Inclusion, exclusion and audit criteria

DEMO DATA

Who to include, who to exclude, and the 32 audit criteria measured in this cycle.

OverviewHow to useProject setupTeamInclusion / exclusionData collectionDashboardSubmissionsFindingsImprovementRe-auditResourcesExport centreSettings
Inclusion criteria
  • •Adults aged 16 years or older (unless locally adapted)
  • •Inpatients documented as medically fit for discharge, clinically ready for discharge, discharge ready, medically optimised or no longer meeting criteria to reside
  • •Patients remaining in hospital after discharge readiness has been identified
  • •Patients where a Discharge Ready Date, criteria-to-reside review or local equivalent should be documented
  • •Patients managed in the wards, units, departments, specialties or pathways included in this audit
  • •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
  • •Patients under 16 years old (unless locally adapted)
  • •Maternity patients unless locally adapted
  • •Mental health inpatient discharges unless locally adapted to mental health clinically-ready-for-discharge processes
  • •Patients who still meet criteria to reside at the point of review
  • •Patients transferred to another acute hospital for ongoing acute care where criteria to reside remain met
  • •Patients who self-discharge, die in hospital or leave against medical advice where DRD does not apply under local policy
  • •Day-case or outpatient episodes unless local scope includes them
  • •Duplicate records or duplicate delay episodes
  • •Records outside the selected audit period
  • •Records unavailable for review
  • •Cases where local governance approval is required but has not been obtained
  • •Direct patient identifiers must not be entered into the tool
Audit criteria (32)
Aligned with NHS England Hospital Discharge & Community Support guidance, the Model Discharge Pathway, Discharge Ready Date guidance, NICE NG27, NICE QS136 and local trust discharge policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C1
    Criteria to reside were reviewed and documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  2. C2
    Discharge readiness status was documented using local terminology.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  3. C3
    Discharge ready date was documented where applicable.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  4. C4
    Date patient became discharge ready was clear.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  5. C5
    Responsible senior clinician or accountable team was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  6. C6
    MDT agreement or relevant professional input was documented where required.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  7. C7
    Discharge pathway was assigned.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  8. C8
    Expected discharge date was documented or updated.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  9. C9
    Named discharge coordinator or responsible coordinator was identified where required.
    Target ≥ 85% · Yes / (Yes + No) — N/A and Unable to determine excluded
  10. C10
    Discharge destination was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  11. C11
    Discharge plan was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  12. C12
    Patient was informed and involved in discharge planning where appropriate.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  13. C13
    Family, carer or important-person involvement was documented where appropriate.
    Target ≥ 85% · Yes / (Yes + No) — N/A and Unable to determine excluded
  14. C14
    Capacity, best interests or advocacy considerations were documented where relevant.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  15. C15
    Safeguarding issues were considered or escalated where relevant.
    Target ≥ 95% · Yes / (Yes + No) — N/A and Unable to determine excluded
  16. C16
    Primary reason for discharge delay was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  17. C17
    Reason for delay was reviewed or updated within the locally agreed frequency.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  18. C18
    Action owner for the delay was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  19. C19
    Next action or escalation step was documented.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  20. C20
    Transfer of care hub referral was completed where required.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  21. C21
    Social care referral or assessment was completed where required.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  22. C22
    Therapy assessment was completed where required.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  23. C23
    Equipment needs were identified and actioned where required.
    Target ≥ 85% · Yes / (Yes + No) — N/A and Unable to determine excluded
  24. C24
    Care package, care home, community bed or intermediate care status was documented where relevant.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  25. C25
    Transport need was identified and actioned where required.
    Target ≥ 85% · Yes / (Yes + No) — N/A and Unable to determine excluded
  26. C26
    Discharge medicines / TTO were prepared or completed where required and not avoidably delayed.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  27. C27
    Discharge summary was prepared or completed where relevant.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  28. C28
    Non-urgent tests, investigations or reviews were not allowed to delay discharge where safe outpatient/community alternatives were appropriate.
    Target ≥ 85% · Yes / (Yes + No) — N/A and Unable to determine excluded
  29. C29
    Escalation of delay was completed where the delay met local escalation triggers.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  30. C30
    Clinical status was re-reviewed if the patient's condition changed during the delay.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  31. C31
    Documentation was clear enough for another clinician or discharge coordinator to understand the delay reason, owner and next action.
    Target ≥ 90% · Yes / (Yes + No) — N/A and Unable to determine excluded
  32. C32
    Any discharge delay-related safety concern was escalated or actioned where identified.
    Target ≥ 100% · Yes / (Yes + No) — N/A and Unable to determine excluded