Governance reminder
Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, local policy, professional responsibility or organisational governance processes. Ensure all improvement activity is agreed and implemented in accordance with local requirements.
1. Baseline findings summary
Pulled from dashboard where possible.
2. Key problems identified
3. Root cause / contributory factors
People · Process · Environment · IT · Documentation · Communication · Training · Workload
4. Improvement aim
Specific, measurable, achievable, relevant, time-bound
5. Suggested local improvement actions
Editable — framed as local implementation ideas, not mandatory national guidance.
| Action | Linked problem | Owner | Target date | Status |
|---|---|---|---|---|
| Standardise criteria-to-reside review at daily board rounds | Criteria-to-reside status not consistently documented | Clinical Director & Site Team | 6 weeks | Planned |
| Make Discharge Ready Date a required EPR field at transition to 'clinically ready for discharge' | DRD frequently missing | EPR Team & Clinical Lead | 10 weeks | Planned |
| Pre-assign a named discharge coordinator for anticipated Pathway 2/3 patients on admission | Coordinator identified late | Integrated Discharge Team | 4 weeks | In progress |
| Introduce a delay-escalation trigger at day 3 with a named action owner | Long delays not escalated | Site Manager | 6 weeks | Planned |
| Weekly ward-level delay dashboard shared at handover | Variation between wards | QI Lead | 3 weeks | In progress |
6. PDSA cycle 1
Plan · Do · Study · Act
7. Intervention log
8. Re-audit plan
9. Sustainability plan
10. Learning points
11. Governance summary
12. ARCP / portfolio evidence summary
Populates the ARCP evidence output.
Improvement themes
Common action areas for reducing discharge delay.
Daily criteria-to-reside review
Discharge Ready Date documentation
Criteria-led discharge
Expected discharge date reliability
Discharge pathway assignment
Discharge coordinator ownership
Transfer of Care Hub referral process
Social care referral process
Care package delays
Care home or placement delays
Community bed / intermediate care delays
Therapy assessment workflow
Equipment ordering and delivery
Transport booking
Discharge medicines / TTO preparation
Discharge summary preparation
Patient and carer communication
Capacity / best interests process
Safeguarding escalation
Escalation of long delays
Weekend and out-of-hours discharge processes
EPR discharge planning prompts
Board round documentation
Ward round discharge planning
Feedback to ward teams
Re-audit and sustainability