Clinical practice guidelines (CPGs) are used to improve the quality of care by providing scientific information that can inform decision-makers (1). In terms of several notable characteristics, quality management policies vary among different countries (2), which have their own cultures and health care systems; CPGs management methods also vary accordingly.

In Korea, over 100 CPGs have been developed in the past decade, with more than 70 CPGs currently in development (3). Futhermore, Korean-specific appraisal tools have also been introduced (4). However, the development of these CPGs is disparate, and development competency remains insufficient (56). Unfortunately, there have been no discussions on the governance of CPGs at the early stages; as a result, CPG quality management policies are minimal and differ according to the organizations developing the CPGs.

In the case of the Korean government, the majority of their focus has been on financial support, but this has not been based on a long-term, detailed plan. Furthermore, different departments within the government support different developers. Guidelines have been developed by only a few research groups or academics working individually (7), such that an interdisciplinary approach is lacking. Moreover, support is not provided after development, and appraisals or implementation strategies are not taken into consideration. As a result, low-quality CPGs and significant variations in their quality represent a serious problem (56).

To address this situation, the Korean Academy of Medical Sciences (KAMS), an organization representing medical science in Korea, has been striving to establish quality control systems and is working in collaboration with the government to create policies that ensure the quality of CPGs. CPG development is now a priority; the situation has reached a point in Korea whereby systematic CPG quality management policies can now be established.

To identify future directions in CPG quality management policies in Korea, this study describes the CPG quality management systems used in Western countries, and introduces the appraisal system of the KAMS, an organization that provides the main policies that provide CPG quality control in Korea.

Countries that have actively introduced CPGs have established unique systems that enable the organization and step-by-step management of the development, distribution, evaluation of CPGs as well as the implementation phases for quality control (28). Furthermore, they manage the whole process in accordance with the cooperation of both public and private organizations; cooperation with the public and private sectors is achieved at a higher administrative level. For such collaborative development of CPGs to address national diseases, building consensuses for various forms of cooperation between countries have been achieved concerning the legal status of CPGs (Table 1).

Among quality control agencies, the relevant public organizations include the National Institute for Health and Care Excellence (NICE) in the UK, the National Health and Medical Research Council (NHMRC) in Australia, and the Agency for Healthcare Research and Quality (AHRQ) in the US. These bodies are responsible for policies on healthcare quality management, which include CPGs (910). The private sector for CPG quality control is represented by the following organizations: the Canadian Medical Association (CMA), the Association of the Scientific Medical Societies in Germany (AWMF), and the German Agency for Quality in Medicine (AZQ). In Canada, the CMA has led CPG quality management activities, including development strategies and the application and implementation of guidelines (11). The AWMF is responsible for the development of CPGs and for the provision of professional training, whereas the AZQ focuses on quality assurance activities such as effective implementation and CPG quality management programs (12). However, public and private cooperation is prevalent in the development of CPGs for high-burden chronic diseases and in quality control in Germany (13). In Korea, KAMS has carried out activities concerned with CPG quality control in Korea. To achieve this, KAMS has established a CPG committee that supports the development and dissemination of CPGs. In particular, KAMS has studied the scientific methodology underlying the development of CPGs, including Korean-specific appraisal tools, scoring guides, etc. Moreover, it has enhanced the capabilities of developers by educating them on the development of CPGs. With respect to the government, the level of cooperation has increased to include CPG topic selection rather than just merely initial financial support.

In the majority of countries, appraisals have commonly been done using standardized tools to improve the quality of the development process. However, CPG accreditation processes vary among countries. Both the US and Canada require checklists to develop CPGs, in addition to periodic updates after guideline registration (141516). Germany also considers each criterion separately during the development and registration of CPGs, and assigns a rating based on the degree of development. In contrast, the UK has a management process involving strict regulatory and certification procedures. To accredit CPGs, Accreditation Advisory Committee meetings are held, with CPGs certified in accordance with regular evaluation procedures. NICE introduces all CPGs that are registered on the National Health Service, but the Accreditation Advisory Committee introduces only those guidelines that have obtained final accreditation (17). Australia also has a CPG accreditation process, which involves eight recommendations with respect to the legal implications of guidelines pertaining to early breast cancer (18). In accordance with the CPG development process suggested by the NHMRC, these recommendations were then included at an institutional level (19).

When it comes to the dissemination of CPGs, almost all countries operate on-line databases for the distribution of CPGs. Clearing houses in the US and Canada verify the requirements for CPGs upon guideline registration, and play a key role in evaluating their quality. In Korea, the Korean Medical Guideline Information center (KOMGI) - a CPG portal - also plays an important role in dissemination and quality assessment (20).

However, strategies and activities concerning the implementation of CPGs are insufficient with respect to the active development and dissemination of CPGs. Countries have attempted to improve their level of CPG use, but establishing effective strategies is difficult because influential factors and health environments vary among countries (21). The proportion of CPGs implemented in Korea reportedly remains at 30%-50% (22).

The goals of CPG quality management are to improve the quality of the development process, to provide fair and reliable evaluation recommendations, and to ensure evidence-based decision-making during patient care and management.

US and Europe share common features in their quality management policies on CPGs with which to appraise the development process by using standardized tools and disseminating qualified CPGs through clearinghouses. Besides, to ensure professionalism and objectivity, and to manage quality on a continuous basis, appraisal by an independent organization of experts is guaranteed (25).

Following the introduction of EBM, the requirement for specialized agencies to support the development of CPGs, and to evaluate developed guidelines, has increased in Korea. KAMS, as a professional body representing the medical community, carries influence regarding the development and management of CPGs; it has established foundations for the assessment of CPGs, including the development of Korean-specific quality appraisal tools. KAMS has also set up an independent appraisal organization (the Executive Committee), established regulations related to appraisals, and improved the evaluation system for CPG quality (which is appropriate to the Korean health care environment). The Executive Committee appraises CPGs and gives accreditation only to those with high quality, which motivates the various societies to manage quality continuously. KAMS has trained staff to conduct appraisals in accordance with the participation of medical academies, to which it assigns appraisals, thereby enhancing the ability of each society to develop CPGs and increasing the quality of CPGs.

KAMS has established a CPG quality management system that reflects the characteristics of the Korean healthcare environment and the needs of its users. In particular, CPG quality appraisals assess their independence and the scientific methodologies used during the development process, and provide users with the most reliable guidelines and recommendations. This could improve the quality of information available to decision-makers and thus ultimately enhance EBM in practice.