In this organization, clinical guidelines reflect current scientific knowledge of practices and expert clinical
judgment. Clinical guidelines are tools to assist the caregivers in clinical decision making; however it is not a
substitute for professional judgment in addressing individual patient needs. By reducing unnecessary variation in care
delivery, clinical practice guidelines can reduce errors, thereby improving patient safety.
Clinical guidelines will be used in designing or improving processes that relate to patient care. The Medical Director,
and/or other providers of care, Performance Improvement committee members/officer, etc. identify criteria for
selecting and implementing clinical guidelines. The guidelines are reviewed and approved before implementation by
the Medical Director/Governing Board. The guidelines will be based on current recommendations of national bodies and
specialty groups such as the AGA, ACG, and AMA. All guidelines will be reviewed and updated at least every year.
Clinical guidelines are categorized via the operating/procedure room log and the outcomes related to
clinical practice guidelines are evaluated through the Peer Review process: guidelines are refined to improve processes.
Clinical Guidelines must meet the following criteria, validity and reliability established, there must be relevance
to the organization's scope of services, they are comprehensive and specific, and flexible.
Various guidelines are found throughout the organization's policy and procedure manual such as Infection Control, Nausea and Vomiting, Malignant Hyperthermia, Pre-procedural testing,
Approved By Governing Board