New guideline (excluding medicines)

• To submit a new guideline which does not make reference to medicine prescribing, please follow the new guideline pathway.
• What you'll need - this reference guide will ensure you have a record of what you need to submit a new guideline. The consultation sheet should be used to record details that you will need for the consultation section of submission form.
• Please use the Policy or guideline process template to format your document
• Once approval has been granted, complete the Guideline/pathway approval and submission form.
• Once the guideline has successfully passed through the submission process, it will be published to Right Decisions website and app.

New guideline (including medicines)

Any guidance which mainly or partially includes medicines content must go through the ADTC approval process. Further details can be found on Athena (available on intranet only) or contact  ADTC@aapct.scot.nhs.uk 

• To submit a new pathway, please follow the new referral pathway
• What you'll need - this reference guide will ensure you have a record of what you need to submit a new guideline. The consultation sheet should be used to record details that you will need for the consultation section of submission form.
• Complete the guideline/pathway approval and submission form.
• Once the guideline has successfully passed through the submission process, it will be published to Right Decisions website and app.

Where approval has previously been granted for a guideline/referral pathway and the guideline/pathway remains unchanged, the staff member will need to complete a guideline/pathway submission form for this content to be added to Right Decisions.

Requests for national or regional (e.g. West of Scotland) guidelines/pathways involving other health boards or organisations should be referred to the appropriate national/regional governance structures.

Guidance on requesting a national/regional toolkit to be added to Right Decisions is available here.

Clinical calculators may be defined as a medical device and require UKCA marking. Examples of calculators can be found in the Calculator suite.

Guidance on requesting a medical calculator can be found here

Requests to provide information for patients that does not include medicines on Right Decisions should be directed to aa.RightDecisions@aapct.scot.nhs.uk. 

The Right Decisions Team will consult with the Patient Information Team for approval of content. If approved, the Right Decisions Team will contact the requestor to arrange for content to be added to the Right Decisions platform.

Other content may include general information for NHS Ayrshire & Arran staff that does not constitute a controlled document or fall into any other category described above.

Please direct enquiries regarding such content to aa.RightDecisions@aapct.scot.nhs.uk

The definitions of a clinical policy, clinical guideline/ protocols, care bundle and checklist are identified below:

• A clinical policy is a statement of the organisation’s stance on key issues, setting out a framework, rules and/or practice within which clinicians and staff must operate / comply.
• Clinical guidelines/ protocols are recommendations on the appropriate treatment and care of people with specific diseases and conditions; they are informed by the best available evidence.
• A checklist is a helpful and important aide memoire to support the delivery of safe and reliable care. The elements in a checklist are used to assist staff to consistently deliver care in a standardised evidence based manner.
• A care bundle is a collection of evidence based practices – generally three to five – that, when performed collectively, reliably and continuously, have been proven to improve patient outcomes and minimise avoidable harm.
• Care bundles and checklists can form specific sections of clinical policies and guidelines, and can be developed as aide memoires for staff.  These can also be used as monitoring tools for clinical care.
• These clinical guidance documents are developed to support staff in providing standardised reliable care. They are not tools to assess clinical competencies.

All of the above will normally require the full governance process set out in the sections above e.g. new local guideline or new referral pathway. If you have any queries, please contact Greg Murdoch from the Governance Support Team - greg.murdoch@aapct.scot.nhs.uk.

Local service specific guidelines

The clinical guidance documents require to be endorsed by the Local Service Governance Group, Specialist Committee for endorsement e.g. Blood Transfusion Committee or within Mental Health Services, the Clinical Documentation Steering Group.

Once endorsed by this group the guidance documents require to be submitted to the overarching Directorate Governance Steering Group for approval.

Organisation wide guidelines

Endorsement / approval will be made by a Multidisciplinary Guidance Endorsement Group with representatives from all Clinical Governance Steering Groups and the Mental Health Clinical Documentation Steering Group. Meetings for this group will be organised on a monthly basis but will only occur when required.

All guidelines and pathways require approval from a Director/Associate Director.