National Framework for developing Policies, Procedures, Protocols and Guidelines

Why do we need a National PPPG Framework?

The HSE National Framework for developing Policies, Procedures, Protocols and Guidelines (PPPGs) is essential to improve the quality of health care provided by the HSE and to enhance organisational effectiveness.

The HSE currently has many PPPGs in place and a consistent and clear approach is needed for the development, implementation and evaluation of PPPGs. In 2015, NCEC developed Standards for Clinical Practice Guidance and in 2016; following an extensive literature review and survey the HSE National Framework for Developing PPPGs has been developed, aligning the NCEC standards with the stages in the PPPG development cycle.

There should be a consistent clear approach to the development, implementation and evaluation of PPPGs. The two key innovative areas of this new national PPPG framework are that:

  • PPPGs are evidence-based and this evidence is documented
  • Approved PPPGs meet the Department of Health (DoH) NCEC Standards for Clinical Practice Guidance (2015) outlined in the HSE National PPPG Framework

PPPG development cycle

It is well recognised and documented that high-performing health systems have robust PPPGs in place in order to deliver quality and safe care.

The benefits of having robust PPPGs serve to:

  • Provide instructions and guidance on the most appropriate actions to be undertaken in specific circumstances
  • Promote evidence-based practice
  • Reduce variation in practice and service delivery
  • Avoid unnecessary duplication
  • Facilitate effective staff induction
  • Act as educational tools
  • Act as a basis for audit, evaluation and continuous improvement
  • Meet the NCEC Standards for Clinical Practice Guidance (2015) and other relevant national standards.
  • Promote clear governance in the development and implementation of PPPGs.

What will the National PPPG Framework do?

The HSE national PPPG framework sets out the standards that must be applied when developing PPPGs. The standards apply to all HSE staff and HSE funded services.

The national PPPG framework covers clinical and non-clinical policies, procedures, protocols and guidelines. This includes:

  • Models of care
  • Care bundles
  • Care pathways
  • Clinical decision aids
  • Checklists and algorithms, as part of the implementation toolbox can be included in the PPPG as  they are components rather than stand-alone practice guidance. Diagrams or flowcharts can be utilised to assist in the visual process in the understanding of PPPGs.

The National PPPG Framework for developing PPPGs sets out the following:

Figure 2 PPPG

Who does it apply to?

This is a whole health system framework and applies across the different governance levels that currently exist. It is the role and responsibility of all managers to ensure this framework is implemented at all levels within their areas of responsibility. All staff are required to implement this framework when developing PPPGs.

PPPG Programme Pack (Accredited Category 1 from NMBI 4.5 CPD Credits)

This training programme has been developed to support staff in the implementation of the PPPG Framework when developing PPPGs. There are 3 parts to this Programme including supporting documentation:

  • Part 1: Overview of the PPPG Framework for developing PPPGs
  • Part 2: Finding and appraising the evidence for PPPGs
  • Part 3: Monitor, audit, evaluate & review of PPPGs

Index Content Pack

8. Evidence-based practice: A practice Manual

1. Presentation Part 1: HSE National Framework for developing PPPGs (Updated October 2019)

9. Hexamethonium Study

2. National Policy for Pronouncement of Expected death by Registered Nurses (2017)

10. Wakefield Study

3. Framework for Improving Quality in our Health Service (April 2016)

11. Presentation Part 3: Monitor, Audit, Evaluate & Review of PPPGs (Updated October 2019)

4. Presentation Part 2: Finding & appraising the evidence for PPPGs (Updated October 2019)

12. 12 Tips for successful clinical audit

5. A Guide to critical Appraisal

13. Monitoring & Review of PPPGs

6. AGREE Short guideline Appraisal Form

14. Example of Evaluation Form

7. Links to locate the evidence

15. Example Flyer

Additional Documentation

HSE National Template for Developing PPPGs (2016)

HSE Checklist for developing Clinical PPPGs

HSE Checklist for developing Non-Clinical PPPGs

Membership of the PPPG Development Group Template

Membership of the Approval Governance Group Template

Conflict of Interest Declaration Form Template

Overview of HSE National Framework for developing PPPGs

PPPG eLearning Video (2018)

You can access the PPPG video by logging into HSELand and type PPPG into search.

NCEC Implementation Guide and Toolkit (2018) 

Implementation science is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, to improve the quality and effectiveness of health services.

The purpose of this Implementation Guide is to support those involved in the development and implementation of National Clinical Guidelines and PPPGs. The Implementation Guide provides the theory, steps and tools for each stage of implementation. The individual tools are also available on the website as individual dynamic pdfs.

Guide and Toolkit

NCEC Implementation Guide and Toolkit 2018 - Tool 4 Implementation planning tool template

NCEC Framework for Public Involvement in Clinical Effectiveness Processes (2018)

Public Involvement strengthens public participation in healthcare decision-making and brings public knowledge and experience to these processes.  This Public Involvement Framework has been developed to assist groups such as guideline, audit and PPPG groups to strengthen public involvement in their processes.

Framework for Public Involvement in Clinical Effectiveness Processes (2018)

Useful Websites

The Practical Guide to Clinical Audit contains sample templates, checklists and summaries. Top tips for the successful development of clinical audit data collection tools. These tips were developed by the Irish Clinical Audit Network a national network of healthcare professional involved in clinical audit. These may also be accessed as standalone documents through the following link:

Bandolier: Bullet-points of evidence from systematic reviews, meta-analyses, randomised trials, and high-quality observational studies

The Cochrane Library:  The “gold standard” for quality, systematic reviews.  Updated quarterly, freely available on the internet

OT SeekerEvidence-Based Practice Resources for Occupational therapy

PEDro:  Physiotherapy Evidence Database

AGREEII: An international tool to assess the quality and reporting of practice guidelines

Health Improvement Scotland: Evidence for healthcare improvement: evidence, advice, guidance and standards

National Institute for Health and Care Excellence (NICE), UKNICE pathways NICE guidance NICE standards and indicators 

Department of Health:  Implementation Guide and Toolkit for National Clinical Guidelines

HSE Quality Assurance &Verification Division 

SIGN (Scottish Intercollegiate Guidelines Network):  Evidence-Based Clinical Practice Guidelines for the National Health Service (NHS) in Scotland

CSO (Central Statistics Office): Statistics relating to the economic, social and general conditions in Ireland.  Includes births/deaths/marriages

ESRI (Economic Social & Research Institute):  Includes national data on Acute Hospital Discharges

Medicine Biomedical database containing more than 24 million citations from more than 5,000 journals (free online version available)

TRIP (Turning Research into Practice)