Areas of good practice
Equipment needs were identified and actioned where required.
91.1%
Transport need was identified and actioned where required.
87%
Priority gaps
Discharge pathway was assigned. (target ≥ 90%)
70.9%
Documentation was clear enough for another clinician or discharge coordinator to understand the delay reason, owner and next action. (target ≥ 90%)
71.7%
Transfer of care hub referral was completed where required. (target ≥ 90%)
73.7%
Family, carer or important-person involvement was documented where appropriate. (target ≥ 85%)
75.4%
Next action or escalation step was documented. (target ≥ 90%)
75.4%
Criteria to reside were reviewed and documented. (target ≥ 90%)
75.9%
Social care referral or assessment was completed where required. (target ≥ 90%)
75.9%
Responsible senior clinician or accountable team was documented. (target ≥ 90%)
76.8%
Escalation of delay was completed where the delay met local escalation triggers. (target ≥ 90%)
76.8%
Expected discharge date was documented or updated. (target ≥ 90%)
78.2%
Care package, care home, community bed or intermediate care status was documented where relevant. (target ≥ 90%)
78.6%
Non-urgent tests, investigations or reviews were not allowed to delay discharge where safe outpatient/community alternatives were appropriate. (target ≥ 85%)
79.7%
Action owner for the delay was documented. (target ≥ 90%)
80%
Discharge plan was documented. (target ≥ 90%)
80.7%
Clinical status was re-reviewed if the patient's condition changed during the delay. (target ≥ 90%)
81%
Discharge summary was prepared or completed where relevant. (target ≥ 90%)
81.5%
Safeguarding issues were considered or escalated where relevant. (target ≥ 95%)
82.1%
MDT agreement or relevant professional input was documented where required. (target ≥ 90%)
82.5%
Discharge ready date was documented where applicable. (target ≥ 90%)
82.8%
Date patient became discharge ready was clear. (target ≥ 90%)
83.1%
Any discharge delay-related safety concern was escalated or actioned where identified. (target ≥ 100%)
83.3%
Discharge medicines / TTO were prepared or completed where required and not avoidably delayed. (target ≥ 90%)
83.9%
Therapy assessment was completed where required. (target ≥ 90%)
84%
Capacity, best interests or advocacy considerations were documented where relevant. (target ≥ 90%)
84.2%
Named discharge coordinator or responsible coordinator was identified where required. (target ≥ 85%)
84.3%
Patient was informed and involved in discharge planning where appropriate. (target ≥ 90%)
84.5%
Primary reason for discharge delay was documented. (target ≥ 90%)
84.9%
Reason for delay was reviewed or updated within the locally agreed frequency. (target ≥ 90%)
85.2%
Discharge destination was documented. (target ≥ 90%)
88.1%
Discharge readiness status was documented using local terminology. (target ≥ 90%)
88.9%
User commentary
Editable interpretation for reports and governance meetings.
Governance & safety implications
Any immediate clinical deterioration, safeguarding concern, capacity concern, unsafe discharge concern, medication safety concern, transport risk or unresolved discharge risk identified during this audit must be escalated through local clinical, operational and governance pathways. This tool does not replace local escalation processes or make discharge decisions.