Clinical Governance 

How to go about developing a guideline

Decide which areas of your practice most need guidelines

Usually two or more of the following will apply:

  • High risk

  • High volume

  • High cost

  • Known or suspected problems

  • New national guidelines

Decide who needs to be involved or consulted

   You will need the help and/or the approval of:

  • Colleagues in your speciality/ profession

  • Colleagues in other specialities/ professions who may have expertise relevant to the guideline

  • Representatives of all professions and/or speciality groups who will have to use the guideline

Note: if your guideline includes guidance to nurses, involve the Nursing Directorate early

  • Representatives of support specialities, if demand for their services may be affected

  • Drug and Therapeutics Committee, if the guideline recommends specific drug therapies

Review and appraise the evidence

  • National guidelines

  • Systematic reviews

  • Other reviews

  • Individual papers

  • Expert opinion

The stronger and more authoritative the evidence the easier it is to get consensus.
BUT you can’t trust literature if its methodology is poor or unclear.
Make a first draft

Use the Trust Guidelines Template (WORD), available from Governance Support or the Pink Book Editor, who can be contacted via the Library (see the contacts page).

Using the template has been found to help ensure that the guideline meets all of the Trust criteria. The template has been designed to enable easy translation to HTML (web page) format, but some advanced features of WORD such as graphics and text boxes may not convert well unless correctly set up. An advice sheet on the use of the template is also available.

Note: documents relating to the development of guidelines can also be found on the documentation page.

Consult, redraft, consult again until agreement is reached

The consultation process may seem onerous but is crucial to successful guidelines development.

When circulating documents for comment, put an explicit time limit on replies and warn that no reply implies agreement.

If you cannot gain full agreement, different options may need to be specified in the guideline to accommodate different views. Document this process in the guideline. Users are more likely to follow recommendations if their origins are clear.

As you draft and revise your guideline, check that all the issues in the Guidelines Appraisal Check List have been addressed (see first panel below for a summary).

Send the final draft to the Pink Book Editor

When you consider that you guideline is complete and has been reviewed by all relevant person, departments and/or committees, send your by e-mail or on a floppy disk to the Pink Book Editor (c/o Library).

The guideline will then be submitted to the Pink Book Editorial Group for approval (see second panel below).

 

Appraisal checklist used by the D&T Committee and the Pink Book Editorial Group

Is the authorship of the guideline clear?

Is there evidence that available literature and/or national guidelines have been reviewed? (Key references and/or source guidelines should be cited.)

Is there evidence that all interested parties have been adequately consulted and the guideline represents their consensus view (including those who must apply the guideline to their daily work)?

Is information given as to how comments were addressed and disagreements resolved?

RATIONALE

Are the reasons for developing the guidelines clearly stated?
Are the guideline objectives clearly stated?

Is there a clear rationale for the recommendations made?

Are there any explicit references to age? If so, is it clear how far these are informed by evidence of clinical effectiveness and/or patient and carer views.

FORMAT

Does the guideline carry a date of issue?

Does it carry a suitable review date? (maximum review period 3 years, 12 months recommended for new practice)

Does it specify the owner (who will be responsible for future review?)?
Can each page be linked to its source document?

IMPLEMENTATION

Is it clear to which patients the guideline applies?

Is it clear to what clinical condition/s the guideline applies?

Is it clear who should use the guideline?

Are the recommendations clearly presented?

If there are there different possible options for management are they clearly stated?

Is there a quick reference guide?

Can auditable standards be easily derived from the guideline document?

Are there likely to be significant resource implications for this Trust or for other members of the local health community? If so, have they been adequately addressed?

Is the guideline approved by the Clinical Director or the Directorate General Manager?

 

About the Pink Book Committee and its editorial subgroup

The Pink Book Committee aims to promote a collaborative approach to the development and effective dissemination of guidelines in West Suffolk. It is chaired by a senior clinician and membership is multidisciplinary, including medical and nursing staff and representatives from Patient Advice and Liaison, the Library, IM&T and Clinical Governance Support.

The Editorial Group is a subgroup of the Pink Book Committee. It meets twice monthly. Its aim is to ensure that new or updated guidelines in the West Suffolk Hospitals Trust are of a high standard and meet the criteria jointly set out by the Drugs and Therapeutics and Pink Book Committees and approved by the Clinical Governance Implementation Group. All new or updated clinical guidelines should be submitted to the panel for approval. See inside this leaflet for criteria used by the panel in their evaluations.

The Editorial Group will consider all guidelines submitted more than 7 days before the relevant meeting and will provide written responses to authors. It may:

  • Approve the guideline

  • Require minor amendments. In this case the chairman can take executive action to approve it immediately these have been made

  • Identify areas of concern and ask for an amended guideline to be resubmitted to a future editorial meeting

Once formally approved, the guideline will be given a Trust registration number and issue date. It will then be made available on the Pink Book, accessible from the Trust Intranet and Suffolk Extranet. Any other dissemination is the responsibility of the document owner.

 

 IN THIS SECTION
Introduction
Clinical Governance
What's Involved
Clinical Guidelines
Documentation
Contacts

Clinical Guidelines

“Systematically developed statements which assist clinicians and patients in making decisions about appropriate treatments for specific conditions”
NHS Executive 1996

Guideline adherence: “Conformity in fulfilling or following official, recognised or institutional requirements, guidelines, recommendations, protocols, pathways, or other standards”
Medline thesaurus

Clinical guidelines support clinical governance. This is about improving the quality of patient care and reducing risk. Wherever possible guidelines should be grounded in evidence-based practice and incorporate national guidance. The intention is to improve clinical practice and simplify audit.

The NHS Executive recommend that local guidelines development is best done by a process of multiprofessional review and adaptation of national guidelines - national guidelines tend to have higher scientific validity but local modification is needed to ensure effectiveness in the local setting by:

  • taking into account local conditions

  • encouraging ownership by those who must apply them

(NHSE, 1996, Clinical Guidelines; Using Clinical Guidelines to Improve Patient Care in the NHS)

West Suffolk Hospitals NHS Trust

Last Modified: July 2002