Policy and Clinical Practice Guideline Development and Management
Clinical Governance provides leadership and support to staff of the HNE Local Health Network (HNELHN) in all aspects of policy, procedures and guidelines for management decision-making and clinical practice.
All instructions, templates, tools, decision-aids and training materials related to policy, procedures and guidelines and associated documents are set out and explained on the HNELHN Policy, Procedures and Guidelines Home Page.
In general terms documents for decision-making can be grouped into whether they are mandatory or non-mandatory in nature. Policy and procedures require mandatory compliance, and Guidelines are statements of best practice to guide best practice.
All authorised documents for decision-making and clinical practice can be searched for on the HNELHN Policy, Procedure and Guideline (PPG) Directory. Documents on this directory include NSW Health and HNELHN policies, policy compliance procedures, clinical guidelines, as well as links to legislation which prevails in NSW Health organisations, NSW Health Safety Alerts and NSW Health Information Bulletins.
Policy
The HNE Health Policy Development and Management Framework, currently under review, was endorsed by the Area Executive in June 2006. In this document, policy is defined as:
“…an Area-wide statement of corporate or clinical action requiring mandatory compliance…”.
Policy development includes the development of Policy Compliance Procedures (PCPs). PCPs are documents which aim to provide staff with a procedure to assist them to comply with a policy.
Guidelines
Guidelines aim to provide guidance to staff to optimise their decision-making.
A Clinical Guideline is designed to set out the evidence and best practice principles for clinical care. Guidelines do not require mandatory compliance, but are instead underpinned by the need for a clinician to exercise clinical judgement in their application. The HNE LHN framework for the development and management of Clinical Guidelines was reviewed in 2010. Reflecting the structures for service decision-making, leadership and governance which have evolved across HNE LHN, the 2010 Guideline for Clinical Guidelines provides mechanisms for clinical leaders to assume authority to authorise clinical guidelines published by their networks, streams or peak clinical committees.
Such mechanisms and process are set out in the HNE LHN Guideline for Clinical Guidelines: Governance, Development, Implementation and Review. NSW Health Guidelines and HNE Health Guidelines are also located on the Policy, Procedure and Guideline (PPG) Directory. NSW Health Guidelines can be accessed also from the NSW Health Policy