Shared Health Provincial Document Development Resources
Jump to: Documents & Templates | Document Development Guidelines | Communication of Practice Changes | Education & Training
The information on this page will assist you in the development of standardized provincial clinical documentation and education/training materials. As the governance structures and decision-making related to the development of provincial clinical documentation change frequently, the resources and information on this page should be considered the most current and primary source of information.
Documents & Templates
Identifies and defines the different types of provincial clinical documents.
Standard: A desired and achievable level of performance against which actual practice can be compared. It provides a benchmark below which performance is unacceptable. There is little to no interpretation allowed. See our template for an example of how to create a Standard.
Guideline: Systematically developed, evidence-based strategies and principles that direct actions and decisions for the management of specific circumstances. They provide direction and guidance for decision-making and allow for professional judgment. See our descriptive template and blank template for examples of how to create a guideline.
Order Set: A set of precise instructions detailing actions for the prevention, care and/or treatment of a clinical condition. Orders set must be client specific and signed by an authorized health-care provider (prescriber). See our template for an examples of how to create an order set.
Policy: A mandatory, clear, formal, and authoritative statement that enables staff to make informed decision-making, prescribes limits, assigns responsibilities/accountabilities and is secondary/subject to relevant government legislation and organizational by-laws. A policy is a document that establishes the rules and values of the organization, and applies to the entire organization. See the Shared Health Policy page for more information (note: site is only accessible if you are connected to the provincial network.)
Standard Work / Standard Operating Procedure (SOP): A precise description of a work activity, including the sequence of tasks and the application of best practices to complete the activity. SOPs ensure everyone knows their roles and responsibilities and performs the procedures or tasks the same way each time. An SOP may be used to operationalize administrative tasks and/or care delivery in a specific area. See our template for an example of how to create an SOP.
Protocol: A mandatory set of decision-making instructions to manage a clinical condition, operational issue or population occurrence. Any deviation requires documented rationale. Protocols are typically applied to a certain work group(s) across the entire organization.
Algorithm: A process flow depicted in graph form. Algorithms can include a decision process or work process. An algorithm must be accompanied by a policy or procedure.
Clinical Pathway: Defined plans of care for specific patient populations during a well-defined period of time. Interdisciplinary with criteria to guide care delivery, Clinical Pathways define the optimal timing and sequencing of interventions and treatments. They are used to reduce variation in patient care and contain defined milestones with established outcomes. Any variances from the pathway are documented.
Form: A fillable sheet with demographic information and other related collected data.
| Clinical Standards | Clinical Guidlines | |
|---|---|---|
| Purpose | Establishes the threshold level of expected care. Uniform provincial application of a clinical or administrative practice. Dierct resources for services provided or funded by the government Optimizes resource utilization Reduces inappropriate clinical variation Provides efficient, effective and high-quality care. | Provincial recommendations on the preferred delivery of care and services. Structures clinical decision making/pathway Spreads innovative practices and system learnings. Aligns with WRHA EIPTs Optimizes resource utilization Reduces inappropriate clinical variation Provides efficient, effective and high-quality care. |
| Variation in Interpretation | None – Exceptions to expectations are clearly defined. | Clinical judgement and specific patient-specific circumstances taken into account. |
| Compliance | Compliance is mandatory. | Compliance is expected, but is still advisory. Deviation may occur in certain circumstances where clinical judgement is leveraged. |
| Enforcement | Performance metrics and monitoring for compliance Reporting to Shared Health or Government Funding levers Contract/employment implications Communication of expectations and collaborative practice networks | Audits Communication of expectations and collaborative practice networks |
| Volume/Quantity | Few – Judicious selection of what is a standard | Many – A common mechanism of communicating provincial clinical expectations |
| Development | Mandatory elements/requirements more likely by the Government of Manitoba of Shared Health. An interdisciplinary and provincially representative group of expert co-develop the clinical standard. Consensus working group not required, but requires Provincial Leadership/Exec table approval to proceed. | Recommended best practices more likely identified by PCTs, RHAs, or programs. And interdisciplinary and provincially representative group of experts co-develop the guideline and reach consensus. Participants represent the best interests of the RHA or program from which they’re from and champion the guidelines as best practice within their respective work areas. |
| Amendments | Rare, infrequent, not easy to modify – durability | Expected to change as evidence, information and practice changes. |
| Evidence | Evidence informed and expertise from provincial SMEs, but may also be used as a mechanism to mobile provincial resources. | Evidence informed and expertise from provincial SMEs. |
Document Development Guidelines
Resources to assist in the development and approval process of provincial clinical documents.
- DRAFT SH Provincial Clinical Document Development Checklist
- Standards, Provincial Clinical Practice
- Guidelines, Provincial Clinical Practice
- Provincial Clinical Order Set Development and Approval Process – draft guidelines for the development of provincial clinical order sets
Communication of Clinical Practice Changes
Provincial initiatives and/or projects led by Provincial Clinical Teams (PCTs) produce deliverables that necessitate the consistent, effective and broad communication of changes to provincial stakeholders. The documents below outline the processes for the coordinated distribution of Shared Health (SH) Clinical Standard and Guideline practice changes to provincial stakeholders.
- Provincial Clinical Practice Change SOP – in review, use as a general guideline.
- Clinical Practice Change Template – Used to announce a new or revised provincial clinical standard, guideline, model of care, etc.
- Clinical Communication Memo Template – Used to provide new or reiterate previous provincial clinical messaging
- Provincial Clinical Practice Communication Email Template
- Stakeholder Analysis Engagement Checklist
- Practice Change Communication Distribution Checklist
- Shared Health Posting Guidelines for Weekly Roundup Newsletter
- Use Shared Health Weekly Roundup as a mechanism for communicating new Provincial Clinical Guidelines and Standards
- Encourage SDO stakeholders to communicate through their weekly newsletters