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As previously raised, there are many competing guidelines (NICE, NSF, PCT, etc.) and formularies (Clinical Terms, prescribing) that clinicians must take account of at the point-of-care. Most clinical systems used in British general practice offer templates to prompt data entry and pick-list formularies for prescribing and coding, but these only go so far. How can a practice take account of this competing management advice to streamline and standardize patient care? The answer, somewhat paradoxically, may be to produce another guideline...

Why produce an in-house guideline?

• It promotes a shared standard of care, based on evidence;
• It can illustrate a role for in-house staff groups (e.g. doctors, nurses, admin) with defined responsibilities;
• It can converge multiple "competing" guidelines into one ("the best of the best");
• It can condense overly complex guidelines for practical use at the point-of-care;
• It encourages continuity of care (we all follow the same plan);
• It enables audit against set criteria/ common Clinical Terms;
• It may improve cost effectiveness (e.g. linkage to a preferred drug formulary, rational lab tests);
• It should improve clinical outcomes ("best practice");
• It could provide documentary evidence for the RCGP QPA;
• It can help maximise quality point payments under the New GMS Contract;
• As a guideline cf. protocol, it allows for clinical judgement/ patient preference;
• It can be useful tool for discussing treatment options with patients.

Why use an intranet to publish in-house guidelines?

• They can be readily updated as the master copy is electronic;
• This ensures everybody is looking at the same (current) version;
• The guideline is easily located;
• It can be cross-linked to other relevant guidelines and documents (e.g. patient info leaflets).

What makes a good in-house guideline?

• It should be developed by people representing all users to foster "ownership" and therefore use;
• It should be based on relevant aims;
• It should define roles clearly;
• It should offer clear, concise, evidence-based decision support concerning well-defined patient populations;
• it should make allowance for clinical judgement and for patient preferences or tolerances;
• It should enable easy understanding;
• It should define necessary recording (e.g. use C04 for hypothyroidism);
• It defines standards, targets and audit criteria;
• It is regularly updated to reflect current best practice;
• It is practical and acceptable to users.

What makes a good clinical guideline?
Scottish Intercollegiate Guidelines Network (SIGN) AGREE criteria

A suggested guideline template

I suggest each topic has two associated documents: a guideline administration document in Word, and a flowchart that will be used as a one-page reference at the point-of-care. For the last few years I've used OmniGraffle to produce image maps which are then uploaded, with the Word document, to our practice intranet. The "Pro" version can export to Microsoft Visio format. The flowchart uses colour codes to define entry and end points, decision points, and to assign responsibility for carrying out each intervention to appropriate team members. Hyperlinks can be created where appropriate to link to other guidelines or related documents already on the intranet, such as patient information leaflets, investigation request forms, or referral pro formas. Each guideline is based on the following template.

The flowchart

The Word document

1. Date;
2. Aims and objectives. Include: Clinical rationale; General outcomes for patients; Resource implications; Allowance for patient preferences;
3. Applicability. Include: Target population; Whom it does not include; Exceptions to following the guideline;
4. Identification of patients;
5. System of recall;
6. Flowchart. Include: Responsibility attribution; Recording of Clinical Terms; nGMS targets; Formulary drugs; Relation to other guidelines via hyperlinks; Follow-up;
7. Standards and audit criteria. Include: Practice requirements; Local requirements; nGMS requirements;
8. Related patient group directions;
9. Related in-house policy & procedures;
10. Resources;
11. References;
12. Review date;
13. Signature.

Download an example

You can download an example guideline (on atrial fibrillation) as a ZIP file (324 KB approx., last update Aug 05) by clicking here.

You can download the flowchart stencils for OmniGraffle and for Microsoft Visio as a ZIP file (70 KB approx., last update Nov 05) by clicking here.

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