Module 5 – Quality, patient safety, and development
In this module, you will focus on quality and patient safety in Hospital at Home, and how safe care can be developed and maintained in practice. You will explore responsibilities and roles, including how clear communication and shared understanding support safe workflows in the home. The module also addresses risks and healthcare-related harm, and how these may differ when care is delivered outside the hospital environment. Finally, you will consider how implementation and improvement work can support sustainable development of Hospital at Home services over time.
Quality in Hospital at Home
This chapter explores how quality is defined and translated into practice within Hospital at Home. When care is transferred from the hospital to the patient’s home, the conditions change—but the goal of high-quality care remains. HaH should deliver care that is as safe, effective, and person-centred as hospital-based care.
What do we mean by quality in healthcare?
Quality in healthcare fundamentally refers to the provision of care and services that increase the likelihood of desired health outcomes and are consistent with the latest scientific evidence.
The WHO defines quality of care as:
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with evidence-based professional knowledge.”
In addition, the WHO highlights seven key dimensions that quality improvement efforts should address:
Safety – avoiding harm
Effectiveness (clinical effectiveness) – care that is evidence-based and appropriate to the patient
Patient-centredness – care that reflects the patient’s preferences and values
Timeliness – care delivered without unnecessary delay
Efficiency – minimising waste of resources
Equity – providing the same quality of care regardless of background
Integration – coordinated care across organisational boundaries
The Hospital at Home context
In HaH, quality is not only about what is delivered, but also about how and where care is provided. Care and treatment need to be adapted to the home environment, which is often more unpredictable and personal, yet can also enhance a sense of safety, autonomy, and involvement.
Quality must therefore be understood in relation to professional, technical, and relational aspects—always with the patient’s everyday life as the starting point.
The home changes the context—but not the goal
Quality work in HaH encompasses both quality assurance and quality improvement. It is carried out systematically within a quality management framework and aims to:
Ensure that care delivered in the home maintains a high standard
Continuously develop the organisation to meet patients’ needs
Quality work should be person-centred and grounded in everyday practice—close to patients and their families. It involves creating safety and reliability in an environment where healthcare professionals are not always physically present and where the setting is not specifically designed for clinical care. Patient safety is a particularly critical priority in HaH, as monitoring and interventions must be adapted to the home context. This requires both flexibility and clear procedures, while still allowing room for professional judgement. When care is delivered outside the traditional hospital setting, particular attention must be paid to accessibility, coordination, and continuity. This is not only a matter of technology, but also of ensuring clear agreements, effective communication, and flexibility in care delivery. Collaboration is essential—both with colleagues and with those living in the home environment.
Quality in Hospital at Home – Adaptation, communication and access
Quality in Hospital at Home relies on more than good intentions. It involves ensuring that care is both professionally sound and meaningful for the individual patient—within a home environment that rarely resembles a hospital setting. Below are some key aspects to consider in quality assurance:
Adaptation to the patient’s needs
Care should be person-centred and take into account the patient’s preferences, circumstances, and living environment—including cultural and psychosocial factors. A lack of adaptation may affect both quality of care and adherence.
Communication and coordination
Effective communication and coordination between healthcare professionals, the patient, and their family are essential. Gaps in information may lead to errors and delays, whereas good coordination supports continuity and a sense of safety.
Access to resources and equipment
The home must be able to accommodate the necessary care interventions. Limited access to medical resources—such as oxygen therapy or infusion pumps—may compromise patient safety.
Evidence-based care as a foundation for quality in HaH
How do we ensure high-quality care and patient safety—both in hospital and in the home? It requires knowledge—and the ability to apply it. Understanding evidence is therefore a cornerstone of modern healthcare practice.
What is evidence?
In healthcare, evidence refers to systematically collected and analysed knowledge used to assess how well a treatment, investigation, or intervention works—and how safe and applicable it is in practice.
For evidence to be considered reliable, it is typically evaluated based on three key criteria:
Objectivity – Have well-designed studies been used, such as randomised controlled trials (RCTs), observational studies, or systematic reviews?
Reproducibility – Can the results be replicated by other researchers under similar conditions?
Reliability and validity – Are the findings credible and relevant to the specific health issue or decision being considered?
Introduction to evidence based practice
Evidence-based practice
Patient safety
Patient safety is a central component of Hospital at Home, where care is delivered in the patient’s own home. This chapter highlights the importance of clear communication, well-defined responsibilities, and collaboration between patients, their families, and healthcare professionals.
Why is patient safety important—and what does it look like in Hospital at Home?
Safe care is a core principle of healthcare—and a shared responsibility. But what does this mean in practice when care and treatment are moved from the structured environment of the hospital to the patient’s home?
In HaH, the situation is often more complex and less controllable than on a hospital ward. Care is delivered in a context shaped by different actors, environments, and fewer standardised routines. This places new demands on collaboration, communication, and clear allocation of responsibilities. It also means that healthcare professionals need to reconsider how patient safety is managed—both proactively and in everyday practice.
What is patient safety?
Patient safety refers to ensuring that patients are not harmed as a result of healthcare interventions—whether due to incorrect treatment, errors, or unintended events. It involves a systematic focus on preventing harm, establishing safe workflows, and promoting a sense of safety for both patients and healthcare professionals.
In HaH, new challenges to patient safety may arise. For example, it may be unclear who is responsible for specific tasks—particularly if the patient is managing their own medication or if family members are involved in care. Ethical dilemmas may also occur, for instance when healthcare professionals assess that the home environment should be adapted for safety reasons, but the patient does not wish to make those changes.
Patient safety in HaH therefore requires:
Clear agreements and effective communication
Adaptation to the possibilities and limitations of the home environment
Respect for the patient’s integrity and autonomy
It is a shared responsibility—and safety is created through the interaction between professional competence, technology, and relationships.
Alice
Alice is six months old and continues intravenous antibiotic treatment at home after bacterial meningitis. Because she is fully dependent on her parents and has central venous access, patient safety depends not only on the treatment itself, but also on how safely the home environment can support that treatment.
Before and during the HaH pathway, the team assesses where medication and equipment can be stored, where the intravenous antibiotics can be prepared and administered, and how the central venous access can be protected in a busy family home with two older siblings. The parents need clear instructions, but they should not be left with unclear responsibility for clinical tasks.
The care plan is therefore adapted to the family’s situation. The team agrees with the parents on practical routines, such as keeping equipment out of reach of the siblings, ensuring a clean space for treatment, and knowing who to contact if Alice develops fever, reduced feeding, unusual tiredness, or changes in responsiveness.
Safe care in HaH – what is required?
When care moves into the patient’s home, responsibilities, collaboration, and the risk landscape change. Healthcare professionals must ensure quality and safety in an environment they do not control—often in close collaboration with municipal services and family members. This places new demands on oversight, coordination, and adaptability.
But what does safe care actually mean when it is delivered outside the traditional hospital setting?
Advancing safety in home care
From principles to practice: who is responsible—and how do we ensure safety in everyday care?
The video introduces five key principles that can help you understand and structure safe care in the home.
The five principles:
Autonomy and person-centred care should form the foundation of all aspects of care in the home
All organisations delivering care at home should develop and maintain a culture of safety
Learning and continuous improvement are essential to achieve and sustain high levels of patient safety
Interprofessional care and coordination are critical for safety in the home
Policies and funding models should support coordinated, high-quality home-based care—and reduce fragmentation caused by reimbursement systems
These principles highlight what is required—at professional, organisational, and system levels—to create safe and reliable care pathways.
However, principles alone are not sufficient. In real-world HaH care, situations frequently arise where responsibilities and roles overlap—and where even well-intentioned actions may lead to uncertainty. It is precisely in this tension between principles and practice that patient safety is tested.
One of the most central and challenging questions in HaH is: who is responsible for what—and how do we ensure that tasks do not fall between the gaps?
Responsibilities and roles
This chapter introduces responsibility and task shifting in Hospital at Home. It highlights how care is distributed between professionals, services, patients, and family members, and why unclear roles can affect safety, continuity, documentation, and follow-up.
Responsibility and task shifting—who does what in HaH?
In HaH, care and treatment are often distributed across multiple actors: nurses, physicians, therapists, home care services, and family members. This enables flexibility and interprofessional collaboration—but also introduces a risk of unclear responsibilities.
When responsibilities shift or overlap, this may lead to:
Uncertainty for both patients and healthcare professionals
Errors in medication management, documentation, or follow-up
Reduced continuity, where important information is lost between providers
This places demands on:
Clear agreements regarding roles and responsibilities
Ongoing communication between professionals and family members
A shared understanding of tasks—even when patients and family members are involved in care
Frameworks for responsibility and information governance
Healthcare professionals are required to document, communicate, and collaborate in ways that ensure continuity and safety in care delivery. While national guidelines and frameworks may vary, the underlying principles are broadly similar and are based on systematic processes, clear allocation of responsibilities, and learning from errors.
As a healthcare professional, it is therefore essential to be familiar with and adhere to the relevant frameworks—whether related to clinical documentation, information sharing, or quality improvement activities.
Risks and healthcare-related harm
This chapter introduces healthcare-related harm in Hospital at Home and how it can be prevented. It highlights risks such as medication errors, infections, falls, inadequate monitoring, pressure ulcers, and safety hazards in the home environment. The chapter explores how clear responsibilities, communication, risk awareness, patient and family education, and learning from incidents support safer care in the home.
Understanding and preventing healthcare-related harm in HaH
Healthcare-related harm refers to injuries that occur as a result of examination, care, or treatment—and that could have been avoided. This may include infections, falls, medication errors, or pressure ulcers. In Hospital at Home (HaH), new types of risks emerge as care is transferred from the familiar hospital environment to the patient’s home, where conditions for control, oversight, and support differ significantly.
Preventing healthcare-related harm is not only about avoiding mistakes, but also about developing ways of working and a culture that promotes learning from what goes wrong—and from near misses. Many incidents are not caused by individual actions alone, but by complex systems in which communication, responsibilities, and relationships play a crucial role.
What types of healthcare-related harm typically occur in HaH?
When care is transferred from the hospital to the home, both the context and the risk landscape change. Several studies indicate that the following types of healthcare-related harm are most common in HaH-like settings:
Medication errors
Errors may occur due to incorrect dosing, missed administration, or misunderstandings between healthcare professionals and patients or their families. The risk increases when patients or family members are involved in medication management.
Infections
Particularly infection-related complications associated with catheters and intravenous therapy. Hygiene in the home and education of patients and family members play a central role.
Falls
The home environment may include trip hazards and physical obstacles that healthcare professionals cannot always control—but which require attention and dialogue.
Inadequate monitoring
When vital signs are measured at home, it is crucial that data are followed up in a timely manner—and that there are clear agreements on who is responsible for what, and when.
Pressure ulcers and skin conditions
Particularly in patients with limited mobility, the absence of continuous clinical supervision may lead to delayed detection of early-stage pressure ulcers.
Physical conditions in the home environment
In HaH, care and treatment take place in an environment not designed for healthcare, which introduces specific safety risks:
Burns and electrical injuries when medical devices are used without appropriate safety measures
Slippery floors, loose rugs, or stairs that increase the risk of falls
Incorrect storage of medication or clinical waste
Limited access to handwashing facilities and inadequate hygiene conditions
Safe care in practice
This chapter introduces collaboration and communication as prerequisites for safe care in Hospital at Home. It highlights how shared responsibilities, clear information, and digital tools support coordination across professionals, sectors, patients, and families. The chapter also explores how patients can contribute to safety without taking over professional responsibility.
Interprofessional collaboration and communication—a prerequisite for safe care
When the patient is a co-creator of safe care, it also requires healthcare professionals to work closely and effectively together. This section explores how interprofessional collaboration and effective communication strengthen safety in HaH.
When care is moved from the hospital to the home, multiple actors are often involved across sectors and professional boundaries. Ensuring safe, coordinated care therefore depends on strong interprofessional collaboration and clear communication.
In HaH, hospital-based staff typically collaborate with municipal services, primary care, home healthcare providers, and the patient’s family. Breakdowns in communication can lead to serious patient safety risks—for example, if information about medication, clinical observations, or treatment goals is not transferred accurately. High levels of complexity and unclear roles further increase the need for structured approaches to communication.
Digital platforms and communication channels
In HaH, digital solutions play a central role in interprofessional collaboration—for example through shared electronic health records, video consultations, and communication tools. However, they may also introduce new challenges if all parties do not have access to the same information or if different IT systems are not interoperable.
The patient as a co-creator of safe care
When responsibilities and roles are not clearly defined, uncertainty can easily arise. However, safe care is not only about who does what within the healthcare team—it also concerns how patients and their families are involved in collaboration. In HaH, it is not sufficient to simply inform the patient; they need to be recognised as co-creators of safety.
Safe care in HaH relies on a trusting and active partnership with the patient and—often—their family members. When care is delivered in the home, the patient is no longer just a recipient, but increasingly a contributor to safety. This may involve participating in observation, handling equipment, and monitoring their condition—for example by measuring vital signs, following care plans, or responding to signs of deterioration.
This approach aligns with recommendations from the World Health Organization, which emphasises the importance of involving patients as active partners in their own care as a key strategy for achieving safe and high-quality healthcare. Similarly, the Institute of Medicine highlights that high quality and patient safety depend on patient involvement and respect for autonomy and preferences.
Viewing the patient as a co-creator does not mean transferring responsibility for safety to the patient. Rather, it involves healthcare professionals creating the conditions for safe, informed, and meaningful participation. This requires clear communication, appropriate support, and alignment of expectations.
In HaH, this form of collaboration can enhance situational awareness and enable earlier identification of changes in the patient’s condition. However, it depends on the patient understanding their role and feeling confident and capable in carrying it out. Cultural, social, and health literacy-related factors also play an important role in shaping this capacity.
Implementation and improvement
This chapter focuses on implementation—that is, how new knowledge and evidence are translated into concrete practice in healthcare. For HaH to become a sustainable and safe model of care, it is not enough for evidence to exist; it must be integrated into everyday practice and adapted to the specific context.
Is there evidence for Hospital at Home?
Before working with the implementation of evidence and new care interventions in HaH, it is important to first consider whether there is sufficient evidence to support HaH as a model of care. For any approach to be implemented systematically and legitimately in healthcare, it must be grounded in research-based knowledge. The first step in any implementation process is therefore to assess whether evidence exists regarding effectiveness and patient safety—and whether this evidence is strong enough to justify wider adoption.
Evidence for Hospital at Home
In many cases, HaH is a safe and effective alternative to traditional hospital care—when offered to appropriately selected patients and supported by suitable organisation.
Safety and mortality – Several studies demonstrate lower or unchanged mortality rates among patients receiving HaH compared with those admitted to hospital. This suggests that the model is safe when delivered under appropriate conditions.
Readmissions – There is a tendency towards fewer readmissions among HaH patients, indicating that care may be both stabilising and sustainable.
Patient satisfaction and quality of life – Patients often report higher satisfaction and improved quality of life. HaH can promote autonomy, a sense of safety, and a more person-centred care experience.
Infections and mobilisation – The risk of hospital-acquired infections is reduced, and patients often mobilise earlier in the home environment.
Overall, these findings indicate that HaH is an evidence-based model of care that can be implemented with expectations of both safety and patient satisfaction—provided that patient selection is appropriate and organisational structures are robust.
From knowledge to practice—why evidence alone is not enough
Although HaH is evidence-based, this does not mean that knowledge is automatically translated into practice. There is often a gap between the knowledge generated through research and what is actually implemented in healthcare. This is particularly evident in new models of care such as Hospital at Home, where existing routines and workflows must be adapted to an entirely different care environment—the patient’s home.
Why does the knowledge–practice gap occur?
Limited access to resources and training
Variation in experience and culture within interprofessional teams
Resistance to change and established habits
Logistics and technology that are not adapted to the home setting
As a result, even well-documented solutions may not be used optimally—potentially affecting both quality of care and patient safety.
Implementation science and Hospital at Home
It is not enough for a healthcare intervention to be effective—it must also be feasible to implement in a complex and demanding real-world setting. This is where implementation science becomes essential. It focuses on how new knowledge can be effectively integrated into practice, and which factors contribute to making interventions sustainable over time.
HaH presents particular challenges: care must function outside the structured environment of the hospital and be adapted to the patient’s home. This requires adjustments across multiple domains, including technology, documentation, communication, and workflows.
Implementation is a process—not a single event. It requires careful planning, organisational support, interprofessional collaboration, and continuous adaptation. Research in implementation science shows that simply “informing and educating” is rarely sufficient; attention must also be given to culture, motivation, and available resources.
An organisation is ready for change when staff:
Believe that the change is important and worthwhile
Have confidence in their ability to carry it out
Feel a sense of responsibility for making it succeed
Models for implementation
A model is a simplified representation of reality that helps structure complex processes—such as the implementation of new knowledge into practice. Models provide a visual and conceptual framework for the different steps and actors involved in translating knowledge into practical action.
In HaH, models can be particularly useful, as healthcare professionals often work in new contexts and need to rethink roles, responsibilities, and collaboration. A model can support understanding of how research-based and practice-based knowledge can be translated into concrete actions—and how to address the challenges and opportunities that arise when the home becomes the setting for care.
One example is the Knowledge-to-Action model which is widely used in implementation research and practice.
The model divides implementation into two overarching components:
Knowledge creation
This involves generating and synthesising knowledge—from research, clinical experience, and patient perspectives. For example, it may include new evidence on the effectiveness of a treatment or insights into how technology functions in the home setting.
Action
This involves making knowledge applicable and usable in practice. It includes adapting knowledge to the specific context, involving relevant stakeholders, initiating activities, addressing barriers, and evaluating outcomes.
A key feature of the model is that implementation is not a linear process, but a dynamic and iterative interaction between knowledge and action. It requires continuous reflection on how new knowledge can best be integrated into the local context—for example, in collaboration with patients and their families within the HaH setting.
Knowledge-to-Action model
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