When busy healthcare professionals have questions about which clinical practice is best for a given situation, they commonly turn to practice guidelines, standards, consensus statements, and position papers. Typically, these documents are issued by government and healthcare agencies and by professional healthcare associations or societies. This article defines each type of document and explains how they differ.
Ideal for helping both practitioners and patients make healthcare decisions in specific circumstances, practice guidelines are systematically developed statements based on the best evidence and the most current data. They help standardize medical care and improve the quality of care.
Practice guidelines are created by expert panels who evaluate the available data regarding screening, prevention, treatment options, diagnosis, risk/benefit profile, and cost-effectiveness of available treatment options for a particular clinical situation. Before publication, they undergo rigorous review by relevant organizations and practitioners. In some cases, a guideline is endorsed by other organizations.
Examples of practice guidelines include the American Pain Society’s pain management guidelines for patients with cancer pain, fibromyalgia, arthritis, and sickle cell disease (available at www.ampainsoc.org/pub/cp_guidelines.htm). Other organizations, including the National Comprehensive Cancer Network, American Pediatric Society, American Geriatric Society, and American Society of Anesthesiologists, have developed pain management guidelines for the patient populations they serve.
Usually established by authority or general consent, practice standards are criteria that, when met, result in the best patient outcomes, establish the best practices, or provide the greatest value. They may be used as the basis for accreditation and to establish expectations; for instance, a healthcare organization may issue standards on how to manage pain. Some standards undergo a trial implementation before they’re implemented officially.
Examples of practice standards are those from the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities, which are developed by interdisciplinary groups and adopted by the regulatory body for implementation. Compliance with standards is expected; noncompliance can bring heavy penalties. Each organization the Joint Commission surveys must demonstrate compliance with the standards or face losing accreditation.
(Note: A standard used to establish criteria isn’t the same as the legal standard of care. The latter refers to the care that the average prudent healthcare provider in a given community would provide to a patient in a specific clinical circumstance.)
Consensus statements and position papers
Consensus statements and position papers offer topic-specific opinions or recommendations. Usually drafted by a medical society, they’re derived from expert or prevailing opinion and undergo some degree of peer review by society members.
• A consensus statement represents the collective opinions or suggestions of a society’s expert panel. It’s meant to encourage safe, high-quality patient care, although it doesn’t guarantee a specific outcome.
• A position paper is a detailed policy report, drafted by members of a society, that explains or advocates a certain course of action. It’s commonly derived from research support studies.
Before they’re issued, consensus statements and position papers are distributed to the larger organization, which decides whether to support the consensus or adopt the position advocated.
Who developed the document?
Commonly, all four types of documents are developed by panels—but these panels vary greatly in size and constituency. Some consist of just a few society members; others consist of a large group of experts representing multiple practices (such as nursing, pharmacy, and medicine). Generally, the larger the panel, the wider the references and the less risk that salient evidence will be overlooked.
What level of evidence supports the recommendations?
If you’re considering using a particular recommendation, check the level of support (ranging from poor to high) on which it’s based. Various rating scales for level of support exist. Some use Roman numerals; others use letters. Several medical journals and agencies (such as the U.S. Agency for Healthcare Research and Quality) have their own grading scales.
• Level I or A is the highest level of support, meaning the data derive from studies with the most rigorous design—usually randomized, double-blind, placebo-controlled studies.
• Level II or B denotes that the data derive from studies of less rigorous design, such as a single randomized trial, nonrandomized studies, retrospective studies, outcomes research, or case studies.
• Level III or C typically is assigned when the data derive from case studies or the recommendation is merely an expert opinion.
Here’s a quick summary of the differences and similarities in the four types of documents.
• Practice standards are authoritative, whereas practice guidelines are recommendations.
• Consensus statements and position papers serve mainly as information sources; their recommendations aren’t binding.
• Practice guidelines and standards usually have the highest level of evidence-based support; position papers and consensus statements usually have the lowest level.
• Practice guidelines and standards undergo more rigorous peer review than consensus statements and position papers.
• All four types of documents can be used to develop expected performance levels and provide education for clinicians and the healthcare community.
• Compliance with all four types is voluntary. However, a healthcare facility may lose its Joint Commission accreditation if it doesn’t comply with the Commission’s standards.
Basing your practice on the evidence allows you to provide the highest quality of care. If you’re seeking information about a specific clinical practice, start by reviewing the available practice guidelines, standards, consensus statements, and position papers on that topic.
You can find valuable information and recommendations in all of these documents. Do your homework and inspect each one carefully—and you’re likely to find answers to your clinical questions.
Beyea S, Slattery J. Evidence-Based Practice in Nursing: A Guide to Successful Implementation. Marblehead, Mass: HCPro, Inc; 2006.
D’Arcy Y. Pain Management: Evidence-Based Tools and Techniques for Nursing Professionals. Marblehead, Mass: HCPro, Inc; 2007.
Yvonne D’Arcy, MS, RN, CRNP, CNS, is a Pain Management and Palliative Care Nurse Practitioner at Suburban Hospital in Bethesda, Md.