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IMPLEMENTATION AND EVALUATION 90 In another area, the medical specialty boards may provide a powerful incentive for the understanding and use of guidelines. For instance, information and practice behaviors relating to guidelines can be built into both certification and periodic recertification procedures. Several medical specialty boards are considering the role of practice guidelines in the practice assessments they undertake or plan to undertake as part of their certification activities. Although steps such as these carry the application and administration of practice guidelines far from the immediate practical concerns of AHCPR, the potential importance of many disparate national and local organizations in the broader scheme of guidelines implementation should not be ignored. Updating and Revising In discussing attributes of guidelines, the committee proposed that developers of practice guidelines specify a date or timetable for a review to determine whether revisions to the guidelines are warranted. Reviews could come earlier than scheduled if there were indications of new clinical evidence or changing professional consensus. The credibility and accountability of this process is as essential as that of the initial process of developing guidelines. The Forum thus needs to establish a follow-up mechanism to see that scheduled review occurs and that unscheduled reviews are initiated when necessary. In addition, the Forum should specify procedures for determining whether revisions are actually warranted and, if so, how those revisions will take place. The first step could be undertaken by AHCPR staff, by contractors, or by an advisory panel. It could include, in addition to the review of new clinical literature or evaluations of the guidelines' impact, a request for comments published in the Federal Register. The second step could involve convening new expert panels to make revisions consistent with the attributes specified in the previous chapter. To the extent that parties outside the government are developing similar or related guidelines, the Forum may also want to support a separate effort to review such ''outside" guidelines as a means of informing its own priorities and processes. This activity could be incorporated into a clearinghouse function. The committee was concerned during its deliberations with the problem of inconsistent guidelines. By determining how the guidelines sponsored by AHCPR and those developed by others conform to each other and then investigating the reasons for inconsistencies, the agency may identify aspects of its guidelines that need updating and revising. As discussed in Chapter 5, however, inconsistencies in guidelines are not necessarily unacceptable. One particular implementation problem for the Forum and other
