Building a Better Guideline: How TRUST Standards Strengthen Clinical Confidence

Clinical practice guidelines shape care decisions throughout healthcare — from primary care to specialty clinics, from procedural suites to intensive care units. When these guidelines are developed with transparency and rigor, they support safer care, reduce variation, and help clinical teams act with confidence. If development processes are unclear, clinicians may hesitate to adopt recommendations, not because the evidence is weak, but because the pathway from evidence to recommendation is difficult to interpret.

The first step in strengthening any guideline is assembling the right Guideline Development Group (GDG). A group that includes multiple clinical specialties helps to prevent narrow interpretation and reduces the risk of blind spots. Guideline developers should ensure that representation reflects the full clinical ecosystem affected by the topic — for example, including both surgical and medical specialties when recommendations intersect perioperative care, or pairing acute and primary care perspectives when guidance spans settings. It’s equally important to document credentials clearly. Titles alone are not enough. Affiliations, departmental roles, disciplines, and areas of expertise should be described so that clinicians and organizational leaders can quickly understand who informed the guidance. One common misconception is that adding a methodologist satisfies the multidisciplinary requirement; in fact, methodological expertise strengthens how recommendations are developed but does not replace the need for broad clinical representation.

Patient and caregiver perspectives also add valuable context to guidance. This can be accomplished by including patient advocates in the GDG, conducting structured surveys or focus groups, or citing literature that examines patient values and preferences. The distinguishing factor is documentation. Simply stating that “patient perspectives were considered” does not help end users understand the depth or influence of that input. Organizations should explain how feedback was gathered, who provided it, and how it influenced the recommendations. For example, if patient representatives were included on the GDG, developers should clearly describe the stages at which they participated (e.g., development of key questions, selection of outcomes, draft review). Similarly, if literature on patient preferences was used, literature should be cited and discussed with the relevant recommendations.

Once the development group is established, attention must turn to building a reproducible and defensible evidence foundation. A trustworthy literature review includes multiple databases, complete Boolean search terms, and clearly stated timeframes. Start dates may be listed as “from database inception,” but must be explicitly noted, and end dates should include month and year at minimum. For updated guidelines, including the most recent search date from the prior version helps users understand continuity of evidence capture. These details matter, as reproducibility and comprehensiveness differentiate a rigorous evidence search from a non-systematic one.

Equally important is documenting the study selection process. Organizations should provide clear inclusion and exclusion criteria, enumerate how many studies were identified, and describe the pathway by which final studies were selected from the total pool. Flow diagrams such as PRISMA or QUOROM are not required but they dramatically improve clarity when paired with reasons for exclusion at each stage. Criteria should reflect patient population, intervention types, comparators, outcomes, study design, study size, and publication language. If PICO (Patient, Intervention, Comparator, Outcome) criteria were used, those should be spelled out clearly.

Once studies are selected, evidence should be summarized through both narrative synthesis and well-structured evidence tables. The narrative should analyze individual study findings, patterns in the body of evidence, and any limitations or inconsistencies. Evidence tables should include study type, patient population, intervention details, comparators, outcomes, results, and evidence quality ratings. Meta-analyses, forest plots, or structured risk of bias assessments can add depth and enhance interpretability, though they are not required for every guideline.

Connecting recommendations to evidence clearly is crucial. Organizations should apply a documented strength-of-evidence rating scheme when appropriate, making it easy for users to see how recommendations derive from the evidence. Similarly, a strength of recommendation rating, preferably based on strength of evidence and other elements such as benefits and harms, is crucial in order for end users to understand relative applicability of the recommendation for the stated population. Ratings may be numerical, alphabetical, or descriptive, but the schemes should be well described and ratings should be linked to recommendations in a way that leaves no ambiguity. If using the GRADE approach, developers should outline how it was applied or adapted. Summaries supporting each recommendation should reflect the quality, quantity, consistency, and relevance of the underlying evidence.

Guidelines should also consider both the potential benefits and harms of recommended interventions. These impacts should be described and linked to the recommendations in a consistent format so clinicians can interpret tradeoffs in clinical contexts. Using headers, tables, or structured narrative sections helps end users quickly locate and interpret benefit-harm information.

Transparency does not stop with evidence. Organizations should clearly disclose actual funding sources for guideline development — not merely stating that external funding was absent but identifying any financial support and its nature. A systematic process for identifying, reviewing, and mitigating financial conflicts of interest (COIs) should be documented, including how COIs were identified, how they were reviewed, and what measures were taken to manage them. External review processes should also be described in detail, including the types of stakeholders invited to review, their affiliations, feedback received, and how that feedback influenced the final document. When reviewers are entirely external to the organization, this enhances confidence in independence and balance.

Finally, guidelines should include a plan for updates with a defined timeframe and a clear process for determining when updates are necessary. Whether it is a guideline-specific updating plan or an organizational policy that applies broadly, the mechanism for keeping guidance current should be transparent and accessible.

Once guidelines are developed with these structural elements in place, they can serve clinicians and healthcare systems with greater confidence and clarity. Clear documentation of multidisciplinary representation, patient input, reproducible evidence review, transparent linkages between evidence and recommendations, accessible discussion/weighing of benefits and harms, and thorough disclosure practices empowers those who apply the guidance to do so more consistently and safely.

For clinicians and decision-makers looking for trusted clinical practice guidelines built with these principles in mind, the ECRI Guidelines Trust® offers a searchable repository of vetted guideline content. It provides access to guidelines that meet rigorous standards of transparency and methodological quality, helping organizations and care teams find and compare guidance efficiently.

Visit the ECRI Guidelines Trust to explore guideline summaries, development methods, and evidence assessments that can support better decision-making in practice.