Delivering Timely Guidelines: Single PICO Flow

First published: September 2022

Last updated: June 2023

As a cornerstone to the continuous improvement of evidence-based medicine, guidelines are most valuable when they are delivered in a timely manner. Put simply, outdated guidelines reduce the efficacy of the health care system, and in the worst cases present risks to all those within it. The imperative of producing timely guidelines burst into global awareness with the COVID-19 pandemic. However, as we know, the systems and structures built for traditional guideline production were poorly suited to deal with the demands.

Vision and Design Rule Timeliness

The vision and design of traditional guidelines is often that of large, sometimes encyclopedic, academic publications in printed medical journals. The vision and design for living guidelines has long been for smaller publications, but still in printed medical journals.

Recently, the GRADE Working Group published a framework for living guideline development that made two key contributions to the vision and design of guidelines. First, it codified that, as a digital product, guideline developing organizations should use their websites as a primary dissemination tool. It also reminds us that when producing living guidelines, the individual recommendation is the unit of work.

For many guideline developing organizations, this marks a significant departure from how traditional guideline projects are managed. Therefore, to operationalize living guidelines we need to rethink how we define a “project”, so that we can begin to manage them appropriately.

Designing For Timeliness

When we think about how to manage the work of a guideline project, essentially how to take a PICO question and produce a recommendation, it typically falls into these four categories of work.

The systematic literature review, developing the recommendation, writing the manuscript, and the review and release process. Let’s say we have a hypothetical guideline with 3 PICO questions.

We might manage the work like this, with each step for each PICO happening in sequence.

Hopefully we can get all this work done before our literature search gets too old and needs updating! Operationally, that means we’re waiting for all the work to finish…before releasing the recommendations.

But for living guidelines, the PICO is the unit of work, which means we can manage our work like this:

This new way of managing “projects” immediately cuts down the necessary wait time before we can begin disseminating completed recommendations.

Operationalizing this new way of managing guideline projects allows for the continuous delivery of timely recommendations. For many organizations, this will likely require redesigning the structures and systems of guideline development. Organizations can then use the levers of productive capacity to drive more timely production of guidelines.

Combined with visualizing the work, such as with a Kanban board, this will also facilitate the creation of “flow” in the guideline development process.

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References:

1. El Mikati et al. A Framework for the Development of Living Practice Guidelines in Health Care. Ann Intern Med. doi:10.7326/M22-0514