National Framework for developing Policies, Procedures, Protocols and Guidelines (PPPG)

Framework Driver 5 Logo Improvement Methods

Why do we need a National 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  (click) 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. (for more details contact Brid Boyce)

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
  • Approved PPPGs meet the standards outlined in the HSE National Framework


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 Framework do?

The HSE national 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 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

This 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 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
4. Presentation Part 2: Finding & appraising the evidence for PPPGs 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


The HSE National Framework for developing PPPGs was presented at a workshop at the Department of Health (DoH)National Patient Safety Office Conference (2016) on the 7th and 8th December.

pppgs pic 1

From left to right: Ms. Marie Kehoe, Dr. Philip Crowley and Ms. Brid Boyce

pppgs pic2

From left to right: Ms Annette Cotter, Ms Brid Boyce , Ms Larraine Gilligan and Ms Maria Lordan-Dunphy


Brid Boyce, RGN, RSCN, H.Dip. QIH, MSc in Quality Safety in Healthcare Mgt 

Quality Improvement Division, Dr Steevens Hospital, Dublin 8

Brid Boyce Tel. 061 483246/ 483232