The problem
the gap after
The mistake is rarely the decision. It is what happens after.
Hospital software is very good at recording what was decided. It is much worse at showing whether it actually happened - whether the prescription was sorted out, the referral came back, the worrying test result was acted on, or the patient ever found a regular doctor.
So R47 starts somewhere else. We treat each thing that was promised as a item in its own right: who owes it, what counts as done, when it is late, and a clock running the whole time. Once every promise is written down that way, it stops being a vague sense that something slipped and becomes something you can actually see.
What we track
six promises
Six kinds of promise
Each one can be opened, given an owner, timed, missed, and put right - which is what makes it countable.
- 01
Medication mix-up
The list of drugs does not add up, and nobody has resolved it.
- 02
Worrying test result
A result came back abnormal and no one has acted on it.
- 03
Referral
A patient was sent to a specialist, and nothing has come back.
- 04
Contact after discharge
Someone was meant to check in after the hospital stay.
- 05
Something in the way
Cost, transport, language or housing is blocking the next step.
- 06
Teach-back
The patient was meant to be shown how to manage at home.
Next
see it