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3 Supporting the delivery of high-quality careclinical leads, the National Institute for Health and CareExcellence (NICE), the Healthcare QualityImprovement Partnership (HQIP), the Care QualityCommission (CQC), Health Improvement Scotland,the National Leadership and Innovation Agency forHealthcare in Wales, specialist societies, other royalcolleges and patient groups.Clinical management guidelinesTo provide optimal patient care it is necessary to knowwhat constitutes optimal care. Determining this can bedifficult, increasingly so as medicine becomes morecomplex, more treatments become available and theassociated scientific literature increases. One way ofhelping clinicians to manage their patients effectively inthe face of information overload is the production ofclinical guidelines. The primary purpose of a guidelineis to set out recommendations for the most appropriatemanagement of patients with a specified condition.Therefore, guidelines should be as clear and direct aspossible. However, a patient with an uncomplicated,single pathology is something of a rarity. Concerns havebeen expressed that an over-reliance on guidelines willproduce doctors who cease to think through theirpractice and make decisions. This is no more anecessary consequence of relying on guidelines than ofusing textbooks or lectures for medical education.Recommendations must be applied to individualpatients with their particular preferences and theirdifferent comorbidities. But it is still important to havea clear, basic foundation from which to build, andguidelines provide this.Guidelines should inform routine patient care andwhile it is reasonable to be at variance from standardguidance, as determined by a patient’s circumstances, itis prudent to document why the alternative course wastaken. This leads to the secondary function ofguidelines – to provide a basis for the audit of thequality of patient care. Recommendations withinguidelines are an important source of audit criteria, andindeed many guidelines encourage this by suggestingappropriate topics.Producing guidelinesClinical guidelines are developed using a variety ofmethodologies. One of the most rigorous approaches isused by the National Clinical Guidelines Centre(www.ncgc.ac.uk).ThecentreishostedattheRCPtodeliver a large and diverse commissioned programmefor NICE. The guidelines have the advantage ofincorporating both clinical and cost-effectivenessevidence. Another common methodology is the ScottishIntercollegiate Guidelines Network (SIGN) approach,which is often adopted by the specialist societies as it isless resource intensive and is consistent with theAppraisal of Guidelines Research and Evaluation(AGREE) collaboration (www.agreecollaboration.org),an international collaboration quality assuringguideline methodology. This methodology is also usedfor the development of guidelines for occupationalhealth, stroke and in the Concise Guidelines to GoodPractice series.The topics that RCP guidelines cover grow on amonthly basis and can be found on the RCP website(www.rcplondon.ac.uk/resources/clinical-resources).Specialist societies produce excellent guidelines whichare particularly useful sources of information on rarertopics that are less likely to be covered by NICE. TheRCP is supporting specialist society guidelines bypublishing the Concise Guidelines series in ClinicalMedicine and in booklet form.National comparative clinical auditDonabedian defined quality of care as ‘the degree ofconformance to, or deviation from, normativebehavior’. 2 Brook and Kosecoff more succinctly definedit as ‘doing the right things . . . well’. 3 In 2010, followinga review of the literature and a consultation exercise, theRCP developed its own definition of quality. Itcomprises seven domains: safety, patients’ experience,effectiveness, equity, efficiency, timeliness andsustainability. All definitions imply the need forstandards – ‘normative behaviour’ and ‘doing the rightthings’ – and the need for measurement of practice, allkey elements of clinical audit.Clinical audit is conventionally considered as a cycle ofquality improvement that involves measurement of theeffectiveness of healthcare against agreed and provenstandards for high quality, and taking action to bringpractice in line with these standards so as toimprove the quality of care and health outcomes.Detailed advice for carrying out clinical audit can befound in New principles of best practice in clinical audit 4and Local clinical audit: handbook for physicians (HQIP,2010). 5Recommendations include the following:Determining standards for practice: increasinglystandards are based on evidence or derived from soundC○ Royal College of Physicians 2013 267