Guideline developers have been working towards “living guidelines” for over two decades. The Guidelines International Network, an international initiative involving guideline developing organizations, was founded in 2002 with aspirations to create living guidelines that can be continuously updated.(1) Since that time, numerous “checklists” have been published to advise guideline developing organizations on how to develop systematic reviews and clinical practice guidelines.(2)
Unfortunately, most of these publications focus almost exclusively on providing detailed descriptions of the methodological practices involved in these endeavors. They do not consider how best to create the needed structures and systems that would facilitate a successful guideline development program at scale.
The Current Crisis
Over the past two years, guideline developers around the world have made heroic efforts to publish and maintain “living” clinical practice guidelines on the treatment and management of COVID-19. These guidelines were developed using a variety of methodologies, team structures and dissemination platforms. But one important theme emerged: they frequently deviated from the traditional practice of releasing large, publication-based manuscripts addressing many clinical questions. Instead, they often relied on web-based platforms to release updated recommendations as soon as possible.
These guidelines demonstrate that the true value of guideline developers is their ability to release timely, relevant recommendations, based on the best available evidence, as quickly as possible. It is not, as decades of practice would suggest, spending years creating large, publication-based guideline manuscripts.
Unfortunately, the significant financial resources and heroic volunteer efforts required to develop the COVID-19 guidelines disrupted normal ways of developing guidelines and are not sustainable due to the limited availability of economic and human resources. They cannot be scaled for application to growing portfolios of guidelines.
Recent Efforts
Recent efforts to improve guideline development efficiency have focused largely on using existing systematic reviews, automated surveillance of new evidence, machine learning, and collaborations. While these ideas have significant merit and will reduce the human burden of guideline development, they fail to address the management systems within which most guideline development is conducted. They make local improvements to the current processes, but do not address the problems with the way this work is organized and managed.
Recent frameworks have outlined the vision and technical design for maintaining “living” guidelines. They do not, however, consider the needed changes to guideline development workflows and technical practices that could sustain such efforts at scale. Therefore, guideline developers must find new ways to manage their work if they wish to maintain an entire portfolio of timely, relevant, and updated guidelines.
Efforts to adapt systems-level approaches like Lean, originally developed by automobile manufacturers, or Agile and Continuous Delivery, used by software developers, have not been widely explored despite their successful applications elsewhere in the healthcare system.(3-5) Guideline developers may benefit from adapting successful systems-level approaches used in other industries to improve efficiencies in guideline development.
Next: The Tipping Point
References:
Marshall, Catherine et al. “Transforming written guidelines into electronic formats--international perspectives.” Studies in health technology and informatics vol. 101 (2004): 123-6
Schünemann, Holger J et al. “Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise.” CMAJ : Canadian Medical Association journal. 186,3 (2014): E123-42. doi:10.1503/cmaj.131237
Tlapa, Diego et al. “Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review.” International journal of environmental research and public health vol. 19,15 9018. 25 Jul. 2022, doi:10.3390/ijerph19159018
Ojo, Bukola et al. “Lean methodology in quality improvement.” Paediatric anaesthesia, 18 Mar. 2022, doi:10.1111/pan.14439
Cox, James et al. "Applying the 'Theory of Constraints' to Solve Your Practice's Most Vexing Problem." Fam Pract Manag. 2014;21(5):18-22
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