers, PCCC

Services and voluntary agencies where appropriate.

Nurses (or HSCP/Other) should be up to date on all aspects of the



If the Nurses (or HSCPs/Others) who are facilitating discharge are off duty, a

second named team member should provide cover to ensure continuity of

care planning.



Page 16


Section Three: Education and training

Nurses (or HSCPs/Others) preparing for a role within discharge should

undertake specific education and training.

The training programme should provide the Nurse (or HSCP/Other) with

supervision, support and opportunities to develop competence in authorised

discharge practice.

Competency in integrated discharge planning should be successfully

completed and authorised by their line manager through appraisal.

The Nurse (or HSCP/Other) should inform their manager if they feel that

their competence or confidence in their discharging abilities is no longer at

an acceptable or safe level.

The Nurse (or HSCP/Other) should not continue with discharge activities in

this case until their needs have been addressed and competence is restored.

Section Four: Discharge framework

Nurses (or HSCPs/Others) who have successfully completed the specific

training in relation to integrated discharge planning and demonstrated

competency will become a Nurse (or HSCP/Other) with responsibility for

patient discharge, authorised by their line manager.

Nurses (or HSCPs/Others) should only discharge patients in the ward or

clinic setting in which they are working or in their area of clinical

responsibility.

Nurses (or HSCPs/Others) should only discharge patients where it has been

documented that no further medical review prior to discharge is required.

Before discharging, the Nurse (or HSCP/Other) should have carried out a

holistic assessment of the patient, which should include obtaining results of

all tests/procedures carried out. Where these are not available, medical staff

should be informed.

The decision to discharge should take cognisance of patient choice and

involvement, and all treatment and care should be considered. Nurses (or

HSCPs/Others) authorised to discharge should also recognise those

situations where it is inappropriate for them to authorise discharge.

I t is the responsibility of each Nurse (or HSCP/Other) to ensure that all the

discharge details are complete and written clearly and legibly.

The Common A ssessment Process (CA P) and Common Summary

A ssessment R ecord (CSA R ) should be undertaken for those patients who will

require access to long term residential care.

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Nurses (or HSCPs/Others) preparing for a role within discharge planning

should undertake specific education and training.

Before discharging, the Nurses (or HSCPs/Others) should have carried out a

holistic assessm ent of the patient, which should include ensuring all relevant

test results have been obtained.

The decision to discharge should take cognisance of patient choice and

inv olv ement, and all treatment and care should be considered. N urses ( or

HSCPs/Others) authorised to discharge should also recognise those

situations where it is inappropriate for them to authorise discharge.

I t is the responsibility of each N urse ( or HSCP/Other) to ensure that all the

discharge details are complete and written clearly and legibly.

The Common A ssessment Process ( CA P) and Common Summary

A ssessment R ecord ( CSA R ) should be undertaken for those patients who will

req uire access to long term residential care.



Page 17


Section Five: Informing patients

Nurses (or HSCPs/Others) authorised to discharge should ensure that

patients are aware of the scope and limitations of Nurse (or HSCP/Other)

facilitated discharge.

Section Six : L egal l iab il ity

The healthcare organisation, as the employer, will invariably be fix ed in law

with vicarious liability for the tortious acts or omissions of Nurses (or

HSCPs/Others) authorised to discharge, provided that they are acting

lawfully and within the normal parameters and scope of their duties of

employment.

I n order to protect the organisation from ex posure to liability, it is important

that:

i. Their duties and responsibilities are clearly defined.

ii. They have undergone the appropriate training and the preparation.

iii. They are deemed competent and qualified to undertake the role and are

subj ect to appraisal by line management.

iv. The framework for authorised discharge has been followed and the

member of staff has been designated with the necessary authority by the

healthcare organiz ation to undertake the role.

v. The provision of this recommended practice has been followed by the

member of staff at all times.

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Nurses (or HSCPs/Others) authorised to discharge should ensure that

patients are aware of the duties of employment and scope of Nurse

(or HSCP/Other) facilitated discharge.

The healthcare organisation, as the employer, will invariably be fixed in law

with vicarious liability for the tortious acts or omissions of Nurses (or

HSCPs/Others) authorised to discharge, provided that they are acting

lawfully and within the normal parameters and scope of their duties of

employment and professional practice.



Page 18

Key tasks pre-admission

4 Key tasks pre-admission

4.1 I ntroduction

Pre-admission assessments are conducted for patients who have planned admissions to

hospital. Such assessments are usually required for patients requiring elective

procedures. The pre-admission assessment determines the patient’ s fitness for

procedures and ensures that adequate arrangements are made in preparation for

hospitalisation and for planning the discharge process.

4.2 S cope

The ob j ective of this procedure is to outline the principles of b est practice for pre-

admission assessment.

4.3 Contents

Section One: A ssessment

Section Two: Estimated length of stay

Section Three: Integrated discharge planning

Section Four: Referral


Section Six : C ommunication

4.4 Procedure

S ection O ne: A ssessment

Pre-admission assessments should b e conducted for patients who have

planned admissions to hospital. Such assessments are usually required for

patients requiring elective procedures.

Patient assessment should b egin either prior to admission or at first

presentation to the hospital.

A n anaesthetic assessment should b e performed where relevant ( this may b e

performed in an anaesthetic clinic) .

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The procedure, risks and expected outcomes should be explained to the

patient and carer.

Options and preferences for hospital care and treatment and convalescence,

as well as patient concerns should be discussed.

An assessment should be carried out concerning:

i. The presence of a carer, the home environment for convalescence and/or

the req uirements for home modifications

ii. S ocial issues which need to be attended to ( such as financial

arrangements and sick ness benefits).

iii. R ehabilitation.

iv. The delivery of PCCC services if req uired ( including eligibility for access

to services).

Where other healthcare professionals across the continuum of care provide

care relating to the condition for which hospital admission is occurring, those

practitioners should be involved in the pre-admission process.

S tandardised, up-to-date, client/healthcare records should be readily

accessible at pre-admission.


Each patient should have an estimated length of stay.

The estimated length of stay should be identified during pre-assessment, on

the post-tak e ward round or within 2 4 hours of admission to hospital.

The estimated length of stay should be based on the anticipated time needed

for tests and interventions to be carried out and for the patient to be

clinically stable and fit for discharge.

The estimated length of stay should be discussed and agreed with the patient/

family and carers.

The estimated length of stay should be communicated to the PCCC service

providers, as appropriate.


healthcare record.

iii. Rehabilitation.

iv. The delivery of PCCC services if req uired ( including eligibility for access

to services).

Where other healthcare professionals across the continuum of care provide

care relating to the condition for which hospital admission is occurring, those

practitioners should be involved in the pre-admission process.


accessible at pre-admission.









family and carers.




healthcare record.

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Social issues which may impact on the patient’s stay.



Page 20


Section Three: Integrated discharge planning

Integrated discharge planning should be commenced by gathering

information about the patients’ pre-admission abilities in relation to potential

discharge issues.

The discharge plan should be discussed and agreed with the patient/family

and carers.

The discharge plan should be communicated with PCCC service providers, as

appropriate.

The discharge plan should be documented in the patient’s healthcare record.

Section Four: Referral

Referral should be made to the other members of the multi-disciplinary team

by the appropriate personnel and this should be documented as appropriate.

Referral should be made to the diagnostic services by the appropriate

personnel and this should be documented as appropriate.

Referral should be made to the PCCC services by the appropriate personnel

and this should be documented as appropriate.

Receipts of referrals should be documented on a integrated discharge

planning track ing form in the patient’s healthcare record within 2 4 hours of


The Common Assessment Process ( CAP) and Common Summary

Assessment Record ( CSAR) should be undertak en for those patients who will


Section Fiv e: M edication m anagem ent

A medication management discharge plan should be developed and co-

ordinated for each patient.

Staff should obtain an accurate pre-admission list, including prescription and

over the counter medicines, nutritional support and other therapies such as

herbal products, at the time of admission.

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A medication management discharge plan should be developed and co-

ordinated for each patient.

Staff should obtain an accurate pre-admission list, including prescription and

over the counter medicines, nutritional support and other therapies such as

herbal products, at the time of admission.

Receipts of referrals should be documented on an integrated discharge

planning tracking form in the patient’s healthcare record within 24 hours of




Page 21


Patient’s admission medication should be reviewed in consultation with the

patient’s GP, community pharmacist or other relevant clinicians, with a view

to:

i. I dentif ying the appropriateness and ef f ectiveness of current medication

management, and rationalising current medication management if

appropriate.

ii. Paying particular attention to any problems associated with current drug

therapy, including any possible relationship with the current medical

condition.

iii. D ocumenting allergies and any previous adverse drug reactions.

A ny necessary pre- admission medication management or treatment should be

commenced.

Section Six: Communication

Peri-operative services or pre-admission clinics should communicate planned

admissions to PC C C service providers before admission.

Information and education should be provided to the patient and the family/

carer in the appropriate language, verbally and in written form relating to:


ii. L ik ely req uirements post-discharge.

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Peri-operative services or pre-admission clinics should communicate planned

admissions to PCCC service providers before admission.

Changes in the patient’s medication or condition between pre-admission

and date of planned admission should be communicated by PCCC to

the acute hospital.

Information and education should be provided to the patient and the family/

carer in the appropriate language, verbally and in written form relating to:


ii. Likely requirements post-discharge.



Page 22

Key tasks on admission

5 Key tasks on admission

5.1 I ntroduction

Management of inpatient admissions and discharges is essential to enhance the q uality

of patient care. A f ter the patient has b een admitted to hospital, the acute hospital

service should work with P CCC service providers to provide an integrated service

delivery sy stem.

5.2 Scope

T he ob j ective of this procedure is to outline the principles of b est practice f or

integrated discharge planning on patient admission.

5.3 C ontents

Section O ne: A ssessment

Section T hree: E stimated length of stay

Section T hree: T reatment plan

Section F our: D ischarge plan

Section F ive: R ef erral

Section Six : Medication management

Section Seven: Communication

5.4 Procedure

Section O ne: A ssessment

P atient assessment should b egin either prior to admission or at f irst

presentation to the hospital.

P atient assessment should continue throughout the patient’ s hospital stay

whenever the patient’ s condition changes.

T he procedure, risks and ex pected outcomes should b e ex plained to the

patient and carer.

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Page 23


Options and preferences for hospital care and treatment, as well as patient

concerns should be discussed.

An assessment should be carried out concerning:

i. R ehabilitation, the presence of a carer, the home environment for

convalescence and/or the req uirements for home modifications.

ii. S ocial issues which need to be attended to ( such as financial

arrangements, sick ness benefits, compensation req uirement) .

iii. The delivery of PCCC services if req uired.

Where other healthcare professionals across the continuum of care, provide

care, relating to the condition for which hospital admission is occurring,

those practitioners should be involved in the admission process.


accessible at admission.

The Common Assessment Process ( CAP) and Common S ummary

Assessment R ecord ( CS AR ) should be undertak en for those patients who will










family and carers.




healthcare record.









family and carers.




healthcare record.

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Page 24


Section Three: Treatment plan

All patients should have a treatment plan.

Section Four: Discharge plan

Co-ordinating and implementing discharge activities should start as soon as

the treatment plan is developed.

I ntegrated discharge planning should be commenced w ithin tw o day s of

admission by gathering information about the patients pre-admission abilities

in relation to potential discharge issues.

The discharge plan should be discussed and agreed with patient/family and

carers.

The discharge plan should be communicated with PCCC service providers, as

appropriate.

The discharge plan should be documented in the patient’ s healthcare record.

The Common Assessment Process ( CAP) and Common S ummary

Assessment Record ( CS AR) should be undertak en for those patients who will


Section Fiv e: R ef erral

Referral should be made to the other members of the multi-disciplinary team

by the appropriate personnel and this should be documented as appropriate.

Referral should be made to the diagnostic services by the appropriate


Referral should be made to the PCCC service providers by the appropriate


Receipts of referrals should be documented on a integrated discharge

planning track ing form in the patient’ s healthcare record within 2 4 hours of


Section Six : M edication management

A medication management discharge plan should be developed and

coordinated for each patient.

S taff should obtain an accurate medication management history, including

prescription and over the counter medicines, nutritional support and other

therapies such as herbal products, at the time of admission.

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Integrated discharge planning should be commenced as soon as possible and

certainly within two days of admission by gathering information about the

patient’s pre-admission abilities in relation to potential discharge issues.



Page 25


An accurate pre-admission medication management list should be

established. Where necessary, this should be done in consultation with the

patient’s GP, community pharmacist or other relevant clinicians, with a view

to:

i. I dentifying the appropriateness and effectiveness of current medication

management, and rationalising current medication management if

appropriate.

ii. Paying particular attention to any problems associated with current drug

therapy, including any possible relationship with the current medical

condition.

iii. D ocumenting allergies and any previous adverse drug reactions.

I f it is not possible to take a complete or accurate medication management

list on admission, a request should be made to take one as soon as is practical

after admission.

Section Seven: Communication

The hospital should notify PCCC service providers of unplanned admissions

at the time of hospitalisation.

Once notified of a patient’s admission, PCCC service providers should

contact the hospital department to discuss premorbid health status to ensure

continuity of care while the patient is in hospital.

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The hospital should notify appropriate PCCC service providers of

unplanned admissions at the time of hospitalisation.



Page 26

Key tasks during in-patient stay

6 Key tasks during in-patient stay

6.1 I ntroduction

Effectiv e integrated discharge planning includes preparing a plan for discharge. S ome

important elements of a discharge plan include the estimated length of stay and the

destination of the patient on discharge. T he discharge plan should b e sub j ect to

ongoing assessment throughout the hospital stay to tak e account of changes in patient

and carer health and social status.

6.2 Scope

T he ob j ectiv e of this procedure is to outline the principles of b est practice for

integrated discharge planning during admission.

6.3 C ontents

S ection O ne: A ssessment

S ection T w o: T reatment plan

S ection T hree: Estimated length of stay

S ection F our: D ischarge plan

S ection F iv e: N urse ( or H S C P / O ther) facilitated discharge

S ection S ix : C ommunication

6.4 Procedure

Section O ne: A ssessm ent

P atient assessment should continue throughout the patient’ s hospital stay.

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Section Two: Treatment plan

The treatment plan should be monitored on a daily basis and changes should

be communicated to the patient.

Any changes to the treatment plan should be communicated to the PCCC

service providers as appropriate.

Any changes to the treatment plan should be documented in the healthcare

record.

Section Three: Estimated length of stay

The estimated length of stay should be proactively managed against the

treatment plan (usually by ward staff) on a daily basis and changes should be

communicated to the patient.

Any changes to the estimated length of stay should be communicated to the

PCCC service providers as appropriate.

Any changes to the estimated length of stay should be documented in the

healthcare record.

Section F ou r: D ischarge p lan

The discharge plan should be proactively managed against the treatment plan

(usually by ward staff) on a daily basis and changes should be communicated

to the patient.

Any changes to the discharge plan should be communicated to the PCCC


Any changes to the discharge plan should be documented in the healthcare

record.

Section Four: Discharge plan

The discharge plan should be proactively managed against the treatment plan

(usually by ward staff) on a daily basis and changes should be communicated

to the patient.

A ny changes to the discharge plan should be communicated to the P C C C


A ny changes to the discharge plan should be documented in the healthcare

record.

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The Common Assessment Process (CAP) and Common Summary

Assessment Record (CSAR) should be undertaken for those patients who will

require access to long term residential care.



Page 28


Section Five: Nurse (or HSCP/Other) facilitated discharge

The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge

should be agreed with the multi-disciplinary team.

Within one hour of patient admission to the ward, an appropriate and

competent Nurse (or HSCP/Other) from the ward should be identified and

assigned to actively manage the patient pathway of care.

This Nurse (or HSCP/Other) should be up to date on all aspects of the



The healthcare record should indicate that it is a Nurse (or HSCP/Other)

facilitated discharge and the name of the Nurse (or HSCP/Other) should be

documented.

Section Six : Com m unication

The hospital should advise PCCC service providers of the planned discharge

date as soon as p ossib le and at least tw o day s p rior to p atient discharge (for

patients who are in-patients for five days or longer) to enable them to plan the

necessary post-hospital service commencement.

Two-way communication between the hospital, the G P, the community

pharmacist and other PCCC service providers should be arranged to ensure

such services are available and in place for the patient to use when needed

post discharge.

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Key tasks twenty-four hours before discharge

7 K ey tasks tw enty-f our hours bef ore discharge

7.1 I ntroduction

Towards the end of the hospital stay, all discharge plans should have been put in place.

Services should be organised and implemented as appropriate, to ensure that there are

no delays on the day of discharge or in the provision of services for the patient

following discharge from hospital.

7.2 Scope

The obj ective of this procedure is outline the principles of best practice for integrated

discharge planning twenty-four hours before discharge.

7.3 C ontents

Section O ne: D ischarge arrangements

Section Two: Transport arrangements

Section Three: M edication management

Section F our: C ommunication

Section F ive M edical certificate

Section Six : P atient education

7.4 P rocedure

Section O ne: D ischarge arrangem ents

D ischarge arrangements should be confirmed with the patient, their family/ carers

and the P C C C service providers.

Section T w o: T ransport arrangem ents

Transport arrangements should be confirmed 24 hours bef ore discharge.

The clinical and/ or mobility needs of the patient should be specified, where

appropriate.

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Key tasks twenty-four hours before discharge

Section Three: Medication management

Medication management review should take place in a planned and timely fashion

before the patient leaves the hospital.

Where appropriate, the patient’ s own medication management should be reviewed

to remove any expired or discontinued medication before return to the patient.

A rrangements should be put in place to facilitate continuity of the patient’ s

medication management supply.

D ispensing of adequate medication, where required, to ensure continuity of

supply, should be facilitated through the Pharmacy D epartment.

Communication should be made with the patient’ s community pharmacy

concerning the following:

i. Special arrangements for administration of medication (e.g. via enteral

feeding tube, provision of compliance aids).

ii. Special arrangements for ordering, supply or facilitation of funding of

medication (e.g. unlicensed or difficult to source medication,

extemporaneous preparation, High-Tech medication, use of the Hardship

scheme).

Section F ou r: C ommu nication

D ischarge information (transfer or discharge communication) should be prepared.

This may include a description of the unresolved, ongoing problems listed on the

hospital care plan, key test results, medication regimen, emergency contact person,

contact number and availability.

The discharge check list should be completed to ensure all of the above activities

have been carried out.

The family/carers, GP, PHN and other PCCC service providers should be

contacted at least the day before discharge to confirm that the patient is being

discharged and to ensure that services are activated or re-activated.

Section F iv e: Medical certif icate

The medical (sick) certificate should be written if required. Note: Social Welfare

certificates have to be issued by a General Practitioner (GP).

Section Six : P atient edu cation

The patient should have received and been educated in the use of any aids/

equipment.

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Communication should be made with the patient’s community pharmacy

concerning the following:

i. Special arrangements for administration of medication (e.g. via enteral

feeding tube, provision of compliance aids).

ii. Special arrangements for ordering, supply or facilitation of funding of

medication (e.g. unlicensed or difficult to source medication,

ex temporaneous preparation, High-Tech medication, use of the Hardship

scheme).

Section Four: Communication

D ischarge information (transfer or discharge communication) should be prepared.

This may include a description of the unresolved, ongoing problems listed on the

hospital care plan, key test results, medication regimen, emergency contact person,

contact number and availability.

The discharge check list should be completed to ensure all of the above activities

have been carried out.

The family/carers, GP, PHN and other PCCC service providers should be

contacted at least the day before discharge to confirm that the patient is being

discharged and to ensure that services are activated or re-activated.

Section Fiv e: M ed ical certif icate

The medical (sick) certificate should be written if required. Note: Social Welfare

certificates have to be issued by a General Practitioner (GP).

Section Six : P atient ed ucation


equipment.

Dispensing of adequate medication, where required, to ensure continuity of

supply, should be facilitated through the Pharmacy Department. Where this

does not apply, the Community Pharmacy will provide one week’s emergency

supply to medical card holders.


equipment as appropriate.

Medical (sick) certificates should be written if required for employees to give to

their Employers. Certificates for persons who wish to apply for Disability Benefit

must go to their own GP as these certificates are only available to GPs and are

supplied by the Department of Social and Family Affairs.



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K ey t as k s o n d ay o f d i s c h ar ge

8 Key tasks on day of discharge

8.1 I ntrodu ction

On the day of discharge, the patient should be ready to leav e the hospital at the agreed

time and the patient/carer/receiv ing healthcare facility should hav e sufficient

information to guarantee continuity of care. Good integrated discharge planning

practices suggest that on the day of discharge all arrangements for PCCC serv ices

should hav e been put in place and v ery little new information should be imparted to

the patient or carer.

8.2 Scope

The obj ectiv e of this procedure is to outline the principles of best practice for

integrated discharge planning on the day of discharge.

8.3 C ontents

Section One: Patient

Section Tw o: Time of discharge

Section Three: Communication

8.4 P rocedu re

Section O ne: P atient

The patient should be confirmed as clinically fit and safe for discharge.

Patient should be discharged from the w ard to their place of residence/transfer

healthcare facility or the discharge lounge.

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K ey t as k s o n d ay o f d i s c h ar ge

Section Two: Time of discharge

Each patient discharge should be effected (i.e. hospital bed becomes available for

patient use) by 12 noon on the day of discharge. This includes completion of all




S e c t i on T h r e e : C om m u ni c a t i on

No patient should leave the hospital until the details of admission, medication

management changes (including addition/deletions) and arrangements for follow

up have been communicated to the healthcare provider(s) nominated by the

patient as being responsible for his or her ongoing care.

A t the time of leaving the hospital, each patient should be provided with an

information pack containing relevant information such as patient/carer plan, a

medication management record, and information on the availability and future

supply of medication.

H ospitals should confirm with PCCC service providers that the patient has left

the hospital and that service provision needs to commence.

Information and education should be provided to the patient and the family/carer

in the appropriate language, verbally and in written form relating to:

i. O ngoing health management.

ii. A n appropriate post discharge contact to answer q ueries and address

concerns.

iii. GP letter.

iv. M edication management.

v. The use of aids and eq uipment.

vi. F ollow- up appointments.

vii. PCCC based service appointments.

viii. Possible complications and warning signs.

ix . W hen normal activities can be resumed.

The transfer/discharge communication and discharge prescription should contain

a complete and comprehensive list of all medication the patient is to continue

tak ing on discharge from hospital. W here possible, any pre- admission medication

which was discontinued during the hospital stay should be listed, outlining a brief

reason for discontinuation. There should be no ambiguity as to whether a

medication which is absent from the list was discontinued or omitted

unintentionally.

Note: the patient’ s community pharmacist should be included in any

communications concerning medication management.

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Each patient discharge should be effected (i.e. hospital bed becomes available for

patient use)no later than 12 noon on the day of discharge. This includes completion

of all necessary discharge procedures, documentation of the time of discharge in the





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Follow up post discharge and evaluation

9 Follow up post discharge and evaluation

9.1 I ntroduction

The purpose of following up a patient after they have been discharged from hospital is

two-fold:

i. To evaluate the impact of the planned interventions on the patient' s recuperation

and possibly identify recurrent and new care needs.

ii. To assess the effectiveness and efficiency of the discharge process.

This part of the discharge process is key to ensuring continuity of care for the patient.

9.2 Scope

The obj ective of this procedure is to provide guidelines in relation to follow up post

discharge and evaluation.

9.3 C ontents

Section One: General principles

Section Two: Tips for telephone follow-up

9.4 Procedure

Section O ne: G eneral principles

All planned interventions should be monitored for their impact on the patient (as

identified in the care plan) . This may involve follow-up of patients post discharge

(either via telephone and/ or contact with the GP and other PCCC service

providers) to find out if the problems identified as requiring intervention post

discharge were adequately addressed and to deal with any new problems.

Teaching initiated in the hospital should also be reinforced and assurance

provided to the patient and their home carers.

The ex pected outcomes identified on the care plan should inform the questions

asked of the patient.

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All planned interventions should be monitored for their impact on the patient (as

identified in the care plan). This may involve follow-up of patients post discharge

to find out if the problems identified as requiring intervention post discharge were

adequately addressed and to deal with any new problems.

Teaching initiated in the hospital should also be reinforced and assurance

provided to the patient and their home carers.

The expected outcomes identified on the care plan should inform the areas

to be evaluated.



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S el f d i s c h ar ge/ d i s c h ar ge agai n s t m ed i c al ad v i c e

10 Self-discharge/discharge against medical advice

10.1 I ntroduction

Healthcare professionals should provide patients with sufficient information during

their hospital stay to enable them to understand their medical treatment. In cases

where a patient decides to self-discharge or takes discharge against medical advice they

should be informed of the risk they are taking and possible consequences of their

actions.

10.2 Scop e

The obj ective of this procedure is to provide guidelines in relation to self discharge/

discharge against medical advice.

10.3 Contents

S ection One: General principles

10.4 P rocedure

Section O ne: G eneral p rincip les

Every effort should be made to persuade the patient to avail of treatment.

If available, the registrar on duty should see the patient prior to their self-discharge

and reinforce the need to stay for treatment.

The senior nurse on duty should witness the ex planation and discussion regarding

discharge between doctor and patient.

There should be clear documentation in the healthcare record regarding the

events.

W ith the patients’ permission, the person nominated by the patient should be

informed of patient’s decision to self-discharge.

The patient and family/ carer should sign a document to indicate that the patient

made a decision to self-discharge which was contrary to medical advice. This

document should be signed by the doctor/ nurse if the patient refuses to sign.

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With the patient’s permission, the person nominated by the patient should be

informed of the patient’s decision to self-discharge.

The patient and family/carer should sign a document to indicate that the patient

made a decision to self-discharge which was contrary to medical advice. This

document should be signed by the doctor/nurse if the patient refuses to sign.

Local incident reporting policy should be complied with.



Page 37

Peo p l e w h o ar e h o m el es s o r l i v i n g i n t em p o r ar y o r i n s ec u r e ac c o m m o d at i o n

11 People who are homeles s or liv ing in t emporary or ins ecure

accommodat ion

11.1 I nt roduct ion

Better integrated health and social care can help prevent the inappropriate use of

specialist or acute healthcare and can help prevent or reduce homelessness. People

who are homeless or living in temporary or insecure accommodation are more lik ely to

suffer from poor physical, mental and emotional health than the rest of the

population, and hospitalisation presents an opportunity to deal with underlying

medical, social and mental health problems and to address their accommodation

needs.

11.2 Scope

T he obj ective of this procedure is to provide g uidelines in relation to discharg e of

people who are homeless or living in temporary or insecure accommodation.

11.3 Contents


11.4 P r oced u r e

Secti on O ne: G ener a l pr i nci pl es

A hospital admission and discharg e policy should be developed in partnership by

the hospital, PCCC service providers, the voluntary sector and the local authority.

Homeless people should be identified on admission and PCCC services and

homelessness services should be notified.

PCCC services and homelessness services should be notified when homeless

people are due for discharg e.

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Pl an n i n g d i s c h ar ge f r o m h o s p i t al f o r p eo p l e w i t h d em en t i a

12 Planning discharge from hospital for people with dementia

12.1 I ntroduction

People with dementia may find acute hospitals stressful and this can have a

detrimental effect on their dementia. T hey should therefore only be admitted when

their physical care needs demand the sort of specialist interventions that are only

available in general hospitals.

12.2 S cope

T he obj ective of this procedure is to provide guidelines in relation to discharge from

hospital for people with dementia.

12.3 Contents


12.4 Procedure

S ection O ne: G eneral principles

People with dementia should only be admitted to acute wards when there is

nowhere else appropriate to manage their physical health problems.

People with dementia should be identified and referred to the discharge

coordinator as soon as possible.

T here should be an agreed care pathway for in place for people with dementia.

T here should be a procedure in place for moving patients with dementia following

a period of acute care.

People with dementia should be returned to their usual place of residence as

quickly as possible.

Information should be available regarding local and national services for people

with dementia.

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12.2 Scope

The objective of this procedure is to provide guidelines in relation to discharge from

hospital for people with dementia.

12.3 Contents


12.4 P r oced u r e

Secti on O ne: G ener a l pr i nci pl es

People with dementia should only be admitted to acute wards when there is

nowhere else appropriate to manage their physical health problems.

People with dementia should be identified and referred to the discharge

coordinator as soon as possible.

There should be an agreed care pathway for in place for people with dementia.

There should be a procedure in place for moving patients with dementia following

a period of acute care.

People with dementia should be returned to their usual place of residence as

quickly as possible.


with dementia.

People with dementia can have complex needs and may find acute hospitals

stressful and this can have a detrimental effect on their dementia. They should

therefore only be admitted when their physical care needs demand the sort of

specialist interventions that are only available in general hospitals. It is recognised

that dementia can sometimes lead to complex discharge needs but not necessarily

so. The authors are aware that there are sensitivities around categorising patients

into such groups.

People with dementia with complex discharge needs should be identified and

referred to the discharge co-ordinator as soon as possible.

There should be an agreed care pathway in place for people with dementia.


with dementia and their carers.

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Part 4: Audit Tool



Page 3

Par t 4

Par t 4

A u d i t T o o l

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Page 4

Contents

Contents

Page

1. Introduction 5

2 . G uidel ines for using th e audit tool 6

3 . R isk l ev el categ ories 15

4 . Standards for integ rated disch arg e pl anning 16

Standard 1—C ommunication and consul tation

Standard 2 —Org anisational structure & accountab il ity

Standard 3 —M anag ement and k ey personnel

Standard 4 —E ducation and training

Standard 5—Operational pol icies and procedures

Standard 6 —Integ rated disch arg e pl anning process

Standard 7—A udit and monitoring

Standard 8—Key performance indicators

5. Q ual ity improv ement action pl an 18

6 . Standard scoring summary sh eet 19

7. A uditors notes 2 0

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80

81

90

91

93

94

95

1. Introduction

2. Guidelines for using the audit tool

3. Risk level categories

4. Standards for integrated discharge planning

Standard 1— Com m unication and consultation

Standard 2— Organisational structure & accountability

Standard 3— M anagem ent and key personnel

Standard 4— Education and training

Standard 5— Operational policies and procedures

Standard 6— Integrated discharge planning process

Standard 7— Audit and m onitoring

Standard 8— Key perform ance indicators

5. Q uality im provem ent action plan

6. Standard scoring sum m ary sheet

7. Auditors notes



Page 5

Introduction

1 Introduction

1 . 1 Standards for integ rated disch arg e p lanning in th e H ealth Serv ice E x -

ecutiv e

During 2 008 , standards for integrated discharge planning in the Health Service Execu-

tive were developed using a consistent methodology. A literature review was

undertaken which included a search for all relevant guidance and evidence. Expert

opinion was also sought for the standards. A national consultation process was under-

taken and feedback where appropriate was incorporated into Version 1.0 of the

standards. An audit tool ( based on the ' Safety and Health Audit Tool for the

Healthcare Sector) was then developed to assist in the monitoring for the standards.

1 . 2 A udit

Audit is a function of all developing and progressive organisations. The outcome from

an audit can facilitate an organisation to be knowledgeable about its areas of non-

conformance and to identify and implement corrective action where necessary.

1 . 3 A udit tool

This audit tool in this document relates to the principles of integrated discharge

planning and includes: organisational structure and accountability, audit and

monitoring and communication and consultation. The audit tool can be used to

provide objective data on conformance with the standards within the Health Service

Executive. Y ear-on-year data can assist in monitoring the effectiveness of integrated

discharge planning programmes and assist in strategic planning to meet long term

integrated discharge planning objectives.

1 . 4 L ev els of audit

There are two levels of audit against the HSE standards for integrated discharge plan-

ning: self-assessment and external review.

Self assessment is a process whereby the organisation measures its conformance against

national standards. Each organisation will be asked to undertake a self-assessment exer-

cise for its service against the standards. This will be completed annually, signed by the

CEO/manager and sent to the Network Manager/Assistant National Director for Pri-

mary, Community and Continuing Care as appropriate.

E x ternal rev iew uses the same national standards to independently measure the or-

ganisation through an on-site audit. The findings from the audit will be summarised in

a written report and organisations will be supported in the development of quality im-

provement action plans.

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Healthcare Sector) was then developed to assist in the monitoring of the standards.

This audit tool relates to the principles of integrated discharge planning and includes:

organisational structure and accountability, audit and monitoring and communication

and consultation. The audit tool can be used to provide objective data on conformance

with the standards within the Health Service Executive. Year-on-year data can assist in

monitoring the effectiveness of integrated discharge planning programmes and assist in

strategic planning to meet long term integrated discharge planning objectives.



Page 6

G u i d el i n es f o r u s i n g t h e au d i t t o o l

2 Guidelines for using the audit tool

2. 1 I ntegrated disc harge p lanning audit tool

The audit tool is intended for use by the discharge co-ordinator, staff with a

demonstrated interest in integrated discharge planning and trained audit personnel.

2. 2 P lanning the audit p rogram m e

It is envisaged that the appropriate committee will plan and prioritise the use of the

audit tool based on a review of specific policies or in response to specific clinical inci-

dents.

2. 3 T im e req uired

The time req uired to complete a specific audit will vary according to the tool, the size

of the organisation, the type of procedures audited and the experience of the auditor.

2. 4 C onform anc e

A conformance categorisation has been incorporated into the scoring system to pro-

vide a clear indication of conformance. The allocation of conformance levels is based

on the scores obtained. F or the purpose of these audits the categories will be allocated

as follows: minimal conformance 7 5 % or less, partial conformance 7 6 -8 4 % and con-

forming 8 5 % or above.

2. 5 F eedb ac k of inform ation and rep ort findings

It is advised that the auditor should verbally report any areas of concern and of good

practice to the head of department in charge of the area being audited prior to leaving.

A written report should also be developed by the auditor and should be given to the

relevant head of department for action. The report should clearly identify areas req uir-

ing action. The head of department is responsible for developing an action plan to

address the issues identified within a given timescale.

The audit team may decide to re-audit the ward/department if there are concerns or a

minimal conformance rating is observed. A system of feedback to the appropriate com-

mittee on the action taken by wards/departments should be in place. This may involve

feedback meetings or the return of completed action plans to the discharge co-

ordinator.

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2.6 Scoring

Eight standards for audit of integrated discharge planning are described in the audit tool work-

sheets. Each standard is stated and followed by questions based on the standard criteria. Below

is an explanation of the abbreviation used under each criterion.

I = I nterview

O = O bservation

D = D ocumentation

Y = Y es

P = Partial

N = N o

I nstructions on the comp letion of a standard work sheet

In order to effectively audit integrated discharge planning it is necessary that all standards are

audited as part of the audit process. The auditor can repeat a full audit of all standards at regu-

lar intervals in order to measure the level of improvement in the effectiveness of integrated

discharge planning.

There are eight standards in the audit tool and for each standard there is a worksheet, which

details a list of questions to be answered. There is specific information to be completed in

each worksheet and this is explained below:

Step 1 :

F or each question the auditor can use an “ X” to indicate the appropriate answer, which is

“ Yes” , “ Partial” or “ No” . In this example we will assume the answer is “ No”

1 Y P N

I

O

D

E ach individual delivering care along the care continuum ( this in-

cludes staff at ward level and staff in PCCC services) shall be made

aware of their resp onsibility in relation to integrated discharge p lan-

ning?

S upporting Evidence/ C omments

Yes Partial No Total score

S core 1 0 S core 5 S core 0

X

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Step 2

For each question the auditor can use an “X” to indicate the method of verification used in

trying to get an answer to the question. The auditor may have interviewed ( I ) an employee,

observed ( 0 ) a particular work practice or reviewed a particular document ( D ). The auditor

may have used all three methods. For this example the auditor interviewed an employee and

used an “X” to indicate this on the worksheet.

Step 3

The auditor can then detail some supporting evidence or comments to explain the reason for

the relevant answer. I n this example the answer to the question was “No” because staff were

not aware of their responsibilities in relation to integrated discharge planning.

Step 7

X

1 Y P N

I

O

D

E ach individual delivering care alo ng the care co ntinuum ( this in-


aware o f their respo nsibility in relatio n to integ rated discharg e plan-

ning ?

S upporting E vidence/ C omments

X

X

1 Y P N

I

O

D

E ach individual delivering care alo ng the care co ntinuum ( this in-


aware o f their respo nsibility in relatio n to integ rated discharg e plan-

ning ?

S upporting E vidence/ C omments

No evidence of staff being made aware of their responsibilities.

X





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Step 4

The auditor can use an “X” to indicate the appropriate answer for each question, which will be

“Yes”, “Partial” or “No”.

T h e d i f f er en t s c o r i n g o pti o n s a r e a s s et o u t b el o w :

If the auditor selects “Yes” as his/her answer to the question, then the auditor uses an “X” to

select “Yes” in the score table and enters a total score of “10” in the score table. An answer of

“Yes” means there is full evidence of conformance and this is allocated a score of 10.

If the auditor selects “No” as his/her answer to the question, then the auditor uses an “X” to

select “No” in the score table and enters a total score of “0” in the score table. An answer of

“No” means there is no evidence of conformance and this will be allocated a score of “0.

If the auditor selects “Partial” as his/her answer to the question, then the auditor uses an “X”

to select “Partial” in the score table and enters a total score of “5” in the score table. An an-

swer of “Partial” means there is evidence of a reasonable level of conformance and this will be

allocated a score of “5”.

N O X

Score 0

Y ES X

Score 10

PA R TIA L X

Score 5

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Step 5

The auditor should check that he/she has entered the appropriate total score in the score table

for each question.

Step 6

The criterion score is then calculated as a percentage. This is explained by a worked example

below:

Number of Q uestions in Standard: 1 3

Maximum Standard Score ( M S )

( Total Number of Q uestions x Maximum Score ( 1 0 ) ) : 1 3 0 ( 1 3 x 1 0 )

A ctual Standard Score ( A S ) ( Sum of the total scores for each question) 1 0 0

Note: I n this example the actual score used is 1 0 0 , however the actual score will vary depend-

ing on the scores allocated to each question.

Standard Score as a percentage = A S/ M S x 1 0 0 / 1

I n this example Standard Score as a percentage = 1 0 0 /1 3 0 x 1 0 0 /1 = 7 6 . 9 2 %

Note: Where a question in a standard is not applicable, it will not be given a score.

Example:

I n t h e ab o v e c as e; i f t h er e w er e o n ly 1 2 q u es t i o n s appli c ab le t h en t h e maxi mu m c r i t er i o n s c o r e ( M S )

w o u ld b e 1 2 0 ( 1 2 x 1 0 ) .

Yes No Partial T otal sc ore

S c ore 1 0 S c ore 0 S c ore 5 0

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The auditor repeats Step 1-6 for each question in the standard worksheet.

Step 8

When a standard has been fully audited, the auditor can detail a summary of the results in the

standard report form. This information can be taken from the worksheet or the auditor may

use his/ her own notes taken during the audit. This report form should be completed for each

standard. An example of what information can be included in this report form is detailed be-

low.

Step 9

Standard 2: Organisational structure and accountability

Responsibility for integrated discharge planning shall be clearly defined and there shall be

clear lines of accountability throughout the organization.

Summary of documentation audited and referenced

Summary of main findings of the audit

C onformance in the area

Managers are aware of responsibilities

N on- conformance in the area

Standard Score: 1 0 0 / 1 3 0 7 6 . 9 2 %

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Guidelines for using the audit tool

The areas of non-conformance in each standard report form should be transferred to a quality

improvement action plan. A n ex ample of a blank quality improvement action plan is detailed

in section 5 of this document. B elow is an ex ample of the type of information that w ould be

documented in this quality improvement action plan by the auditor.

The auditor may have a number of areas of non-conformance for each standard. The quality

improvement action plan w ill need to be ag reed in consultation w ith the senior manag ement

committee ( or appropriate committee) . The action plan is used to summarise the main find-

ing s of the audit and it is used as a tool for continuous improvement.

Note: The auditor may use the auditors note section in section 7 of this document to compile

further relevant information.

Standard Area of Non Conformance Corrective Action Responsible Person Time-frame

Review

1 Staff not aware of their responsibilities in relation to integrated discharge planning

Discuss with each relevant H ead of department

Discharge co-ordinator

Dec 2008 Feb2009

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STANDARD SCORING SUMMARY SHEET

St e p 1 0 :

Th e s c o r i n g f o r e a c h St a n d a r d i s d e t a i l e d i n a St a n d a r d Sc o r i n g Su m m a r y Sh e e t . A c o m -

p l e t e d St a n d a r d Sc o r i n g Su m m a r y s h e e t i s d e t a i l e d b e l o w a n d a b l a n k St a n d a r d Sc o r i n g

Su m m a r y s h e e t i s d e t a i l e d i n s e c t i o n 6 o f t h i s d o c u m e n t .

Standard Actual Stan-

dard Score

(AS)

M ax im um Standard

Score (M S)

T otal N um b er of

Q ues tion x M ax im um

Score (10)

Standard Score as a

p ercentag e

(AS/ M S x 100/ 1)

1 70 100 70

2 90 110 8 1.8 1

3 4 0 60 66.66

4 50 90 55.55

5 125 13 0 96.15

6 3 50 4 90 71.4 2

7 100 13 0 76.92

8 110 14 0 78 .57

Overall Audit Score 965 1,250 77.2

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Step 11:

Using the example above the overall audit score is calculated as follows.

Overall

audit score = Sum of all actual standard scores ( AS) / Sum of all maximum standard

Scores ( M S) x 1 0 0 / 1

Overall audit score = 9 6 5 / 12 5 0 x 10 0 / 1 = 7 7 . 2 %

This overall audit score can be used to benchmark performance from year to year and the indi-

vidual standard score allows the auditor to identify areas where most attention is needed.

A summary sheet with Standard and overall audit score could be attached to the quality im-

provement action plan as a full audit report.

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Page 15

R i s k l ev el c at ego r i es

3 Risk level categories

A response is categorised as non-conforming if it does not meet the criteria identified in the

H ealth S ervice E x ecutive S tandards for I ntegrated D ischarge P lanning. An indication of the

seriousness of the non-conformance is given b y a risk category that is attached to each non-

conformance statement. The categorisation of risk should provide some assistance in prioritis-

ing remedial actions.

On the right hand side of each statement is a risk level categorisation. These are organised as

shown in Tab le 1.

T ab le 1 : D ef in ition of risk levels u sed in n on - con f orm an ce statem en ts

Level C a t eg o r y D es c r i p t i o n

1 Ob servation This category includes reported

facts which, although not neces-

sarily non-conformances, should

b e considered when any remedial

action is planned.

2 Low Risk The reported fact( s) indicate a

minor hazard with a low likeli-

hood of the hazard occurring.

3 Medium Risk The reported fact( s) indicate

either a minor hazard with a

significant likelihood of the haz-

ard occurring or a significant

hazard with a low likelihood of

the hazard occurring.

4 H igh Risk The reported fact( s) indicate a

significant hazard with a signifi-

cant likelihood of the hazard

occurring.

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Standards for integrated discharge planning

4 Standards for integrated discharge planning

Standard 1 : C om m u nication and consu ltation

Appropriate and effective mechanisms shall be in place for communication and consultation

on matters relating to integrated discharge planning, with k ey stak eholders within and outside

the organisation.

Standard 2 : O rganisational stru ctu re and accou ntab ility

Responsibility for integrated discharge planning shall be clearly defined and there shall be clear

lines of accountability throughout the organiz ation.

Standard 3 : M anagem ent and k ey personnel

Appropriately qualified k ey personnel shall be in place to ensure that the integrated discharge

planning service is provided safely, efficiently and cost-effectively.

Standard 4: E du cation and training

Education and Training in relevant aspects of integrated discharge planning shall be provided

to all new and existing staff members (both permanent and temporary).

Standard 5 : O perational policies and procedu res

Written policies, procedures and guidelines for the integrated discharge planning process shall

be based on the Health Service Executive Recommended Practices for Integrated Discharge Planning

( Part 3 ) , shall be available, implemented and shall reflect relevant legislation and published pro-

fessional guidance.

Standard 6 : I ntegrated discharge planning process

I ntegrated discharge planning shall include the patient and as appropriate, the family/ carer in

the development and implementation of the patient’s discharge plan and shall ensure that

steps are tak en to address necessary link ages with other healthcare providers in order to ensure

a seamless transition from one stage of care to the next.

Standard 7 : A u dit and m onitoring

Audits shall be carried out to ensure that the procedures for integrated discharge planning con-

form to the required Standards and that the processes undertak en conform to the procedures.

The audit results shall be used to identify opportunities for improvement.

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Page 17

Standards for integrated discharge planning

Standard 8: Key performance indicators

Key perf ormance indicators that are capable of show ing improv ements in the ef f icacy of inte-

grated discharge planning in the organisation shall be used.

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Page 18

Quality improvement action plan

5. QUALITY IMPROVEMENT ACTION PLAN Sta

n-

dar

d

Ref

er-

ence

Are

a o

f N

on

-

Co

nfo

rman

ce

Lev

el

of

Ris

k

Co

rrec

tive

Act

ion

to

be

tak

en

Res

po

nsi

ble

Per

son

Tim

e F

ram

eC

ost

Imp

lica

tio

ns

Rev

iew

of

Imp

lem

enta

-

tio

n o

f A

c-

tio

n

Co

m-

men

t

Off

ice

Use

On

ly

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Page 19

S t an d ar d s c o r i n g s u m m ar y s h eet

5. STANDARD SCORING SUMMARY SHEET

Standard Actual Stan-

dard Score

( AS)

Maximum Standard

Score ( MS)

Total Number of

Question x Maximum

Score ( 1 0 )

Standard Score

as a percentage

( AS/ MS x

1 0 0 / 1 )

1

2

3

4

5

6

7

8

O v era l l A u d i t

Score

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Auditors notes

5. AUDITORS NOTES

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Auditors notes

AUDITORS NOTES

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Part 5: Additional Resourcesand Appendices



Page 3

Par t 5

Addit io nal R eso u r ces

and Appendices

Par t 5



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Page 4

Contents

1. References

2. Abbreviations

Ap p end ix 1: M em bersh ip of N ational I nteg rated D isch arg e P l anning S teering C om m ittee

Ap p end ix 2: L ist of k ey stak eh ol d er g rou p s

Contents



Part 5 - Additional

Resources and Appendices

1. Discharge Checklist

2. Key Tasks

A ppendix 1: M em bership of N ational Integrated Discharge Planning Steering Com m ittee

A ppendix 2: List of key stakeholder groups

3. Patient Inform ation Brochure

4. References

5. A bbreviations

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Discharge Checklist (please note that this is not an exhaustive list)

Own medications (once reviewed)

Own equipment

Own X-Rays

Valuables

Yes (Y)/No (N)/

Not A p p lic a b le

(NA )

P er son a l item s r etu r n ed to p a tien t

Yes (Y)/No (N)/


(NA )

GeneralPractitioner (GP)

OPD (please specify)

Medicalspecialist/other hospital(pleasespecify)

Other (please specify)

F ollow u p a p p oin tm en ts

Patient understands findings and treatmentplan

Observations within normallimits

Yes (Y)/No (N)/


(NA )

G en er a l *

Pain controlsatisfactory

Adequate nutrition and fluid intake

Passed urine

Alldressings checked

Transfer/Discharge communication

Medications and medication list— explained topatient/carer, as appropriate

Follow-up appointment

Yes (Y)/No (N)/


(NA )

Item s a r r a n g ed for /p r ov id ed to p a tien t

Aids and appliances

Information pack

Wound care information

Relative/friend

Taxi

Ambulance

Community transport provider

T im e B ook ed

(2 4 h ou r ) T r a n sp or t


P C C C S er v ic es R efer r ed to/A r r a n g ed

Contact made withPublic HealthNurse (PHN)

Home Help

Meals on Wheels

OccupationalTherapist

Yes (Y)/No (N)/


(NA )

Speech& Language Therapist

Physiotherapist

*A medical review of the patient prior to discharge is required if theanswer to any of the above questions is ‘No’

Community Pharmacist

Common Summary Assessment Record(CSAR) completed

Carer identified


Home oxygen

IV cannula�removed

Signature/Printed Name Date Time (24 hour)

Part 5 - Additional




KEY TA SKS FO R STA NDA RD

A DMISSIO N A ND DISCHA RGE PRO CESS

Pre admission

� Patient assessment

� Explain procedure, risks, expected outcomes

� D iscuss options and preferences for hospital care and treatment

� D iscuss patient concerns

� Assessment concerning—social issues/rehabilitation/delivery of PCCC

services/availability of carer

� Standardised, up-to-date, healthcare records available

� Common Assessment Process (CAP) and Common Summary Assessment Record

(CSAR) should be undertaken, where appropriate

� Identify estimated length of stay (ELOS)

� D iscuss ELOS with patient/family/carers

� Record ELOS in the patient’s healthcare record

� Communicate ELOS to PCCC service providers

� Gather information regarding pre-admission abilities (potential discharge issues)

� D iscuss discharge plan with patient/family/carer

� Communicate discharge plan with PCCC service providers

� D ischarge plan recorded in the patient’s healthcare record

� Referral to other members of the multi-disciplinary team

� Referral to PCCC services

� Referral to diagnostic services

� D ocument receipt of referrals on discharge planning tracking form

� Establish pre-admission medication list, if necessary in consultation with the

patient’s GP and community pharmacist

� Commence pre-admission medication/treatment as appropriate

� Communicate planned admissions to PCCC service providers

� Provide information and education to the patient/family/carer in the appropriate

language, verbally and in written form

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On admission


� Explain procedure, risks, expected outcomes

� D iscuss options and preferences for hospital care and treatment

� D iscuss patient concerns

� Assessment concerning—social issues/rehabilitation/delivery of PCCC

services/availability of carer

� Standardised, up-to-date, healthcare records available

� Common Assessment Process (CAP) and Common Summary Assessment Record

(CSAR) should be undertaken, where appropriate

� Identify estimated length of stay (ELOS)

� D iscuss ELOS with patient/family/carers

� Record ELOS in the patient’s healthcare record

� Communicate ELOS to PCCC service providers

� Patient treatment plan available

� Co-ordinate and implement discharge plan

� D iscuss discharge plan with patient/family/carer.

� Communicate discharge plan with PCCC service providers

� D ocument discharge plan in the patient’s healthcare record

� Referral to other members of the multi-disciplinary team

� Referral to PCCC services

� Referral to diagnostic services

� D ocument receipt of referrals on discharge planning tracking form

� Obtain an accurate medication history

� Review admission medication in consultation with patient’s GP, the community

pharmacist and other relevant clinicians

� D evelop and co-ordinate a medication discharge plan

� Notify PCCC service providers of unplanned admissions

� PCCC service providers contact hospital to discuss premorbid health status

Part 5 - Additional




During in patient stay


� Monitor treatment plan on a daily basis

� Communicate changes to the patient

� Communicate changes to PCCC service providers

� D ocument changes to treatment plan in the healthcare record

� Manage ELOS against treatment plan

� Communicate changes to the patient/carer


� D ocument changes to the ELOS in the healthcare record

� Manage discharge plan against treatment plan

� Communicate changes to the patient/carer


� D ocument changes to the discharge plan in the healthcare record

� MTD agree suitability of patient for nurse (or HSCP/Other) facilitated discharge

� Identify nurse (or HSCP/Other) to facilitate discharge within one hour of

admission

� D ocument the name of the nurse (or HSCP/Other) to facilitate discharge in the

healthcare record

� Advise PCCC service providers/carer of planned discharge (at least 2 days prior to

discharge)

� Arrange 2 way communication between the hospital, the GP, the community

pharmacist and other PCCC service providers

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24 hours before discharge

� Confirm discharge arrangements with the patient/family/carers and PCCC service

providers

� Confirm transport arrangements 24 hours before discharge

� Undertake medication review

� Put arrangements in place to facilitate ongoing supply of the patient’s medication

� Prepare transfer/discharge communication

� Complete discharge checklist

� Contact family/carers and PCCC service providers to confirm that the patient is

being discharged

� W rite medical (sick) certificate

� Check that the patient/carer has received and been educated in the use of any

aids/equipment

Part 5 - Additional




On day of discharge

� Confirm that patient is clinically fit and safe for discharge

� D ischarge patient to place of residence/transfer healthcare facility or discharge

lounge

� D ischarge to be effected by 12 noon

� Ensure transfer/discharge communication has been communicated to the

healthcare provider(s) nominated by patient

� Confirm with PCCC service providers that patient has left the hospital and that

service provision needs to commence

� Provide patient with information pack

� Provide information and education to the patient/family/carer in the appropriate

language, verbally and in written form

� Determine if the patient needs follow-up

If follow-up is required...1. Determine who should telephone the patient post hospitalisation

2. Obtain the patient’s/carer’s consent for the follow-up call

3. Ask them to nominate a call time

4. Check that telephone details are correct

5. Check language skills and record any special needs for the telephone follow-up

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Post discharge

� Reinforce teaching initiated in the hospital

� Provide assurance to the patient and their home carers

Part 5 - Additional






Patient Information

Brochure

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PLANNING YOUR TRANSITIO N FROM

HO SPITAL TO HOME

INTRODUCTION

� Many people require no special services after they have been discharged home.

� If you require some extra assistance then hospital staff, your GP and primary, community

and continuing care (PCCC) staff will help you to plan ahead so that the appropriate

arrangements can be made before you are discharged.

� This brochure is to prompt you (the patient) and your carer, family and friends to consider

a range of practical aspects about your return home from hospital.

YOUR DISCHARGE PLAN

� From the day you are admitted to hospital, a number of different staff involved in your care

(the multidisciplinary team) will work with you, your relatives and carers to plan your

discharge.

� Your length of stay will depend on your condition. The date of your discharge will be

agreed and discussed with you by the consultant and the multidisciplinary team.

� Please advise your nurse, as early as possible during your stay, if you think you will have any

problems with going home.

� On the day of your discharge please make arrangements to be collected no later than 12

midday. This is necessary to make way for other patients who are being admitted to

hospital.

Part 5 - Additional




QUESTIO NS YOU NEED TO ASK ABOUT YOUR CARE

� How long will I be in hospital?

� W hat can I expect to happen to me during my time in hospital?

� How soon should I feel better after leaving the hospital?

� W hen can I expect to return to work?

� Are there any special instructions for my daily activities?

� W ill I need any special equipment at home? W ho will help me to arrange this? Is this

equipment covered by my insurance or medical card?

� Do I need to have follow-up tests? W ho should I follow-up with to get the test results?

� If I need help and care at home after I leave hospital, who will help me to arrange it?

� W ill I need to have other treatment following my time in hospital?, (e.g. physiotherapy).

Are there any exercises that I need to do? (If so, ask for written instructions).

� W hen I leave hospital, will I be able to go directly home?

� W ill there be any follow-up appointments?

� Do I need to schedule any follow-up visits with my doctor?

� W ill I be able to walk, climb stairs, go to the bathroom, prepare meals, drive, etc.

� W ho can I call if I have any problems after leaving the hospital?

QUESTIO NS YOU NEED TO ASK ABOUT YOUR MEDICINES

� W hat medicines will I need to take at home? Get a complete list of all your medicines at

discharge, including any changes made while you were in hospital. Take this list with you when

you leave the hospital.

� Can I get written instructions about my medicines? Ask any questions before you leave the

hospital.

� Are there any food or drinks that I should avoid while taking my medicines?

� Are there any drugs (including non-prescription drugs) or vitamins that I should not take

with my medicines?

AFTER YOU LEAVE THE HO SPITAL

� The hospital staff will let your GP/Public Health Nurse (PHN) know when you are leaving

hospital.

� W hen you leave the hospital, hospital staff will prepare a discharge communication (a

summary of medical information about your treatment in hospital and ongoing services

that have been arranged for you). This communication will be given to you and a copy will

be sent to your GP.

� You may wish to make an appointment to see your GP following discharge.

� If you feel that you are not well and/or are not managing at home, contact your GP and/or

PHN.

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TH INGS TO DO BEFO RE YOU GO H OME

� Speak to at least one hospital member about how long it might be before you will be

feeling better and can expect to resume usual activities.

� If your physical abilities have changed as a result of your illness, make sure you

understand about what you can and can’t do when you go home.

� A sk staff questions about what has happened to you, and what changes you can expect in

your health and daily activities when you return home.

� If you have any questions after you leave hospital, you may wish to contact your GP or

Public H ealth Nurse (PHN).

MULTIDISCIPLINARY TEAM

The staff involved in your care are known as the multidisciplinary team and may include the

following:

� Medical Staff (Consultant, Registrar)

� Nursing Team

� D ischarge Co-ordinator

� Community Services D ischarge Liaison Officer

� D ietician

� Physiotherapist

� Occupational Therapist

� Speech & Language Therapist

� Pharmacist

� Social W orker

� Public Health Liaison Nurse

� Chaplain / Spiritual A dvisor

H ospital/Local H ealth O ffice (LH O ) Name H ere

Phone: 555-555-5555

Fax: 555-555-5555

E-mail: [email protected]



Page 5

1. Department of Health and Children (2001). T h e N a t i o na l He a l t h S t r a t e g y: Q u a l i t y

a nd f a i r ne s s - A He a l t h S ys t e m f o r yo u .

2 . Department of Health N HS (2003 ). D i s c h a r g e f r o m h o s pi t a l : pa t h wa y, pr o c e s s a nd

pr a c t i c e D e pa r t me nt o f He a l t h , N HS ( 2 0 0 3 ) .

3 . HeB e (2003 ). A dmi s s i o ns a nd D i s c h a r g e G u i de l i ne s , He a l t h S t r a t e g y I mpl e me nt a t i o n

P r o j e c t .

4 . Lees, L. (2007). N u r s e F a c i l i t a t e d Ho s pi t a l D i s c h a r g e , M & K P ub lishing. I S B N : 9 78 1-

9 0553 9 - 12- 3 .

5. Lees, L. (2006). E mergenc y Care (Delay ed Hospital disc harge: The Health P erspec tiv e).

T h e N a t i o na l E l e c t r o ni c L i b r a r y f o r He a l t h . N LH E mergenc y Care S pec ialist Lib rary .

www.lib rary .nhs.uk / emergenc y .

6. Lees, L., Holmes, K., (2005). E s t i ma t i ng a da t e o f di s c h a r g e a t wa r d l e v e l : a pi l o t s t u dy,

V ol. 19 , N o. 17, pp 4 0 – 4 3 . N ursing S tandard. www.nursing- standard.c o.uk .

7. Lees, L., Temple, R. (2005). C o mmu ni t y C a r e : P o l i s h i ng u p t h e A c t t o e s t i ma t e a da t e

o f di s c h a r g e . I ssue F eb ruary 2005, V ol., 9 , N o., 1. pp 22 – 24 . J ournal of Health S erv ic es

M anagement. www.ihm.org.uk .

8 . Lees, L. (2004 ). M a k i ng nu r s e l e d di s c h a r g e wo r k t o i mpr o v e pa t i e nt c a r e . N ursing

Times; 100: 3 7, pp 3 0 – 3 2. www.nursingtimes.net.

9 . Lees L. (2006). N o t j u s t a no t h e r s h e e t o f pa pe r : di s c h a r g e c h e c k l i s t s . The

Communic ator: RCN disc harge planning and c ontinuing c are forum. S ummer, 4 - 5.

10. Lees L, Holmes K (2005). E s t i ma t i ng a da t e o f di s c h a r g e a t wa r d l e v e l : a pi l o t s t u dy.

N ursing S tandard. 19 , 17, 4 0- 4 3 .

11. Lees L (2004 ). I mpr o v i ng t h e q u a l i t y o f pa t i e nt di s c h a r g e f r o m e me r g e nc y s e t t i ng s .

B ritish J ournal of N ursing. 13 , 7, 3 4 5- 4 3 2.

12. N E HB (N ov 2006). C o nt i nu u m o f C a r e , D i s c h a r g e a nd T r a ns f e r o f C a r e P o l i c y.

13 . N ew S outh W ales Department of Health (2006). N S W : A ne w di r e c t i o n f o r M e nt a l

He a l t h . www.health.nsw.gov .au/ polic ies/ pd/ 2008 / P D2008 _ 005.html

1 . R ef er en c es



Part 5 - Additional



Page 7

Please see at t ac h ed

Please see at t ac h ed

Appendix 1: Membership of National Integrated Discharge Planning Steering

Committee

N am e T i t le

John O’ Brien National Director Winter Initiative- Chairperson

Claire Broderick , Discharge Co- ordinator, AM NCH

Dr. Garry Courtney, Consultant Physician, St L uk es Hospital, Kilk enny

Jennifer Feighan, Proj ect M anager, National Hospitals Office

Ken Fitzgibbon, Acting Assistant Director of Nursing/ Bed M anager Beaumont Hospi-

tal

Cate Hartigan, Assistant National Director PCCC

Anne Keating, Bed M anager, Cork U niversity Hospital

Helena M aguire, Senior Proj ects Officer, Sligo General Hospital

Frank M cClintock , Assistant National Director, Ambulance Service

Winifred Ryan, Joint Chairperson, NHO Healthcare Records Steering Committee

Carmel Taheny, General M anager, PCCC, Sligo/ L eitrim

David Weak liam, Consultant in Public Health M edicine, Population Health

William Reddy, Transformation Programme 1 M anager

M ary Boyd, Director of Nursing, Cork U niversity Hospital

Dr Ronan Collins, Consultant Geriatrician, AM NCH

Dr Joe Devlin ( co- opted) Consultant Rheumatologist, WRH and Joint Chairperson of NHO

Healthcare Records Group

E ddie Byrne ( co- opted) Director of Nursing, Cavan/ M onaghan General Hospital, member

of NHO Healthcare Records Steering Committee

Tamasine Grimes Research Pharmacist, AM NCH

Brendan M urphy ( co- opted) General M anager, Organisational Design & Development and mem-

ber of NHO Healthcare Records Steering Committee

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Name Title

John O’Brien National D irector W inter Initiative - Chairperson

Claire Broderick D ischarge Co-Ordinator, AMNCH

D r. Garry Courtney Consultant Physician, St. Luke’s Hospital, Kilkenny

Jennifer Feighan Project Manager, National Hospitals Office

Ken Fitzgibbon D ivisional Nurse Manager, Medical D ivision,

Beaumont Hospital

Cate Hartigan Assistant National D irector PCCC

Anne Keating Head of Bed Management, Cork University Hospital

Helena Maguire Senior Projects Officer, Sligo General Hospital

Frank McClintock Assistant National D irector, Ambulance Service

W inifred Ryan Joint Chairperson,

NHO Healthcare Records Steering Committee

Carmel Taheny General Manager, PCCC, Sligo/Leitrim

D r. D avid W eakliam Consultant in Public Health Medicine, Population Health

W illiam Reddy Transformation Programme 1 Manager

Mary Boyd D irector of Nursing, Cork University Hospital

D r. Ronan Collins Consultant Geriatrician, AMNCH

D r. Joe D evlin (co-opted) Consultant Rheumatologist, W RH and Joint Chairperson of

NHO Healthcare Records Group

Eddie Byrne (co-opted) D irector of Nursing, Cavan/Monaghan General Hospital,

member of NHO Healthcare Records Steering Committee

Brendan Murphy (co-opted) General Manager, Organisational D esign & D evelopment and

mamber of NHO Healthcare Records Steering Committee

Tamasine Grimes Research Pharmacist, AMNCH

Virginia Pye D irector of Public Health Nursing, Longford/W estmeath

D r. Siobhan O’Halloran D irector of Nursing Services, HSE

Maureen Howley D ischarge Co-ordinator, Sligo/Leitrim

John W ickham Organisation D evelopment, HSE W est

Ms. Liz Lees Consultant Nurse, NHS and External Advisor

Appendix 2: List of Key Stakeholder Groups

Part 5 - Additional




Key Stakeholder Groups Key Stakeholder Groups

Irish D irectors of Nursing and Midwifery Asso-

ciation

Royal College of Physicians of Ireland

Royal College of Surgeons of Ireland D epartm ent of Health and Children

Association of O ccupational Therapists of Ire-

land

National Council for Nursing & Midwifery

Psychological Society of Ireland Patient Focus

Irish Association of Speech & Language Ther-

apy

Irish Advocacy Network

Medical Social W orkers Group Patients Together

Irish Chiropodists/Podiatrists O rganisation Patient Partnership

Irish Society of Chartered Physiotherapists Hospital Pharm acists’ Association of Ireland

Irish Nutrition and D ietetic Institute Irish Association of Em ergency Medicine

Irish Patients Association Irish Gerontological Society

National Casem ix Program m e The Federation of Irish Nursing Hom es

Irish College of General Practitioners Public Health Nursing Association

Am bulance Association Bed Managers Association

Irish Medication Safety Network Irish Pharm acy U nion

Irish Hospital Consultants Association

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