Tool for organisation and cooperation in multidisciplinary guideline development

1. Introduction

Multidisciplinary guidelines are developed in teams of professional experts and, where possible, patient representatives. Originally, guideline development groups were a forum for weighing evidence. Transparency in the process and group procedures is extremely important partly because there is often a hierarchy of interests. To achieve optimal results, good communication and cooperation is needed. Although all parties involved are responsible for promoting cooperation and good guidance of the development process, the chair and project leader, advisor or coordinator of the development group have special tasks about which agreements should be made at the start of the project.

Process management is aimed at the ongoing back and forth communication. The responsibility for process management need not necessarily lie with a particular group member or professional, but nevertheless must be assigned to one or various members of the guideline development group. A process manager focuses on supporting interactions, discussions and negotiations between stakeholders. The central focus of this task is the dynamics and complexity of the interests and perspectives of the many stakeholders involved. Adequate process management is not just crucial during the preparation stage, but also after the development and completion phases of the guideline project. This tool focuses on the following aspects of process management:

  • communication about tasks, roles and interests and
  • communication about the process during each phase of the guideline project within the development group itself and also towards outside parties.

Multidisciplinary guideline projects are complex and require a professional approach. The rising number of parties and stakeholders involved increases the complexity. For complex projects to be successful, it is important to distinguish between project and process management.

  • A project manager concentrates on managing five different aspects within the project: content quality, costs, time, organisation and information.
  • A process manager focuses on supporting interactions, discussions and negotiations between stakeholders.

In multidisciplinary guideline development groups, these roles can be performed by a single individual or a number of different individuals. In the case of the latter, the project and process manager should complement one another and be able to collaborate well together. Interprofessional collaboration as well as cooperation between professionals and patients/patient representatives is an important part of the process in multidisciplinary groups. This tool provides recommendations (tips, tricks, examples and references) for managing processes in multidisciplinary guideline development groups. The Tool project management in guideline development contains recommendations for the project management process in guideline development.

2. Objective of this tool

The objective of this tool is to provide practical tips for and examples of process management, to promote (interprofessional) cooperation in guideline development groups.

3. Process management during the preparation phase

3.1. The group members’ explicit roles, tasks, responsibilities and authority

The large number of those involved in multidisciplinary guideline projects can lead to fragmentation and lack of clarity concerning roles, tasks, responsibilities and authority of the different development group members. It is important that the members of the guideline development group all start the project at the same time. The patient organisation should also be involved from the outset.

During this phase it is important to indicate what the project entails, who will be involved and what results should be delivered. It is also important to define the roles and to determine the tasks, responsibilities and authority of the development group members. A useful tool for this is the RASCI matrix.

3.2. Outlining the interests of the different parties

It is important to have clarity before the start of the development phase about the substantive interests of the relevant associations (professional and patient) and development group candidates for participating in the project (see Code for the prevention of improper influence due to conflicts of interest). Each association and development group candidate answers the following questions to gain insight into the substantive interests concerned.

  1. Do you/your association currently have a view towards the theme addressed in this guideline?
    Please elaborate
  2. How important is it to you/your association that the guideline addresses this topic or provides a solution?
    Please elaborate
  3. Which instruments or therapies would you/your association like to see addressed in the guideline?
    Please elaborate
  4. Do you/your association have a view towards these instruments or therapies? If so, what is this view?
    Please elaborate
  5. What do you/your association see as a risk or pitfall that this guideline cannot solve?
    Please elaborate
  6. What recommendation might this guideline provide that you/your association would not endorse?
    Please elaborate
  7. What do you/your association consider to be the worst recommendation that this guideline could contain?
    Please elaborate

Completed forms will be discussed with the chair during the introductory meeting. Any indicated conflicts of interests between the association and  a development group candidate will be discussed during the meeting with that candidate.

3.3. Preparation for filling chair position

Good chairmanship is essential for both the quality of the guideline development process and for the ultimate success of the group. It is recommended that the chair candidates be interviewed for the position during which time the following topics should be discussed to help verify whether the candidates have the required skills:

  • the required and necessary time investment
  • duration of the project
  • experience conducting group meetings
  • Experience with process management (suggestion: experience of participating in at least one guideline development group)
  • Experience with guideline development (suggestion: experience of participating in at least one guideline development group)
  • positive vision for and experience with patient participation
  • positive vision for and experience working with other professional groups
  • positive vision for and experience with evidence based medicine
  • mutual expectations regarding chairmanship of the project
  • tasks, roles, responsibilities and authority of the chair and other development group members (use the RASCI matrix)
  • support for chair in professional group
  • no interests/conflicts that could compromise the chairmanship
  • income for potential chair (material and immaterial)
  • agreements about division of tasks between chair and project leader
  • expectations, wishes and concerns regarding the future guideline identified from among development group candidates.

3.4. Preparation for filling project leader role

In addition to the chair, the project leader also plays an important role in process management. As the chair and project leader need to form a united team in the process management of guideline development groups, it is important they ‘click’ and both start the project with like-minded expectations and positivity. If there is no such ‘click’ between the chair and project leader, a different chair or project leader may need to be appointed. The chair and project leader can make written agreements upfront about the division of tasks and activities within the project.

3.5. Selecting and profiling the other development group members

To ensure a well-functioning development group, it is important that development group members meet a certain profile. This requires that the chair and project leader/process facilitator interview (via telephone or in person) all development group candidates to discuss the following subjects in order to verify whether they possess the required skills:

  • motivation and interests in participating in the development group and any conflicts of interest between them and the association based on the completed form
  • positive vision for and experience with evidence based medicine
  • active preparation for and participation in guideline development group meetings
  • providing adequate input for answering the review questions
  • adhering to agreements and deadlines
  • formulating specific, clear and transparent recommendations in the guideline
  • providing feedback to (the board of) the (scientific) association
  • maintaining a balance between the scientific foundation of the guideline and its practical applicability
  • being open to others’ opinions
  • dealing with feedback.

If a selection must be made from a group of candidates, this check list can help to select the most suitable ones.

3.6. Determining and coordinating guideline development methodology

People who fulfil a methodological role in the guideline development project (for example, doing the literature research, drafting the review questions and writing the guideline texts) may come from different organisations that apply different guideline development methodologies. It is therefore good to determine which methodology the development group will use during the preparation phase of guideline development and to communicate this decision with the supporting development group members.

4. Process management during the development phase

4.1. The first development group meeting

It is important that the first development group meeting is face-to-face so the members of the development group can be introduced. The face-to-face aspect is not as important or necessary for subsequent meetings. The development group can decide on the meeting form during the first development group meeting. The chair will lead the introduction of the development group members. This method has the advantage that the chair, in addition to introducing and positioning the development group members, can focus on everyone’s role in the project and its impact on the guideline. Furthermore, this method has the advantage that the chair can explicitly emphasise that the development group members are intended to complement each other. The introduction needs to focus on everyone’s role as well as expertise.

4.2. Interest chart

Joint discussion of the motives of development group members for participating in the project add value by providing insight into the preconceived views, joint interests (shared values) and individual scientific, commercial and/or professional interests of those involved. For this reason, it is advisable to compile an interest chart of development group members’ needs, expectations and concerns that were identified during the preparation phase. This will be discussed at an aggregate level during the first development group meeting. When the chair and/or development group members consider a member’s interests in the guideline contents to be incompatible with participation in the guideline development group, this must be openly discussed.

4.3. Agreements about course of events during development group meetings and intervening periods

It is advisable that the chair and the development group members make a number of agreements during the first meeting regarding the course of events during the following meetings. It is important that everyone involved consent to these agreements so that the chair can refer to these if problems occur in the group process. These agreements will concern the following:

  • development group meeting attendance
  • rules on communication behaviour
  • how to deal with interests
  • decision-making methods
  • rules regarding email traffic in between development group meetings
  • adhering to agreements
  • adhering to deadlines and
  • reports for stakeholders.

4.4. Agreements on dealing with interests

The interests of guideline development group members are likely to partially overlap, but may also somewhat differ or have different priorities. During guideline development group meetings those different interests may manifest themselves and start to play a role. Differences in interests need not be problematic, as long as they are taken into account and careful and transparent choices are made to prevent problems from occurring in the guideline process. One option is for the chair to identify interests by having each development member answer the following questions:

  • Do you have a personal view on this topic?
  • Do you have interests invested in this topic?

The chair must indicate that the purpose of this repeated round of questions is to communicate the interests and not to discuss, justify or explain these interests. Each round should last no more than ten minutes. This method enables the separation of the political debate and the scientific debate. If a person has interests in relation to the proposed agenda topic, the following rules will apply:

  • development group members with clear interests (e.g. financial or scientific) may participate in the discussion, but should refrain from making recommendations
  • if the chair has interests in a topic, he or she will pass the chairing role on to another development group member while the topic in question is addressed.

4.5. Agreements about decision-making methods

It is recommended that guideline development groups clearly communicate to the group in advance when and how a decision-making process for a particular item will take place.

4.6. The agenda for development group meetings

It is recommended that the chair and project leader set the agenda in joint consultation while preparing for each development group meeting. The following is some advice regarding this based on good local and international experiences:

  • distinguish between functional components, for example, opening and closing and agenda items relating to guideline content
  • add a general time schedule to the agenda
  • give the status of the topic under each item along with the type of dialogue expected: brainstorming, discussion or decision-making
  • make a note to identify interests for each agenda item
  • consider having the following fixed agenda items:
    • opening and announcements
    • discussion of minutes/reports
    • progress of the project
    • discussion of draft texts
    • task division/follow-up agreements and
    • conclusion.

4.7. Stimulating and motivating development group members

The chair and project leader of a guideline development group have the task to keep the participants motivated, stimulate those involved and monitor the progress of the guideline process. It is therefore important that they maintain a positive and supportive attitude with those involved and, if necessary, remind them of their agreements. They can apply the following rules when problems arise in this area:

  • Contact a development group member by e-mail if he or she has been absent from development group meetings twice or has twice failed to submit documents at the agreed upon time. Ask for the reasons.
  • If a member has been absent more than twice or has failed more than twice to submit documents as agreed upon, the chair will discuss this with the development group member concerned.
  • If a member is absent or fails to deliver documents as agreed upon following this talk, the chair will inform the association concerned about the course of events and approach used until that point in time, and will inform the development group member concerned.
  • If a member is absent or fails to deliver documents as agreed upon after the association has been informed of the issue, the development group will expel the development group member in question and request the association to delegate a new member.

4.8. Dealing with conflicts

Conflicts can occur at different levels, for example, between patients and professionals and between professionals of different specialisations. If one or more members of a guideline development group cannot − for good reasons − agree with the majority view, the development group should first hear the arguments behind this. If there are valid arguments for the different viewpoints, the development group has the following options:

  • try to reach a formulation that also does justice to the minority view, for example, by using a consensus method
  • refrain from formulating a recommendation but rather present a transparent description of the different viewpoints.

Unspoken conflicts may also occur. Such conflicts are difficult to approach rationally because they often involve personal sensitivities. In the event of such conflicts, there are several possibilities:

  • organise a separate talk between the chair and the development group member(s) concerned
  • if needed, organise a board meeting between the associations concerned to de-escalate the situation
  • if needed, bring in a third party with mediation skills.

In the event of conflict, it is advisable for the chair to discuss the step to be taken as a result of the conflict with the entire development group.

4.9. Evaluation of group process

It is advisable to explicitly reflect on the group process both half-way through and at the end. If this evaluation reveals bottlenecks due to a lack of process management skills, the chair and/or project leader could be offered training in this area. It can also be effective for the chair/project leader to have contact with more experienced chairs/project leaders to exchange tips and tricks and discuss case histories together.

5. Process management during the completion phase

5.1. Dealing with commentary from external parties

Some guideline topics attract the attention of the general public and journalists. Guidelines that have reached the commentary phase, and are therefore accessible to a larger audience, can stir up controversy. It is good to consider the following aspects:

  • Make it clear that no rights can be derived from the guideline draft.
  • Estimate the topic’s sensitivity in advance and, if necessary, put together a communication plan with the following components:
    • determine spokesperson
    • send press releases
    • deal with confidentiality of texts
    • have spokesperson report on media coverage to other group members
    • deal with the media
    • bring in a communication expert.

5.2. Communication during the authorisation phase

The commentary and authorisation phases can be lengthy and can even stagnate if an association has a problem with the guideline draft. It is important that the chair and the process facilitator address these problems carefully. The following should be taken into account when doing so:

  • as chair and project leader, stay in charge of the authorisation process
  • adhere to earlier agreements about authorisation that were made with associations involved
  • identify the problems related to authorisation and discuss how to solve these with the parties concerned
  • inform the other associations involved of progress in a neutral and unambiguous way
  • communicate any difficulties clearly and neutrally to outside parties so that no damage is caused to the organisation concerned.

5.3. Process the commentary from the referees and boards

It is sometimes useful to first discuss the commentary received from the referees and boards in a small group before presenting this to and making a decision with the entire development group.

5.4. Evaluate and conclude the group

During the evaluation in the last meeting, the development group will evaluate the entire process and discuss the level of satisfaction with the product and process. In addition, the development group will list the points for improvement.

6. Literature

  • Bekkering, T., &  Walter, J. (2009). Management van processen. Houten: Spectrum.
  • Nauta AP. Samenwerking als proces bekeken. Tijdschrift Sociale Gezondheidszorg 2003;  81(3): 159-162.
  • Gerritsen A, Nauta AP. Samenwerken is te leren, maar hoe? TMO (Tijdschrift voor Medisch Onderwijs) 27 (2008): 109-119.
  • RASCI.