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Goal 5: Optimal hospital care and discharge practice from the point of admission

Optimal hospital-based care is provided for people who need short term, or ongoing, assessment or treatment for as long as it adds benefit to outcome, with a relentless focus on good discharge practice.

Quality Statement:

·        People admitted to hospital should be treated consistently and reliably in line with the expectations of health, social care, third and independent sector partners in Wales as described in Welsh Government Hospital Discharge guidance. 

·        People admitted as an emergency to a hospital setting should: 

    • Be reviewed by an appropriate consultant as soon as possible after admission. This should be no later than 14 hours from the time they were admitted to hospital. Frailty assessments should be completed where required on admission.
    • Should have a reconciled list of their medications within 24 hours of their admission.
    • Be fully involved in and informed of plans for their treatment, recovery and discharge from hospital. They should have answers to four key questions on a daily basis: What is the matter with me? What is going to happen to me today? When am I going home? What is needed to get me home?
    • Have a structured patient handover during transitions of care, with a focus throughout on return to home as soon as they are clinically fit to leave.
    • Have a patient care plan that includes active intervention to avoid deconditioning, maximise recovery and support independence throughout their hospital stay.
    • Have access to rehabilitation regardless of condition and ward to which they are admitted; available immediately upon admission, or as soon as the person is medically able to participate to accelerate recovery and reductions in side effects.

·        Frail and vulnerable people, including those with disabilities and mental health problems of all ages, should be managed assertively but holistically (to cover medical, psychological, social and functional domains) and their care transferred back into the community as soon as they are medically fit, to avoid loss of ability to self-care. 

·        The person’s consultant is responsible for deciding when they are clinically ready to move on from an acute phase of their care, and agrees an ‘individual clinical criteria for discharge’ to enable return home even if the consultant is not present. 

·        People who are eligible for discharge through Non-Emergency Patient Transport Services will receive safe, timely and comfortable transport to and from their destination, without detriment to their health. They are treated with dignity and have their religious and cultural beliefs respected. Where people are at a hospital ward or department, the Health Board will ensure they are ready to leave at the time they notify the transport provider of readiness to travel.


It is essential that pharmacy teams are fully integrated in multidisciplinary teams. Doing so supports efficient patient flow through hospitals, minimises medicines related harm that can occur at transfers of care, and facilitates safe and timely discharge.

Pharmacy services can help to ensure that patients are discharged from hospital in a safe and efficient way and health boards should ensure they are implementing in full the guidance Optimising Pharmacy Services at Hospital Discharge published in 2022.

To read more about Goal 5 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 5 Lead: Rachel Taylor -