SIGN 50: A guideline developer's handbook - Section 9: Presentation and dissemination

Section 9: Presentation and dissemination

9.1 CONTENT AND PRESENTATION OF THE GUIDELINE

Guidelines with a wide range of styles and formats have been shown to be effective in changing practice. Whilst there is little information available on the effect that style and presentation have on the adoption of guidelines, clarity – of definitions, language, and format – is obviously important. Guidelines should, therefore, be written in unambiguous language and should define all terms precisely. The best format for presenting guidelines will vary depending on the target group(s), the subject matter, and the intended use of the guideline. Ideally, end users should be consulted regarding the most appropriate method of presentation for them. This is an additional function of the extensive peer review process to which all SIGN guidelines are subject (see Chapter 8).

Each SIGN guideline includes an introduction, outlining the need for the guideline (including evidence of variation in practice) and defining carefully the remit of the guideline, including the patient and practitioner groups to which it applies. Within the main body of the guideline, the structure should as far as possible reflect the development process that the guideline development group has followed, ie (for each chapter):

A clear statement of the question/issue under consideration.
A brief explanation of the treatment options available.
A summary of the conclusions drawn from the critical appraisal of the evidence (the evidence statement, annotated with the level of evidence and key references). This should provide the justification for the recommendation to follow – ie the evidence for improved outcome resulting from the recommended action.
The recommendations that the group has derived from this evidence (graded according to the strength of the supporting evidence).
A brief discussion of any practical points (eg resource/geographical considerations to be taken up in the discussion of local guidelines for implementation), or outstanding treatment options for which there is no evidence (the last should be stated clearly).
Finally, if the group feels it is important to give guidance in any of these latter areas where there is no suitable evidence, a “good practice point” may be presented.

Having a well developed and defined template for presentation of the final guideline can greatly facilitate the development process, enabling guideline development groups to plan at the outset what type of information will be required and also to envisage what format the content will take. By following the model for systematic review and formation of guideline recommendations outlined in chapters 6 and 7, guideline development groups will find that most of the required information will then be produced in a structured, accessible fomat, ready to slot into the guideline structure.

The guideline should also include key points for audit (accompanied where possible with a recommended minimum data set: see Chapter 9.7), suggested outcome measures, recommendations for further research, and information for patients and carers (see Chapter 9.5). Brief details of the systematic review on which the guideline recommendations are based is also provided, although the majority of this information is made available for reference on the SIGN website.

9.2 RECOMMENDATIONS FOR RESEARCH

SIGN guidelines themselves may act as a stimulus to research. An important subsidiary outcome of the guideline development process is in highlighting gaps in the evidence base and guidelines contain a chapter or annex listing the guideline development group’s recommendations for research. The review of a guideline is an opportunity to discover whether any of the gaps in the evidence base have been filled

9.3 QUICK REFERENCE GUIDES AND KEY MESSAGES

Each SIGN guideline is published with an accompanying Quick Reference Guide (QRG). This provides a summary of the key recommendations and other information from the guideline, often following a loosely algorithmic format illustrating the recommended care pathway. The Quick Reference Guides are normally printed on the back cover of the guideline and as a separate leaflet, and have proved very popular with practitioners. It is important to note that the ‘key’ recommendations will not necessarily be the highest grade of recommendations (ie those with the strongest supporting evidence) but those considered by the guideline development group as having the greatest potential impact on patient care (see Chapter 7.2.3).

9.4 ELECTRONIC PUBLISHING

All SIGN guidelines and quick reference guides, along with any updates to guidelines, are available free of charge on the SIGN website: www.sign.ac.uk. With advances in access to technology, and the increasing importance of currency of information, these electronic versions are now the definitive versions of SIGN guidelines. Paper copies will continue to be produced, but it is anticipated that the number of copies printed will be substantially reduced in coming years.

9.5 INFORMATION FOR PATIENTS

All SIGN guidelines now include an ‘information for patients and carers’ chapter, which highlight those issues where patients and their families will most likely require information to help them understand and cope with the diagnosis, treatment options and possible outcomes. This chapter is targeted at health professionals, to help them produce local evidence based information materials although patients and carers themselves may also find this chapter useful. The issues highlighted in this chapter are informed by the:

results of patient views gathered earlier in the development process (see Chapter 4.2)
patient representatives on the development group,
other guideline development group members.

This chapter also includes appropriate general background explanations to the clinical condition and details of appropriate help lines, support groups and reading materials.

SIGN has introduced patient versions of the guidelines. These patient versions are lay translations of the clinical guidelines and are intended to act as a tool for healthcare professionals to use when discussing management and treatment options with patients and their families. SIGN plans to carry out an evaluation of these and if results are positive they will become integrated with SIGN methodology.

As part of SIGN’s commitment to the equality agenda of NHS Scotland, versions of guidelines (either full or patient versions) can be produced in the nine community languages identified by the Scottish Government, in large print, or in Signing in response to specific requests from users.

9.6 DISSEMINATION

Guidelines must obviously be made as widely available as possible in order to facilitate implementation and SIGN guidelines are distributed free of charge throughout the NHS Scotland. However, distribution of printed guidelines alone has been shown to be ineffective in achieving change in practice: guidelines are more likely to be effective if they are disseminated by an active educational intervention, and implemented by patient-specific reminders relating directly to professional activity. Distribution of SIGN guidelines in NHS Scotland is organised within each NHS Board by local distribution coordinators, who are often also responsible for facilitating implementation.

SIGN has initiated a review of its publication and dissemination processes with a view to improving the targeting of guidelines to those health care professionals most likely to find them useful.

9.7 LINKS WITH AUDIT

Development, dissemination and implementation of a guideline should be monitored and evaluated through clinical audit. During the development of the guideline, the development group identifies key points for audit. These should allow the implementation of the guideline recommendations and the impact of these on the processes and, where possible, the outcomes of care to be measured objectively. Often these process and outcome indicators are presented in the form of a minimum data set. SIGN has recently been collaborating with the Information and Statistics Division (ISD) and the Scottish Government to produce national datasets specific to guideline topics.

Clinical audit of guidelines can provide valuable information for standard setting and service accreditation. SIGN guidelines provide the evidence base for many of the national standards developed and monitored by NHS Quality Improvement Scotland. This joint approach to producing evidence based guidelines, which contain national datasets, which in turn are used to set clinical standards that are audited, should, in theory at least, improve the quality of health care delivered. Audit in turn is able to inform guideline reviews and further improve the implementation of specific recommendations.