Ethon AI
Governance template

Turn “a human is always available” into a testable operating contract.

Complete one matrix for each approved workflow. The hospital owns the destination, response target, patient-facing language, context boundary, and after-hours fallback.

This template is not an operational policy until the responsible hospital teams fill it, test every branch, and approve the final version.
Workflow
Department and location
Policy owner
Clinical-risk reviewer
Privacy or security reviewer
Effective date
Version
Review cadence
Kill-switch owner
Escalation matrix

Nine categories. Eight decisions for each.

CategoryObservable triggerImmediate responseBlocked actionsDestinationContext allowedAcceptance targetFallback
Urgent language
Clinical question
Identity or privacy failure
Explicit request for a person
Low confidence or ambiguity
No permitted slot or action
Source-system conflict
Tool or system outage
Complaint, opt-out, or do-not-contact request
Policy block 1

Hard-stop rules

  1. 01Identity is not verified to the hospital-approved level
  2. 02The patient asks a clinical question or describes urgent symptoms
  3. 03The source system is unavailable or returns conflicting state
  4. 04The requested action exceeds configured permission
  5. 05The patient asks for a person
  6. 06Confidence remains below the approved threshold after one safe clarification
  7. 07Consent, contact, opt-out, or do-not-contact state is uncertain
  8. 08The approved destination and fallback are both unavailable
Policy block 2

Minimum context package

  1. 01Workflow and escalation category
  2. 02Verified identifier or verification-failed state
  3. 03Current appointment or task state
  4. 04Concise patient request and safe transcript excerpt
  5. 05Attempted action and tool result
  6. 06Urgency or fallback flag
  7. 07Timestamp, source, and correlation ID
Policy block 3

Failed-handoff procedure

  1. 01Tell the patient what will happen next using approved language
  2. 02Create the fallback task or callback
  3. 03Prevent additional automated actions that could conflict
  4. 04Record destination failure and owner
  5. 05Apply the after-hours or urgent pathway
  6. 06Include the event in the next QA review
Policy block 4

QA and incident-review metrics

  1. 01Escalations by trigger category
  2. 02Time to human acceptance
  3. 03Failed or abandoned transfers
  4. 04Cases missing required context
  5. 05Repeat contact caused by unresolved escalation
  6. 06Unsafe continuation after a hard stop
  7. 07Complaints and opt-out failures
  8. 08Policy changes created after incident review
Approval checklist

No blank owner. No untested fallback.

Every trigger is observable and testable
Every hard stop names the blocked actions
Every destination has an owner and fallback
Patient-facing language is approved
The context package is minimum necessary
After-hours behavior is tested
Call-drop and tool-outage cases are tested
Audit fields and the review owner are configured
The kill switch and manual procedure are documented
Source and review references

Use the source, then make the hospital decision.

Human Escalation Rules for Healthcare Voice AIHealthcare Voice AI Implementation Checklist for Hospitals in IndiaWHO Ethics and Governance of Artificial Intelligence for HealthNIST AI Risk Management Framework
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