Policy for the Discharge and transfer of children and young people ...

7.2. All managers will be aware of the contents of this policy and will ensure that theirstaff have read and understood the procedures and processes relating to the dischargeand transfer of patients. New versions of the policy will be circulated to all managers fordissemination to their staff with a summary of all amendments made to the updatedversion.8. Monitoring compliance and effectivenessElement to bemonitoredLeadToolFrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedCompletion of a discharge planDocumentation of liaison with other professionals and agenciesTimeliness of documentation to other professionalsCompletion of a transfer documentDocumentation of details of transfer in patient notesSenior Matron Child HealthAn agreed audit tool developed by the Directorate and registeredwith clinical effectiveness as part of the annual records audit, toinclude the elements to be monitored described aboveMonthly quality audits will monitor the completion of discharge plansAnnually for the whole policy through audit of recordsMonthly for ward quality audits on discharge plansAudits will be reported via the Divisional Audit and Guidelinesmeeting in the Directorate. Action plans, incidents and complaintsrelated to discharge and transfer will be brought back to theDirectorate via Clinical Governance meetings.Reports should be discussed at the appropriate Operational BoardReports should be discussed at the appropriate Operational Board andany high risk areas highlighted and action plans developed to addressany gaps identified.Lessons will be shared with all the relevant stakeholders bypresentation at Child Health audit and guidelines meetings and via theChild Health risk management newsletter. Following liaison withrelevant stakeholders, any required changes to practice will bediscussed at Directorate Clinical Governance meetings, prior to beingreflected in this policy and implemented clinically.9. Updating and ReviewThe policy author is responsible for ensuring the policy is kept up to date, with reviews beingcarried out at least once every 3 years, reflecting changes in legislation where necessary.The author must also ensure the policy has been screened to establish if it requires a fullImpact Assessment against the Race Relations Amendment Act to ensure no minority groupis discriminated against within the document.10. Equality and Diversity10.1. This document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement.10.2. Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Policy for the discharge and transfer of children and young people from child healthPage 11 of 38