Q How do we make sure that the guidelines we develop remain relevant?
A All guidelines, whether developed locally or nationally, should have an in-built review date. It is also important to ensure that someone is responsible for keeping a 'watching brief' on the subject so that relevant material that appears before the review date can, if necessary, be incorporated into a new version of the guideline. This material will include:
- New research findings
- New consensus statements
- Results of local audit or other peer review activity
- Changes in local circumstances (such as opening a high dependency unit, agreeing open access to certain tests etc.).
The key here is not to leave formal review to change, or responsibility for the 'watching brief' to a group of people, none of whom is clearly responsible to the group for raising questions about whether a guideline needs to be reviewed.
The creation of NICE in England, and similar initiatives elsewhere in the UK (such as SIGN and SHTAC in Scotland) will make it easier than in the past to access up-to-date information about best practice and to avoid local work which duplicates effort to no-one's benefit.
Q With the advent of PRODIGY, and the likelihood that it will be widely disseminated among GPs, we will be faced with readymade guidelines. There is a certain amount of latitude for individualisation within the system, but major changes in the guidelines will not be easy. Might we lose many of the benefits gained from locel guideline adaptation and development, or can we use such software to develop them even further?
A Guidelines are not a substitute for clinical judgment. It remains the privilege – or burden – of every clinician to deal with each patient in the most appropriate way. This means taking into account relevant evidence and recommendations, but in addition deciding how these apply – if at all – to the individual's circumstances.
This principle remains true whether or not the guideline is embedded in a nationally developed computer-based system such as PRODIGY. What appears on the screen when PRODIGY is used is advice, not instruction. If your judgment – based on locally developed guidelines or otherwise – differs, then you must follow your judgment.
However, this does not mean that you can ignore advice on a whim: a good test to apply to all decisions that do not follow properly developed guidelines is to ask yourself whether you would have a clear and convincing answer to the question: 'Why did you not follow the guideline in this case?'
Local adaptation or development of guidelines may benefit from the work that goes into a system such as PRODIGY. It is important, though, to be quite certain that the reasons for local work on guidelines are clear and do not include 'not-invented-here-so-it-can't-be-any-good'.
Q I am seeking working definitions of, and the differences between, guidelines, standards, procedures,apolicies, protocols etc., for teaching purposes. Recent advice seems to indicate that the legal position of the document depends more on how it is written than on what it is called. What can we say to healthcare professionals when they ask us to help draw up one or other of these documents? Is there any effective difference in law?
A Words such as 'guideline' and 'protocol' are, unfortunately, used in different ways by different people at different times. Although the following definitions are not universally accepted, you may find them useful.
- Audit: A process used by health professionals to assess, evaluate and improve the care of patients in a systematic way, to enhance their health and quality of life1 or
A systematic, critical analysis of the quality of care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient2
- Criteria: Predefined dimensions or variables against which activity can be compared3
- Critical appraisal: A means of assessing the usefulness and validity of the information for a particular question or decision4
- Effectiveness: The degree of conformity between actual result and desired outcome3
- Evaluation: The systematic and scientific process of determining the extent to which a planned intervention or programme achieves predetermined objectives3
- Guidelines: Systematically developed statements that assist in decision making about appropriate healthcare for specific clinical conditions3
- Outcome: Alteration in the health status of the patient directly attributable to clinical action or inaction2
- Policy: A course or principle of action adopted or proposed by a government, party, business or individual5
- Procedure: An established or official way of doing something5
- Protocol: An adaptation of a clinical guideline to meet local conditions and constraints3
- Standard: Specification of process and/or outcome against which performance can be measured2
- Clinical Resource and Audit Group. Clinical Guidelines. Edinburgh: Scottish Office, 1993.
- National Audit Office. Clinical Audit in England. London: HMSO, 1995.
- Community Practitioners' and Health Visitors' Association. Clinical Effectiveness Information Pack. London: CPHVA, 1998.
- Irvine D, Irvine S. Making Sense of Audit. 2nd edn. Abingdon: Radcliffe Medical Press, 1997.
- New Oxford Dictionary of English. Oxford: Claringdon Press, 1998.