Section 5: The guideline development group

5.1 COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP

One of the US Institute of Medicine’s strongest recommendations for ‘good guidelines’ was that the process of developing guidelines should include participation by representatives of key groups and disciplines affected.3 Farmer has also stressed that guidelines should not be developed by academics and senior clinicians insulated from the day to day pressures involved in providing medical care, warning that “Unless a guideline accurately reflects the routine working practices of most doctors it will act only as a gold standard to be admired.”10

A Canadian Medical Association workshop held in 1992 to establish the principles on which to base the formulation of individual clinical practice guidelines also recommended that clinical practice guidelines should be developed by physicians in collaboration with representatives of those who will be affected by the specific intervention(s) in question, including relevant physician groups, patients, and other health care providers as appropriate.11 Studies have shown that the balance of disciplines within a guideline development group has considerable influence on the guideline recommendations.12,13 Establishing a multidisciplinary guideline development group is therefore important to ensure that:

Following the acceptance of a guideline proposal into the SIGN development programme (see Chapter 3), the SIGN Executive discusses which specialties and professions should be represented on the guideline development group with the topic proposer(s), with advice from the appropriate Specialty Subgroup(s) and SIGN Council. This ensures that all of the relevant professions in Scotland can input into and feel ownership over the guideline development process.

SIGN guideline development groups vary in size depending on the scope of the topic under consideration, but generally comprise between 15 and 25 members. There is necessarily a trade-off between the number of organisations or specialties that should be represented on the guideline development group, and achieving the optimum group size for effective decision making. Care is also taken to ensure that the group is balanced geographically, with representatives from across Scotland.

In putting together a guideline development group, SIGN is aware of the many psychosocial factors, including the problems of overcoming professional hierarchies that can affect small group processes. Grimshaw (1995) states: “To ensure that guidelines achieve their full potential… requires a programme of research and development that accords at least as much thought to the psychology of group dynamics as the science of systematic reviews”.15 Research into the progress and functioning of SIGN’s own guideline development groups has shown the impact of professional or status differences on members’ contributions to group discussions.16,17 A clear relationship between the perceived status of a group member and their level of contribution to group discussions was identified. This may be difficult to avoid, as members with highest status often have the greatest amount of research expertise, which is of great benefit when interpreting evidence. Care is therefore taken to offer support to those who may feel at an initial disadvantage compared with the group’s “experts” (see Chapter 5.2). This begins with selecting a balanced group that is not “top heavy” and a chairperson with an awareness of these hierarchies and with skills in facilitating full participation by all group members.

The process for establishing SIGN guideline development groups is illustrated in Figure 7. The membership of a typical guideline development group is shown in Figure 8.

[Figure 7: Establishing the guideline deveopment group]

Figure 8: Membership of the SIGN peripheral arterial disease guideline development group

Chairman: Professor of Epidemiology, Public Health Sciences, Edinburgh
Group members:
Consultant Vascular Surgeon, Aberdeen
Consultant Vascular Surgeon, Dunfermline
General Practitioner, Beith
Health Economist, Glasgow
Clinical Nurse Specialist, Edinburgh
Vascular Liaison Nurse, Glasgow
Vascular Liaison Nurse, Inverness
Vascular Nurse, Stirling
Patient representative, Glasgow
Patient representative, Penicuik
Chief Pharmacist, Dundee
Senior Vascular Physiotherapist, Inverness
Superintendent Physiotherapist, Glasgow
Professor of Vascular Medicine, Dundee
Public Health Lecturer, Edinburgh
Specialist Registrar in Public Health, Edinburgh
Vascular Radiologist, Edinburgh
Vascular Technologist, Glasgow
SIGN Programme Manager
SIGN Information Officer

5.2 RESPONSIBILITIES OF DEVELOPMENT GROUP MEMBERS

SIGN’s experience in coordinating the work of over 100 guideline development groups has shown that the role of the group leader is crucial to ensure that the group functions effectively and achieves its aims.18 Chairs of guideline development groups must be sensitive to pre-existing inter-professional tensions and hierarchies and ensure that all members of the group feel able to contribute fully to the guideline development process.

The most successful guideline development groups have a Chair who is aware of and constantly attentive to small group processes (eg how the group interacts and communicates, decision making processes and chairing strategies). The Chair must be prepared to overcome potentially serious difficulties by careful negotiation.16,17

The SIGN Programme Manager assigned to each guideline helps the Chair to identify potential barriers to successful group work, to plan and progress the guideline development project, and acts as facilitator at group meetings. Some SIGN guideline development groups are co-chaired by the SIGN Programme Manager and the group leader in order to help reduce potential conflicts.

Guideline development group members in turn must make a full commitment to the group and the tasks involved in guideline development, and be responsible for indicating areas of concern to the Chair. Guideline development group members should also bear in mind that they represent both a geographical region and a specialty or professional group, and must be prepared to consult with colleagues to ensure that the widest possible range of views are considered.

Each guideline development group requires a mix of the following skills:

A healthcare professional joining a guideline development group is not expected to be an expert in all of these areas. Many group members may feel they have only one or two of these skills, but at some point in the development of the guideline, their knowledge and experience will be invaluable.

Many potential development group members are concerned that their critical appraisal skills may not be sufficient to complete the systematic review of the literature. To address this, SIGN runs a range of training seminars in critical appraisal skills that all group members are encouraged to attend. In addition, guideline development groups are also supported throughout the development process by the SIGN Executive. The Programme Manager and Information Officer assigned to each guideline development group give regular presentations on SIGN methodology, and will also ensure that methodological checks are correctly applied and that the development process itself is fully documented.

The life span of each guideline development group is approximately 28 months, with groups meeting on average once every two months, although groups may form subgroups which meet more frequently. The development timetable of a typical guideline, and the associated tasks, is shown in figure 9. Guideline development groups are supported by the SIGN Executive.

The work commitment of the healthcare professionals and patients who take part in the development of a SIGN guideline is significant and should be recognised before accepting an invitation to join such a group. In addition to taking on the responsibility of representing both a geographical region and a specialty group, group members need to pledge a considerable amount of their time to guideline development. Prospective guideline development group members are encouraged to attend critical appraisal training prior to joining a group to ensure that they understand the commitment they are about to undertake.

[Figure 9: Timetable for guideline development]

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