Intended for healthcare professionals


Breaking the rules: understanding non-compliance with policies and guidelines

BMJ 2011; 343 doi: (Published 13 September 2011) Cite this as: BMJ 2011;343:d5283
  1. Jane Carthey, human factors consultant1,
  2. Susannah Walker, anaesthetic registrar2,
  3. Vashist Deelchand, research associate2,
  4. Charles Vincent, professor of clinical safety research2,
  5. William Harrop Griffiths, consultant anaesthetist3
  1. 1Imperial College London, London, UK
  2. 2Department of Biosurgery and Technology, Imperial College London
  3. 3Department of Anaesthesia, Imperial College Healthcare NHS Trust, London
  1. Correspondence to: J Carthey, London W4 1TF jcarthey_gosh{at}
  • Accepted 4 August 2011

Healthcare organisations use policies and guidelines to standardise and clarify care and improve efficiency, productivity, and safety. But Jane Carthey and colleagues are concerned that their burgeoning number makes it impossible to distinguish the essential from the irrelevant and is affecting compliance

Healthcare staff in the National Health Service are expected to comply with and keep up to date with numerous policies covering every aspect of their daily work. The National Institute for Health and Clinical Excellence (NICE) has guidelines on a huge number of clinical issues ranging from how to treat breast cancer to how to insert a central venous catheter.1 2 Other guidelines are generated by external bodies such as the royal colleges and professional bodies, the General Medical Council, or the Care Quality Commission and reflect the external regulatory framework in which healthcare operates. The NHS Litigation Authority requires trusts to have clinical governance and risk assessment policies in order to get a discount on their insurance contributions. Additionally, many guidelines are locally generated and cover routine activities and the management of different types of risk. Although policies and guidelines are important, the large number of guidelines and many different sources make it impossible for staff to comply with all of them.

Information overload

As part of a research project aimed at understanding the causes of non-compliance, we identified guideline publishers and also counted the number of policies and guidelines on three trust intranet sites. The former NHS Library had a list of 152 publishers of guidelines and 17 references to guidelines about how to develop guidelines.

The number of guidelines and policies on the intranets of three central London NHS acute trusts varied between 192 and 457. In addition to these trust specific guidelines, staff have to understand and comply with local, professional, and governmental policies and …

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