Appendix 1. Definition


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There are no definitive ‘official’ definition for clinical guidelines, policies, protocols, procedures and care
pathways. This list has been compiled from information brought together from a number of online sources.
This information is provided as a point of reference to support the labelling of decision making support

Clinical Guidelines

Clinical guidelines are evidence-based statement (or series of statements) used to assist clinicians in the decision-making process about appropriate treatment and care in specific circumstances. Clinical guidelines are not intended to replace clinical freedom; however they usually should be followed unless there is a good reason not to do so. Clinical guidelines often include algorithm/flow-charts – if A happens do B; if X happens do Y and Z.

Clinical guidelines are not the ultimate decision makers regarding a particular clinical procedure or treatment plan. This must be made by the practitioner in the light of each individual patient’s condition, circumstances, and the diagnostic and treatment options available.

What are clinical guidelines for?

  • Guidelines provide recommendations for effective practice in the management of clinical conditions where variations in practice are known to occur and where effective care may not be delivered uniformly throughout Scotland.
  • Guidelines can be used to develop standards to assess the clinical practice of health professionals.
  • Guidelines can be used in the education and training of health professionals.
  • Guidelines can help patients to make informed decisions, and improve communication between
    the patient and health professional.


A policy is a guiding principle used to set direction in an organisation. It can be a course of action to guide and influence decisions. It should be used as a guide to decision making under a given set of circumstances within the framework of objectives, goals and management philosophies as determined by senior management.

Policies are usually general statements about aims, intentions or an approach to a particular issue, which summarises an organisation’s position on an issue, and is presented as a statement of intent or a plan of action.

The purpose is often that a clear message is effectively conveyed with the appropriate information and knowledge throughout the organisation and to all relevant stakeholders.


Guidelines are often spoken interchangeably with protocols. Some clinicians take the view that protocols must be followed, whereas clinical guidelines are only there to advise and inform decision-making. However, it is doubtful whether in law this distinction is helpful or meaningful. Whether you call something a guideline or a protocol, if agreement has been reached that this document constitutes best practice, you should be able to justify any occasions when the protocol isn’t followed, the same as for a clinical guideline.

To direct clinicians along preferred treatment pathways by outlining detailed management plans for discrete clinical conditions judged amenable to stepwise decision making processes (flowcharts, algorithms).

Detailed descriptions of the steps taken to deliver care or treatment to a patient and are sometimes called the “integrated care pathway”.

Medline definition: ‘Precise and detailed plans for the study of a medical or biomedical problem and/or plans for a regimen of therapy’.


A procedure is a standardised series of actions taken to achieve a task so that everyone undertakes it in an agreed and consistent way to achieve a safe, effective outcome.

Care Pathway (CP)

Care pathways are multi-professional shared documents which follow a patient through a part (or all) of their journey from referral through to discharge. They are therefore best suited to routine, relatively predictable forms of surgery (e.g. hip replacement). Care pathways are another way of defining best practice in a given situation (and once again, if you don’t follow the pathway, you need to justify your actions). They can be an effective way of bringing together standards and guidelines - which may already exist – into a user friendly and well-managed package.

A simple clear plan of proposed clinical activities occurring within a defined timescale and developed by a multidisciplinary group expert in the treatment of patients for which the CP is written.

Last reviewed: 01 March 2018

Next review: 31 January 2020

Version: 3

Approved By: Board Clinical Governance Forum