Key Definitions: Decision-Making Support Tools
Clinical Guidelines, Policies, Protocols, Procedures & Care Pathways
There are no definitive ‘official’ definition for clinical guidelines, policies, protocols,
procedures and care pathways. This list has been compiled from information brought
together from a number of online sources. This information is provided as a point of
reference to support the labelling of decision-making support tools, however there is an
element of judgement required. The Clinical Governance Support Unit can provide support
to categorise decision support materials, and therefore determine the development and
review processes to follow.
Clinical Guidelines
Clinical guidelines are evidence-based statement (or series of statements) used to
assist clinicians in the decision-making process about appropriate treatment and care
in specific circumstances. Clinical guidelines are not intended to replace clinical
freedom; however they usually should be followed unless there is a good reason not
to do so. Clinical guidelines often include algorithm/flow-charts – if A happens do B;
if X happens do Y and Z.
Clinical guidelines often contain guidance related to medicines or other clinical
intervention or content.
Clinical guidelines are not the ultimate decision makers regarding a particular clinical
procedure or treatment plan. This must be made by the practitioner in the light of
each individual patient’s condition, circumstances, and the diagnostic and treatment
options available.
What are clinical guidelines for?
- Guidelines provide recommendations for effective practice in the management of
clinical conditions where variations in practice are known to occur and where
effective care may not be delivered uniformly throughout Scotland.
- Guidelines can be used to develop standards to assess the clinical practice of
health professionals.
- Guidelines can be used in the education and training of health professionals.
- Guidelines can help patients to make informed decisions, and improve
communication between the patient and health professional.
Policy
A policy is a guiding principle used to set direction in an organisation. It can be a
course of action to guide and influence decisions. It should be used as a guide to
decision making under a given set of circumstances within the framework of
objectives, goals and management philosophies as determined by senior
management.
Policies are usually general statements about aims, intentions or an approach to a
particular issue, which summarises an organisation’s position on an issue, and is
presented as a statement of intent or a plan of action.
The purpose is often that a clear message is effectively conveyed with the
appropriate information and knowledge throughout the organisation and to all
relevant stakeholders.
Key Definitions V1, 12/01/2023
Protocols
Guidelines are often spoken interchangeably with protocols, and there is often
crossover between the two. While a clinical guideline will present evidence-based
information to support a clinician in the management of a specific clinical problem, a
protocol would provide a description of specific steps to follow once a clinical
management decision has been made. There is some debate as to whether
protocols are a requirement to follow, in comparison to clinical guidelines which are
there to advise and inform decision making. However, it is doubtful whether in law
this distinction is helpful or meaningful. Whether you call something a guideline or a
protocol, if agreement has been reached that this document constitutes best practice,
you should be able to justify any occasions when the protocol isn’t followed, the
same as for a clinical guideline.
To direct clinicians along preferred treatment pathways by outlining detailed
management plans for discrete clinical conditions judged amenable to stepwise
decision making processes (flowcharts, algorithms).
Detailed descriptions of the steps taken to deliver care or treatment to a patient and
are sometimes called the “integrated care pathway”.
Medline definition: ‘Precise and detailed plans for the study of a medical or
biomedical problem and/or plans for a regimen of therapy’.
Procedure
A procedure is a standardised series of actions taken to achieve a task so that
everyone undertakes it in an agreed and consistent way to achieve a safe, effective
outcome.
Care Pathway (CP)
Care pathways are multi-professional shared documents which follow a patient
through a part (or all) of their journey from referral through to discharge. They are
therefore best suited to routine, relatively predictable forms of surgery (e.g. hip
replacement). Care pathways are another way of defining best practice in a given
situation (and once again, if you don’t follow the pathway, you need to justify your
actions). They can be an effective way of bringing together standards and guidelines
- which may already exist – into a user friendly and well-managed package.
A simple clear plan of proposed clinical activities occurring within a defined timescale
and developed by a multidisciplinary group expert in the treatment of patients for
which the CP is written.
Key Definitions V1, 12/01/2023