Development and Implementation of a Condition H policy: Family Initiated Escalation of Care

Abstract

Patient safety remains a critical priority in healthcare, particularly in recognizing and responding to early signs of patient deterioration. Family-initiated escalation of care programs allow patients and families to activate a rapid response team (RRT) when concerns about a patient's condition are not adequately addressed. At a Magnet-designated Level I trauma center in Montana, the existing Condition H program lacks a formal policy, standardized workflow, and consistent education for staff and patients, limiting its effectiveness and sustainability. This quality improvement project aims to develop and implement a policy and workflow protocol for Condition H to improve patient safety and align with Leapfrog Hospital Safety Grade standards. Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and evaluated using Plan-Do-Study-Act (PDSA) cycles, the project includes policy development, staff education, and patient-family educational materials. Implementation is expected to improve communication between families and healthcare teams, support early recognition of patient deterioration, and strengthen patient-centered care. Anticipated outcomes include a ten percent reduction in ICU transfers and failure-to-rescue events, and enhanced Leapfrog patient safety scores.