1 | Identify a ‘key worker’ to lead the process, usually a clinical nurse specialist |
2 | Clarify the hospital's overall philosophical approach to transition |
3 | Establish the timing of transfer with agreed management practice, particularly where there are differences—for example, endoscopy |
4 | Ensure adequate preparation for transfer, particularly in the paediatric service |
5 | Outline the step-by-step transfer process |
6 | Use any formal arrangements already set up |
7 | Identify how the process is coordinated. Clarify who are the key workers |
8 | Document the hospital's policy for involving other services |
9 | State how smooth communication and confidentiality will be maintained |
10 | Formally agree which hospital will lead transition if patients are receiving shared care |
11 | Document how the process will be monitored, evaluated and improved |