Understanding the Theory and Process of Strategy Development: Clinical Guidelines

Clinical guidelines are systematically developed statements to assist practitioner and patient decisions about the provision of appropriate health care in specific clinical circumstances. They can change clinical practice and affect patient outcome but their effectiveness depends on how they are developed, implemented and monitored.

They can be used for:

• the introduction of a new drug/intervention (e.g. to stop people smoking, obesity drug)
• re-assessment of a drug (e.g. use of antibiotics).

They should:

• be given priority if national guidelines exist or are developed (don't forget NICE guidelines)
• be firmly based on clinical and cost effectiveness
• have recommendations that are explicitly linked to evidence.

They are more effective if they:

• take into account local circumstances, there is always a tension between nationally developed guidelines and the need for local ownership
• are disseminated through proactive education
• are implemented by patient specific reminders.

Obstacles:
Development

• Internal barriers
  • inadequate evidence base
  • lack of validity
  • lack of reliability
  • lack of reproducibility
  • clinical inflexibility
  • poorly structured or ambiguous guidelines
  • absence of local ownership
     
• External barriers
  • problems with dissemination
  • problems with user groups
  • perceived additional workload
  • concerns of eroding clinical autonomy
  • fear of external audit
  • fear of increased litigation
  • no systematic programme to promote, disseminate or monitor guidance

Implementation

• failure to link marketing of guidelines to educational initiatives
• accessibility of guidelines when required in the clinical context
• professional resistance: fatigue, priority overload, guideline booklet huge

Monitoring

• lack of resources from audit or academic detailing (can use EPACT data for drugs):
• Electronic Prescribing
• Analysis
• Costing

© K Enock 2006