Clinical Guideline Development

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  • Guideline - provides the best evidence-based way to achieve an optimal outcome, given current knowledge and resources and may include step-by-step procedures. A guideline is different from a policy in that it allows some flexibility based on the specific circumstances (e.g. a specific patient). Most Auckland District Health Board (ADHB) guidelines will be clinical.

  • Policy - states what must (or must not) be done, implying mandatory compliance, or it simply provides a position statement. A policy may include step-by-step procedures and although a policy can be clinical or non-clinical, most ADHB policies will be non-clinical.

  • ADHB Policy and Guidelines refers to the ADHB policies and guidelines that are managed internally by the ADHB Policy and Guideline team

  • Starship Clinical Guidelines refers to guidelines managed through the Starship website by the Starship Clinical Guideline team


Governance of Guidelines and Policies follow the directorate structure

Clinical governance
Clinical guidelines and policies should be managed by the Starship Clinical Excellence program structure. Some clinical guidelines and policies span the directorate and will be managed by the senior leadership team, including the Nursing Best Practice committee for Child Health nursing documents.

Most clinical guidelines will be led by a specific service, even though the relevance of the guideline may span more than one service.

Guidelines must have the following:

  • Owner clinician (name and role)

  • Owner service (name and role)

  • Review date (maximum of 3 years)

Authors are acknowledged.


Non-clinical guidelines and policies should be managed in the Directorate/Service management structure using a similar methodology to that described for clinical documents.

Difference between Starship Clinical Guidelines and ADHB Policy and Guidelines

Duplication of documentation and information is undesirable for a range of reasons and these two sites should be complementary.

Guidelines that are used day to day to guide clinical care in Starship Child Health will be primarily placed on the Starship Clinical Guidelines.

The rationale for this is that Starship Child Health is a reference centre and has an important role in provision and dissemination of information to clinicians around New Zealand and beyond. Guidelines that have relevance to clinicians beyond ADHB are placed on the Starship Clinical Guideline site. Clinicians in Starship Child Health and beyond use the Starship Guideline site as the primary source of clinical information and guidance.

Starship Clinical Guidelines will be linked to relevant ADHB Policies and Guidelines to avoid duplication of information and to provide an additional source of important clinical information.

Starship Child Health policies should not be placed on the Starship Clinical Guidelines unless they are used to guide day to day clinical care.

Local processes and information
There are a number of documents that are neither guideline nor policy e.g. patient information sheets. These will be managed by individual services and where relevant Starship Clinical Guidelines will link to these patient information sheets.

Guideline format

Recommended format for guidelines

  • Keep guidelines as brief and focused as possible

  • Guidelines can be edited in a word document with minimal formatting (this is added when uploaded to website)

  • Keep guidelines brief and focused on actions – avoid including information readily available from alternative online sources (which can be linked if useful)

  • Put key information first, especially important assessment and management information

  • Do not use appendices – a series of headed sections work best on a website

Important information can be highlighted – this should be used sparingly to make the most important information stand out.

Where possible acute care guidelines should have a management algorithm at the start of the guideline for ease of use.

A suggested structure follows. Not all sections will be required, and some guidelines will lend themselves to a different structure.

  • Section 1: Specific inclusions or exclusions to use of guideline

  • Section 2: Equity and te Tiriti O Waitangi considerations when using this guideline

  • Section 3: Investigations/Assessment

  • Section 4: Treatment/Management

  • Sections 3 and/or 4 may be replaced by an algorithm

  • Section 5: Follow up/Ongoing management

  • Section 6+: Background information, additional information, etc

  • Section 7: Parent/family information, other resources, etc

  • Section 8: References


  • Emergency drug dosing should appear in guideline

  • Non-standard drug dosing (or very specialised use) should appear in guideline

  • All other medications should refer to New Zealand Formulary for Children for dosing


  • Use APA referencing style, e.g.

    • In document: (Sainaghi, 2008)

    • In reference list: Sainaghi, R. (2008). Strategic position and performance of winter destinations.
      Tourism Review, 63(4), 40-57.

  • Minimise use of references to those most relevant

Contact the Starship Clinical Guidelines Team

For management and development of Starship Clinical Guidelines

Dr Greg Williams (Clinical Guidelines Editor, Service Clinical Director General Paediatrics)

Susan Cato-Symonds (Child Health Website and Digital Innovation Manager)