Implementing Martha’s Rule: from permission to empowerment

Martha’s Rule is a National Patient Safety Initiative that gives patients, families and staff the right to ask for a rapid review if they are worried someone’s condition is getting worse. The initiative also uses a patient wellness questionnaire to help detect any unexpected signs of deterioration early. Verity Mather, Quality Improvement Lead in our Patient Safety and Care Improvement team, reflects on her role in helping colleagues to implement the initiative.

Supporting the Liverpool Heart and Chest Hospital (LHCH) team in testing Martha’s Rule has been genuinely inspiring. From the outset, our role was to facilitate and guide, creating the conditions for the team to explore, test, and refine the work in a way that made sense for them as a site. The progress that has been made belongs to the team; our contribution was to support their thinking, encourage reflection, and help remove barriers along the way.

When LHCH joined Phase 2 of the pilot, I was conscious of the very real pressures on staff time and competing priorities. I expected some resistance, or at least limited capacity to engage. The reality was quite the opposite. I was struck by the tenacity and determination of the team, and by how strongly they valued the opportunity to connect with Phase 1 pilot sites. That connection offered not only practical learning, but also reassurance and a sense that they were on the right path and not working in isolation.

One member of staff captured the impact perfectly: “You gave us the space to slow down, plan properly, and test one component at a time. It’s given us the confidence and encouragement to really drive this work forward.”  

This reflected our coaching-style approach, focusing on site-specific challenges, encouraging small tests of change, and allowing the team to build confidence through their learning.

As testing progressed, it became clear that while a patient call-for-concern route already existed, the greatest opportunity lay in strengthening staff escalation. A key focus was helping teams fully understand and trust the principle that any member of staff can request a review from a different team at any time if they are worried about a deteriorating patient. That cultural shift from permission to empowerment was critical.

The testing period allowed the team to step back and look honestly at how reliably escalation processes function in the realities of a busy clinical environment. While the intent to escalate concerns was always there, the pathways were not always clear enough. With close observation and refinement, uncertainty was removed and clarity improved. This reinforced an important learning: when processes are complex, staff feel less able to use them. Simple, consistent systems are far more likely to be used without hesitation.

Perhaps the most powerful reflection from this work is that effective escalation is not primarily about the process itself, but about the culture that surrounds it. Policies alone do not create safety. What matters is whether people feel confident, empowered, and psychologically safe enough to speak up and act on concern. Martha’s Rule provided a structured lens to explore this, prompting meaningful conversations about confidence, hierarchy, and shared responsibility amongst staff.

Personally, I found this work deeply gratifying. Watching the team grow in confidence, challenge assumptions, and take ownership of the changes reminded me why this kind of improvement work matters. Seeing staff feel enabled rather than overwhelmed and hearing them describe how the work had given them clarity and momentum, was incredibly rewarding. It was a privilege to support a team so committed to learning, collaboration, and doing the right thing for patients and staff.

Landmark for Martha’s Rule implementation: read more about our support for the implementation of Martha’s Rule Health Innovation North West Coast - Landmark for Martha's Rule implementation