AGREE II INSTRUMENT7DOMAIN 1. SCOP.docx

AGREE II INSTRUMENT
7
DOMAIN 1. SCOPE AND PURPOSE
1. The overall objective(s) of the guideline is (are) specifically
described.
1
Strongly Disagree
234567
Strongly Agree
Comments:

2. The health question(s) covered by the guideline is (are)
specifically described.
1
Strongly Disagree
234567
Strongly Agree
Comments
3. The population (patients, public, etc.) to whom the guideline
is meant to apply is specifically described.
1
Strongly Disagree
234567
Strongly Agree
Comments
DOMAIN 2. STAKEHOLDER INVOLVEMENT

4. The guideline development group includes individuals from
all relevant professional groups.
1
Strongly Disagree
234567
Strongly Agree
Comments
5. The views and preferences of the target population (patients,
public, etc.) have been sought.
1
Strongly Disagree
234567
Strongly Agree
Comments
6. The target users of the guideline are clearly defined.

1
Strongly Disagree
234567
Strongly Agree
Comments
DOMAIN 3. RIGOUR OF DEVELOPMENT
7. Systematic methods were used to search for evidence.
1
Strongly Disagree
234567
Strongly Agree
Comments:
8. The criteria for selecting the evidence are clearly described.
1
Strongly Disagree

234567
Strongly Agree
Comments
9. The strengths and limitations of the body of evidence are
clearly described.
1
Strongly Disagree
234567
Strongly Agree
Comments
DOMAIN 3. RIGOUR OF DEVELOPMENT continued
10. The methods for formulating the recommendations are
clearly described.
1
Strongly Disagree
234567

Strongly Agree
Comments
11. The health benefits, side effects, and risks have been
considered in formulating the recommendations.
1
Strongly Disagree
234567
Strongly Agree
Comments
12. There is an explicit link between the recommendations and
the supporting evidence.
1
Strongly Disagree
234567
Strongly Agree

Comments
13. The guideline has been externally reviewed by experts prior
to its publication.
1
Strongly Disagree
234567
Strongly Agree
Comments
14. A procedure for updating the guideline is provided.
1
Strongly Disagree
234567
Strongly Agree

Comments
DOMAIN 4. CLARITY OF PRESENTATION
15. The recommendations are specific and unambiguous.
1
Strongly Disagree
234567
Strongly Agree
Comments
16. The different options for management of the condition or
health issue are clearly presented.
1
Strongly Disagree
234567
Strongly Agree
Comments

17. Key recommendations are easily identifiable.
DOMAIN 5. APPLICABILITY
1
Strongly Disagree
234567
Strongly Agree
Comments
18. The guideline describes facilitators and barriers to its
application.
1
Strongly Disagree
234567
Strongly Agree
Comments

19. The guideline provides advice and/or tools on how the
recommendations can be put into practice.
1
Strongly Disagree
234567
Strongly Agree
Comments
20. The potential resource implications of applying the
recommendations have been considered.
1
Strongly Disagree
234567
Strongly Agree
Comments
DOMAIN 5. APPLICABILITY continued

21. The guideline presents monitoring and/or auditing criteria.
1
Strongly Disagree
234567
Strongly Agree
DOMAIN 6. EDITORIAL INDEPENDENCE
Comments
DOMAIN 6. EDITORIAL INDEPENDENCE
22. The views of the funding body have not influenced the
content of the guideline.
10
1
Strongly Disagree
234567
Strongly Agree
Comments

23. Competing interests of guideline development group
members have been recorded and addressed.
1
Strongly Disagree
234567
Strongly Agree
Comments
OVERALL GUIDELINE ASSESSMENT
For each question, please choose the response which best
characterizes the guideline assessed:
1. Rate the overall quality of this guideline.
1
Lowest possible quality
2
3
4

5
6
7
Highest possible quality
2. I would recommend this guideline for use.
Yes
Yes, with modifications
No
NOTES
11
BBA 2026, Organizational Communication 1
Course Learning Outcomes for Unit III
Upon completion of this unit, students should be able to:

5. Recommend communication techniques that are effective in
managing conflict.
5.1. Analyze conflict in an organization.
5.2. Apply Rahim’s functional and dysfunctional outcomes to
managing conflict.
Reading Assignment
In order to access the following resource(s), click the link(s)
below:
Bain, V. (2000). How to diagnose and treat poor performance.
The Journal for Quality and Participation,
23(5), 38-41. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=http://s
earch.proquest.com.libraryresources.c
olumbiasouthern.edu/docview/219160561?accountid=33337
Antonioni, D. (1995). Practicing conflict management can
reduce organizational stress. Industrial
Management, 37(5), 7-8. Retrieved from
earch.proquest.com.libraryresources.c
olumbiasouthern.edu/docview/211594375?accountid=33337
Click here to view the Unit III Presentation.
Click here to view the Unit III Presentation transcript.

Unit Lesson
Introduction
For many people, conflict can be a word with negative
connotations. Within an organization, employees may
equate conflict to open hostility or harsh, interpersonal clashes.
However, conflict is merely a state of
unresolved differences between entities. Sometimes, the
difference is functionally productive; sometimes, it is
dysfunctional. This unit explores conflict within organizations
and discusses communication techniques that
can help to effectively manage conflict.
Course/Unit
Learning Outcomes
Learning Activity
5
Unit Lesson
Unit III Presentation
Article: “Practicing conflict management can reduce
organizational stress”
Article: “How to diagnose and treat poor performance”
Unit III Article Review
5.1
Unit Lesson
Article: “How to diagnose and treat poor performance”

5.2
Unit Lesson
UNIT III STUDY GUIDE
Managing Conflict in an Organization
Through Communication
earch.proquest.com.libraryresources.columbiasouthern.edu/docv
iew/219160561?accountid=33337
https://online.columbiasouthern.edu/bbcswebdav/xid-
53427126_1
https://online.columbiasouthern.edu/bbcswebdav/xid-
53427150_1
UNIT x STUDY GUIDE
Title

Consequences of Conflict
In Managing Conflict in Organizations, M. Afzalur Rahim
(2000) explains that conflict has the potential for both
positive and negative consequences. In order to achieve the
benefits from conflict, an organization must
mitigate the negative or dysfunctional outcomes of conflict and
develop the positive effects to their highest
potential. Rahim (2000) lists seven categories for both
functional outcomes and dysfunctional outcomes that
have been studied extensively by a variety of authors. The
functional outcomes have been provided below
(Rahim, 2000, p. 7):
Rahim’s Functional Outcomes
1.Conflict may stimulate innovation, creativity, and growth.
2.Organizational decision-making may be improved.
3.Alternative solutions to a problem may be found.
4.Conflict may lead to synergistic solutions to common
problems.
5.Individual and group performances may be enhanced.
6.Individuals and groups may be forced to search for new
approaches.
7.Individuals and groups may be required to articulate and
clarify
their positions.

In their groundbreaking study, Scientists in Organizations,
Donald Pelz and Frank Andrews (1976) concluded
that a certain amount of creative tension had to exist between
the states of worker security and conflict to
stimulate innovation, creativity, and growth. They noted that
employee productivity increased when the
organizations they studied changed established patterns or when
technical disputes arose. During these
times of conflict, communication between employees and
between management and employees increased.
Pelz and Andrews (1976) also noted that output improved when
management provided positive reinforcement
and encouraged employees to participate in policy-making.
Positive communication between management
and employees helped to promote the functional outcome.
After T. J. Peters and R. H. Waterman reviewed the practices of
companies like IBM, 3M, GE, Boeing, and
Hewlett Packard, they found that the companies used
management practices that were designed to stimulate
competition. Many of the organizations created a contest
atmosphere by assigning the same problem to two
different teams. This manufactured conflict allowed managers to
see who would come up with the best
solution (Denton, 2002).
A degree of serendipity can develop from conflict. The
conversations generated because of the disagreement
can lead to alternative solutions by accident.
When conflict occurs between employees working on a project,
managers should encourage a dialogue to
exchange information regarding the issues. During this
information exchange, employees will need to explain

their differences in perspective. Without the conflict, this
exchange might never happen. Employees will be
forced to reevaluate project goals and problems, which can lead
to better solutions.
When conflict arises, the organization simply cannot follow the
status quo—the established way of doing
things—and the need to resolve the conflict can force
organizations to try new approaches. This encourages
communication, which can trigger creative solutions for
problems and encourage new ways to achieve goals.
Conflict can have a direct impact on communication. It can
force employees to explain their perspectives and
to seek information from coworkers on an issue. Employees will
need to explain their differences in
perspectives, which might not happen otherwise (Rahim, 2000,
p. 7).
UNIT x STUDY GUIDE
Title
Rahim’s (2000) dysfunctional outcomes have been provided
below (p. 7):
Rahim’s Dysfunctional Outcomes

1.Conflicts may cause job stress, burnout, and dissatisfaction.
2.Communication between individuals and groups may be
reduced.
3.A climate of distrust and suspicion can be developed.
4.Relationships may be damaged.
5.Job performance may be reduced.
6.Resistance to change can increase.
7.Organizational commitment and loyalty may be affected.
Too much conflict burdens and overwhelms the minds/emotions
of the employees, shutting off the capacity
for creativity. For example, the University of Wisconsin-
Madison conducted a study that evaluated elements of
job stress, burnout, and dissatisfaction for middle managers in
organizations that were experiencing
organizational changes (Antonioni, 1995). The survey also
assessed how the organizations used conflict
management to resolve the stressors faced by the employees.
Organizations that had regular communication
regarding the conflict management had employees with lower
levels of stress. Organizations that employed
individuals who had concerns about discussing situations with
their superiors had employees with higher
levels of stress. The study demonstrates that knowing how to
manage and resolve conflict is a valuable skill
to combat workplace stressors. As Antonioni (1995) suggests,
successfully managing stressful work
situations to help avoid burnout and job dissatisfaction boils

down to mastering communication skills.
Sometimes, different conversational styles or faulty inferences
create apparent conflicts when no real
disagreement exists. Efficiently managing conflict involves
matching the style of communication with the
situation (Rahim, 2000). Managers need to analyze their
audience before addressing any type of conflict and
to recognize not only the personal feelings of the employees but
also the policies and procedures of the
organization. As Antonioni (1995) relates, communication has
to work both ways: Active listening must be a
part of the communication process. All of the concerned parties
must claim responsibility for their actions and
collaborate to find a solution that is satisfactory to both sides.
Unacknowledged conflicts rarely go away; rather, they fester
and make subsequent exchanges more difficult.
In “How to Diagnose and Treat Poor Performance,” Victoria
Bain (2000) explains that teamwork is
undermined by derogatory attitudes. Employees do not function
at a high level of effort when they are cast
into stereotypes or oppressed by bias (Bain, 2000).
Conflict is difficult to resolve when an employee criticizes
another person instead of focusing on the issue.
This leads to counterattacks and an escalation of the conflict.
The issue becomes more difficult to resolve
because feelings are hurt.
Bain (2000) recommends that managers take an active role in
resolving the conflict rather than letting the
employees work it out amongst themselves. The author
recommends gathering specific information about
complaints rather than general information. This makes it easier

for the employees to address the problem.
Bain discusses an example from a chemical plant where an
employee did not feel valued by his manager and
intentionally reduced the amount of work he did on a daily
basis. The manager did value the employee but
never communicated this to him. The conflict developed due to
this lack of communication and was resolved
only when a dialogue between the two began.
Managers need to review systems and/or procedures for changes
that may have caused the conflict. People
who have already made up their minds about a situation are
highly resistant to change. The structure of a
work group in an organization may have altered, new
technology may have been introduced, or resources
that once were plentiful may now be scarce (Bain, 2000).
In order to overcome the opposition, it is important to send an
unambiguous message: People who are
embroiled in conflict can misread topics that neutral parties may
consider clear. It also can help to start a
message with an area of agreement or common ground.
Often, conflict arises because an employee does not feel
respected or appreciated by the other members of
the organization. Bain (2000) considers it a manager’s
responsibility to determine root causes and develop
solutions.

UNIT x STUDY GUIDE
Title
Antonioni (1995) describes the following situation that shows
how a project manager phrases a request may
make a great deal of difference. If the manager states that he or
she wants the employee to attend meetings
because he or she values the employee’s input, this is a positive
way to phrase the request. If the manager
states that he or she wants the employee to attend meetings
because it is a corporate policy, this is a
negative way to make the request.
In this example, the conflict could arise because the statement
“you need to be at the meeting because that is
our policy” does not reflect the reality of the situation.
Attendance may indeed be a policy of the organization,
but the desired outcome of that policy is the important input of
the employee. If this is not communicated,
conflict can arise.
Communication Techniques
In “Practicing Conflict Management Can Help Reduce
Organizational Stress,” Antonioni (1995) discusses four
communication techniques that can help effectively manage
conflict in organizations. These techniques can
both promote functional conflict and resolve dysfunctional
conflict.
needs to stand up for his or her rights,
needs, and expectations while also being attentive to the same

attributes for the other person
(Antonioni, 1995). It is helpful to determine what is at stake
and who will be affected by the decisions.
The message will be most effective if it considers the entire
organizational context as well as the
larger context of shareholders, customers, and so forth.
shared understanding of a problem
(Antonioni, 1995). Often, individuals do not listen attentively
when another person speaks. The
listeners may be distracted or, during a conflict, may be trying
to formulate a response to win the
argument. In active listening, listeners (receivers) demonstrate
that they have understood a speaker
through feedback. Receivers can paraphrase the content, mirror
the speaker’s feelings, ask for
clarification, or request additional information.
causes are essential aspects of helping to
manage conflict through communication.
possible before deciding on a solution. In all
but the very simplest problems, there are several possible
solutions. Antonioni (1995) believes that
both parties need to utilize effective negotiation skills. Focus on
seeing the issues from the other
party’s perspective, he recommends, rather than negotiating
solely from a fixed individual position.
Conclusion

As Rahim (2000) notes, it is impossible to eliminate all conflict
from an organization. He believes that a
moderate amount of conflict is beneficial for an organization
and is even necessary for maintaining
effectiveness. What remains central to both the functional and
dysfunctional results of conflict is
communication.
Through communication, the participants establish what the
conflict means and the way that it affects the
organization. In the functional examples, conflict led to greater
communication among the participants. In the
dysfunctional examples, employees and/or managers did not
communicate effectively, and the conflict was
resolved only through increased levels of communication
between the participants.
References
Antonioni, D. (1995). Practicing conflict management can
reduce organizational stress. Industrial
Management, 37(5), 7-8.
Bain, V. (2000). How to diagnose and treat poor performance.
The Journal for Quality and Participation,
23(5).
Denton, J. (2002). Organisational learning and effectiveness.
New York, NY: Routledge.

UNIT x STUDY GUIDE
Title
Pelz, D., & Andrews, F. (1976). Scientists in organizations.
Retrieved from
http://babel.hathitrust.org/cgi/pt?id=mdp.39015071812346;view
=1up;seq=27
Rahim, M. A. (2000). Managing conflict in organizations.
Westport, CT: Greenwood Press.
Suggested Reading
In order to access the following resource(s), click the link(s)
below:
Denton, J. (2002). Organisational learning and effectiveness.
New York, NY: Routledge. Retrieved from
http://site.ebrary.com/lib/columbiasu/detail.action?docID=1007
0700&p00=organisational+learning+eff
ectiveness
Rahim, M. A. (2000). Managing conflict in organizations.
Westport, CT: Greenwood Press. Retrieved from

7971&p00=managing+conflict+organiz
ations
Pelz, D. & Andrews, F. (1976). Scientists in organizations:
Productive climates for research and development.
Retrieved from
=1up;seq=27
Learning Activities (Nongraded)
Apply What You Have Learned
Consider organizations where you have worked in the past or
where you are currently employed. Have you
encountered any situations of functional or dysfunctional
conflict? If so, how did this conflict affect your
working environment and job performance?
Nongraded Learning Activities are provided to aid students in
their course of study. You do not have to submit
them. If you have questions, contact your instructor for further
guidance and information.
0700&p00=organisational+learning+effectiveness
0700&p00=organisational+learning+effectiveness
7971&p00=managing+conflict+organizations

7971&p00=managing+conflict+organizations
=1up;seq=27
Guideline Evaluation using the Agree II Instrument
Student Name
Grand Canyon University: DNP 820
Date
Guideline Evaluation using the Agree II Instrument
The following table outlines a critical appraisal of the guideline
written by Kalil et al. (2016) on "Management of Adults with
Hospital-Acquired and Ventilator-Associated Pneumonia: 2016
Clinical Practice Guidelines by the Infectious Diseases Society
of America and the American Thoracic Society" using the
AGREE II Instrument (2009). Pneumonia that occurs greater
than 48 hours after admission to the hospital (HAP) or greater
than 48 hours after endotracheal intubation (VAP) has special
considerations, separate from the considerations for community-
acquired pneumonia, and this guideline was written to address
these specific considerations and circumstances (Kalil et al.,
2016). This guideline includes 25 recommendations outlining
how to best diagnose and treat HAP and VAP. Serum and
microbiology laboratory testing option recommendations related
to HAP and VAP are outlined, and then antibiotic selection and

duration recommendations make up the majority of
recommendations included in the guideline (Kalil et al., 2016).
Domains with Questions:
Score (1-7):
Comments:
Domain 1: SCOPE AND PURPOSE
1. The overall objective(s) of the guideline is (are) specifically
described.
7
Kalil et al.'s (2016) overall objectives are found on the first
page where an abstract would normally be found.
2. The health question(s) covered by the guideline is (are)
6
While not introduced overtly as the health questions covered in
this guideline, it is very easy to tell from the introduction
summary that Kalil et al. are answering the questions how to
diagnose and how to treat HAP and VAP. In the scope and
purpose section it is even more clear.
3. The population (patients, public, etc.) to whom the guideline
is meant to apply is specifically described.
7
Kalil et al. explain in great detail who the target population of
patients is to whom the guideline is meant to apply.
Domain 1 total: 20/21 calculates to 94.4%
Domain 2: STAKEHOLDER INVOLVEMENT
4. The guideline development group includes individuals from
all relevant professional groups.
7
Professionals from a multitude of relevant groups (e.g.
pulmonary, critical care, infectious disease, pathology, and
microbiology medicine groups) who are from at least six
countries are part of the Kalil et al. author group.Comment by

Lane, Kari: Who is missing from this group/
5. The views and preferences of the target population (patients,
2
In their table on interpretation of strong and weak (conditional)
recommendations, Kalil et al. take patient preference into
consideration, but the patient preference is assumed rather than
explicitly sought. This is likely because evidence on patient
preferences for how HAP and VAP are diagnosed and treated is
scarce and not very applicable as patients are grossly
uninformed on the topic.
6. The target users of the guideline are clearly defined.
7
Kalil et al. clearly define the target audience for the guidelines
on page nine in the scope and purpose section.
Domain 2 Total: 16/21 calculates to 72.2%
Domain 3: RIGOUR OF DEVELOPMENT
7. Systematic methods were used to search for evidence.
7
Kalil et al. describe their methodology employed for developing
the guideline, including that two health science librarians who
are experts in searching for evidence developed the literature
searches, and more details on the searches can be found in
supplementary material.
8. The criteria for selecting the evidence are clearly described.
3
Kalil et al. write that the literature search results were reviewed
by panelists who then selected and reviewed the articles. More
details are available on how the search was conducted and how
the evidence was evaluated after selection than on how the
articles were selected. Comment by Lane, Kari: Where are they
available from? How did you decide on a score of 3 here, justify
your decision.
9. The strengths and limitations of the body of evidence are
clearly described.

7
A summary of the evidence with the strengths and limitations is
included after every recommendation Kalil et al. give.Comment
by Lane, Kari: What limitations do you see? Often the creators
do not see limitations in their own work, so really look for
downfalls.
clearly described.
7
Kalil et al. include a rationale for the recommendation section
after the summary of evidence that accompanies every
recommendation.
7
This is thoroughly discussed by Kalil et al. in the rationale for
the recommendation section. Comment by Lane, Kari: What is
missing?
12. There is an explicit link between the recommendations and
the supporting evidence.
7
Kalil et al. give their recommendation and then detail the
evidence and their rationale, clearly linking every
recommendation with the evidence.
13. The guideline has been externally reviewed by experts prior
to its publication.
7
Per Kalil et al., external peer reviewers gave feedback, and then
the guideline was reviewed and endorsed by the Society of
Critical Care Medicine and the Society for Healthcare
Epidemiology of America before final review and approval was
obtained from the boards of directors of the Infectious Diseases
Society of America and the American Thoracic Society.
14. A procedure for updating the guideline is provided.

2
Kalil et al. describe how this guideline is an update from their
2005 guidelines, but they do not address a procedure for future
updating.
Domain 3 Total: 47/56 calculates to 81.3%
Domain 4: CLARITY OF PRESENTATION
15. The recommendations are specific and unambiguous.
7
Each recommendation summary is written clearly and precisely
by Kalil et al..
16. The different options for management of the condition or
health issue are clearly presented.
7
Kalil et al. specify options when appropriate and also include
room for provider judgment in individual patients or special
situations.
17. Key recommendations are easily identifiable.
7
Kalil et al. do an excellent job in how they present the concise
recommendation summaries in the beginning and also how they
re-present their recommendations clearly in the more detailed
section later.
Domain 4 Total: 21/21 calculates to 100%
Domain 5: APPLICABILITY
18. The guideline describes facilitators and barriers to its
application.
4
Barriers to application of the guideline are described by Kalil et
al. in a few applicable places.Comment by Lane, Kari: And
facilitators? What is missing here, can you see any gaps or
loopholes, where this might not work in your setting?
19. The guideline provides advice and/or tools on how the

5
Tables are given that can be used as tools to implement the
guideline recommendations in specific situations.
20. The potential resource implications of applying the
6
Kalil et al. are aware of resources necessary for diagnosing and
treating HAP and VAP, and they address resource
considerations. Comment by Lane, Kari: Do they offer
resources to assist with implementation?
21. The guideline presents monitoring and/or auditing criteria.
7
Several of Kalil et al.'s recommendations address monitoring
patients' response to treatment.Comment by Lane, Kari: Would
these be easily applied? How so?
Domain 6: EDITORIAL INDEPENDENCE
22. The views of the funding body have not influenced the
content of the guideline.
7
The content of Kalil et al.'s guideline is very clearly based on
researched evidence, and no apparent other influences were
noted.Comment by Lane, Kari: Does the guideline specifically
declare conflicts of interest or state no conflicts of interest were
declared?
23. Competing interests of guideline development group
members have been recorded and addressed.
7
Kalil et al. include both a "discloser and management of
potential conflicts of interest" section in the body of their
guideline and a potential conflicts of interest list at the end.
Total Domain scores:

1. 20/21 calculates to 94.4%
4. 21/21 calculates to 100%
Overall Total: 137/161 calculates to 82.6%
Overall Rating of Quality:
6
Using this Agree II Instrument (2009) to structure this
evaluation, the guideline by Kalil et al. (2016) performs very
well in the areas of scope and purpose, clarity of presentation,
and editorial independence, obtaining scores of greater than
90% in all three of those domains. Scores in the other three
domains are all over 70%. The lowest score is in the domain of
stakeholder involvement, and this area is low partially due to
the low applicability of patient preferences in how HAP and
VAP is diagnosed and treated.
Recommended for use:
YES
I see no reason why the guideline by Kalil et al. should not be
followed in the vast majority of HAP and VAP diagnoses or
suspected diagnoses, and the rigor with which the authors
evaluated evidence to build the guideline makes it an excellent
reference for finding best practices. The clarity with which the
recommendations are presented makes it easy to use for all
providers.
Running head: GUIDELINE EVALUATION 1
6
GUIDELINE EVALUATION USING THE AGREE II
INSTRUMENT

References
AGREE Next Steps Consortium (2009). The AGREE II
Instrument [Electronic version]. Retrieved from:
http://www.agreetrust.org
Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J.,
Sweeney, D. A., Palmer, L. B., & ... Brozek, J. L. (2016).
Management of adults with hospital-acquired and ventilator-
associated pneumonia: 2016 clinical practice guidelines by the
Infectious Diseases Society of America and the American
Thoracic Society. Clinical Infectious Diseases, 63(5), e61-e111.
doi:10.1093/cid/ciw353
I, student name, verify that I have completed ## clock hours in
association with the goals and objectives for this assignment. I
have also tracked said practice hours in the Typhon Student
Tracking System for verification purposes and will be sure that
all approvals are in place from my faculty and practice mentor.
Apply Rubrics
Critical Appraisal of Practice Guidelines
1
Unsatisfactory
0.00%
2
Less Than Satisfactory
74.00%
3
Satisfactory
79.00%
4
Good
87.00%
5

Excellent
100.00%
70.0 %Content
20.0 %Discuss a practice guideline in which you might have
questioned the recommendations.
Discussion of the practice is not presented.
Discussion of the practice is presented but incomplete.
Discussion of the practice is presented but at a cursory level.
Discussion of the practice is clearly presented and convincing.
Sources cited are from current scholarly but some outdated
sources.
Discussion of the practice is clearly presented and perceptive.
Sources cited are from current scholarly sources.
25.0 %Create a table for each domain (similar to the one shown
in the manual) and add domain scores and an overall guideline
assessment.
A table with each domain is not presented.
A table with each domain is presented but incomplete.
A table with each domain is presented but at a cursory level.
A table with each domain is clearly presented. Scores are
present for each domain and justification is beyond surface
understanding.
A table with each domain is clearly presented. Scores are
present for each domain and justification is insightful.
25.0 %Create a table for the overall guideline assessment.
A table for the overall guideline assessment is not presented.
A table for the overall guideline assessment is presented but
incomplete.
A table for the overall guideline assessment is presented but at a
cursory level.
A table for the overall guideline assessment is clearly presented
and convincing.
A table for the overall guideline assessment is clearly presented

and perceptive.
20.0 %Organization and Effectiveness
7.0 %Thesis Development and Purpose
Paper lacks any discernible overall purpose or organizing claim.
Thesis and/or main claim are insufficiently developed and/or
vague; purpose is not clear.
Thesis is apparent and appropriate to purpose.
Thesis is clear and forecasts the development of the paper.
Thesis is descriptive and reflective of the arguments and
appropriate to the purpose.
Thesis is comprehensive and contains the essence of the paper.
Thesis statement makes the purpose of the paper clear.
8.0 %Argument Logic and Construction
Statement of purpose is not justified by the conclusion. The
conclusion does not support the claim made. Argument is
incoherent and uses noncredible sources.
Sufficient justification of claims is lacking. Argument lacks
consistent unity. There are obvious flaws in the logic. Some
sources have questionable credibility.
Argument is orderly, but may have a few inconsistencies. The
argument presents minimal justification of claims. Argument
logically, but not thoroughly, supports the purpose. Sources
used are credible. Introduction and conclusion bracket the
thesis.
Argument shows logical progressions. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.
Clear and convincing argument that presents a persuasive claim
in a distinctive and compelling manner is present. All sources
are authoritative.
5.0 %Mechanics of Writing (includes spelling, punctuation,

grammar, language use)
Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice and/or
sentence construction are used.
Frequent and repetitive mechanical errors distract the reader.
Inconsistencies in language choice (register), sentence
structure, and/or word choice are present.
Some mechanical errors or typos are present, but are not overly
distracting to the reader. Correct sentence structure and
audience-appropriate language are used.
Prose is largely free of mechanical errors, although a few may
be present. A variety of sentence structures and effective
figures of speech are used.
Writer is clearly in command of standard, written, academic
English.
10.0 %Format
5.0 %Paper Format (Use of appropriate style for the major and
assignment)
Template is not used appropriately or documentation format is
rarely followed correctly.
Appropriate template is used, but some elements are missing or
mistaken. A lack of control with formatting is apparent.
Appropriate template is used. Formatting is correct, although
some minor errors may be present.
Appropriate template is fully used. There are virtually no errors
in formatting style.
All format elements are correct.
5.0 %Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to assignment and
style)
Sources are not documented.
Documentation of sources is inconsistent or incorrect, as
appropriate to assignment and style, with numerous formatting

errors.
Sources are documented, as appropriate to assignment and style,
although some formatting errors may be present.
Sources are documented, as appropriate to assignment and style,
and format is mostly correct.
Sources are completely and correctly documented, as
appropriate to assignment and style, and format is free of error.
100 %
Running Head: Critical Appraisal of Practice Guidelines
Page1

DNP 820
Date
CHECKLIST ITEM AND DESCRIPTION
REPORTING CRITERIA
Page #
DOMAIN 1: SCOPE AND PURPOSE
1. OBJECTIVES
Report the overall objective(s) of the guideline. The expected
health benefits from the guideline are to be specific to the

clinical problem or health topic.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 6
Nurses are not recognized and are underutilized in this program
Health intent(s):
Evidence-based guidelines for implementation and measurement
of antibiotic stewardship interventions in inpatient populations
including long-term care (Barlam et al, 2016).
The purpose of this guideline is to comprehensively evaluate the
wide range of interventions that can be implemented by ASPs in
emergency department, acute inpatient, and long- term care
settings as they determine the best approaches to influence the
optimal use of antibiotics within their own institutional
environments. In addition, this guideline addresses approaches
to measure the success of these interventions (Barlam et al,
2016).
The guidelines emphasize the importance of physician and
pharmacist leadership for an ASP, the need for infectious
diseases expertise, and the role of measurement and feedback as
critical components of ASPs (Barlam et al, 2016).
Expected benefit(s) or outcome(s)
The benefits of antibiotic stewardship include improved patient
outcomes, reduced adverse events including Clostridium
difficile infection (CDI), improvement in rates of antibiotic
susceptibilities to targeted antibiotics, and optimization of
resource utilization across the continuum of care (Barlam et al,
2016).
Target(s) (e.g., patient population, society

Health Professionals in the following areas: internal medicine,
emergency medicine, microbiology, critical care, surgery,
epidemiology, pharmacy, and adult and pediatric infectious
diseases specialties (Barlam et al, 2016).
2. QUESTIONS
Report the health question(s) covered by the guideline,
particularly for the key recommendations.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: 7
Antibiotic stewardship is strongly needed in all health care
settings
Health care setting or context:
Guideline for Implementing an Antibiotic Stewardship Program
in inpatient populations including long-term care (Barlam et al,
2016).
3. POPULATION
Describe the population (i.e., patients, public, etc.) to whom the
guideline is meant to apply.
1
Strongly Disagree
2
3
4
5
6

7
Strongly Agree
COMMENTS: Rate 7
· Target population, sex and age Clinical condition (if relevant)
Severity/stage of disease (if relevant) Comorbidities (if
relevant)
Excluded populations (if relevant)
For Health care professionals who work with inpatient
populations including long-term care (Barlam et al, 2016).
DOMAIN 2: STAKEHOLDER INVOLVEMENT
4. GROUP MEMBERSHIP
Report all individuals who were involved in the development
process. This may include members of the steering group, the
research team involved in selecting and reviewing/rating the
evidence and individuals involved in formulating the final
recommendations.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 6
· Name of participant
· Discipline/content expertise
· Institution
· Geographical location
· A description of the member’s role in the guideline
development group
Evidence-based guidelines for implementation and measurement

of antibiotic stewardship interventions in inpatient populations
including long-term care were prepared by a multidisciplinary
expert panel of the Infectious Diseases Society of America and
the Society for Healthcare Epidemiology of America (Barlam et
al, 2016).
Led by Co-chairs Tamar Barlam and Sara Cosgrove, a panel of
18 multidisciplinary experts in the management of ASPs was
convened per the IDSA Handbook on Clinical Practice Guide-
line Development in 2012. In addition to members of IDSA and
the SHEA, representatives from diverse geographic areas,
pediatric and adult practitioners, and a wide breadth of
specialties representing major medical societies were included
among the panel’s membership (American College of
Emergency Physicians [ACEP], American Society of Health-
System Pharmacists [ASHP], American Society for
Microbiology [ASM], PIDS, Society for Academic Emergency
Medicine [SAEM], Society of Infectious Diseases Pharmacists
[SIDP], and the Surgical Infection Society [SIS]). A guideline
methodologist and member of the GRADE Working Group and a
medical writer were added to assist the panel (Barlam et al,
2016).
5. TARGET POPULATION PREFERENCES AND VIEWS
Report how the views and preferences of the target population
were sought/considered and what the resulting outcomes were.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7

· Statement of type of strategy used to capture patients’/publics’
views and preferences (e.g., participation in theguideline
development group, literature review of values and preferences)
· Methods by which preferences and views were sought (e.g.,
evidence from literature, surveys, focus groups)
· Outcomes/information gathered on patient/public information
· How the information gathered was used to inform the
guideline development process and/or formation of the
recommendations
The expert panel followed a process used in the development of
other IDSA guidelines, which included a systematic weighting
of the strength of recommendation and quality of evidence using
the GRADE (Grading of Recommendations Assessment,
Development and Evaluation) system (IDSA, 2015).
PubMed, which includes Medline (1946 to present), was
searched to identify relevant studies for each of the antibiotic
stewardship guideline PICO (population/patient, intervention/
indicator, comparator/control, outcome) questions. Search
strategies were developed and built by 2 independent health
sciences librarians from the Health Sciences Library System,
University of Pittsburgh. For each PICO question, the librarians
developed the search strategies using PubMed’s command
language and appropriate search fields. Medical Subject
Headings terms and keywords were used for the main search
concepts of each PICO question Barlam et al, 2016).
6. TARGET USERS
Report the target (or intended) users of the guideline.
1
Strongly Disagree

2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 6
· The intended guideline audience (e.g. specialists, family
physicians, patients, clinical or institutional
leaders/administrators)
· How the guideline may be used by its target audience (e.g., to
inform clinical decisions, to inform policy, to inform standards
of care)
For Health care professionals who with inpatient populations
including long-term care. That is considered for use in
pediatrics, oncology, community hospitals, small hospitals, and
nursing home and long-term care environments, and not limited
to acute care facilities Barlam et al, 2016).
This guideline discusses a broad range of possible ASP
interventions. They emphasized the need for each site to assess
its clinical needs and available resources and individualize its
ASP with that assessment in mind Barlam et al, 2016).

DOMAIN 3: RIGOUR OF DEVELOPMENT
7. SEARCH METHODS
Report details of the strategy used to search for evidence.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Named electronic database(s) or evidence source(s) where the
search was performed (e.g., MEDLINE, EMBASE, PsychINFO,
CINAHL)
· Time periods searched (e.g., January 1, 2004 to March 31,
2008)
· Search terms used (e.g., text words, indexing terms,
subheadings)
· Full search strategy included (e.g., possibly located in
appendix)
PubMed, which includes Medline (1946 to present), was
searched to identify relevant studies for each of the antibiotic
stewardship guideline PICO (population/patient, intervention/
indicator, comparator/control, outcome) questions. Search
strategies were developed and built by 2 independent health
sciences librarians from the Health Sciences Library System,
University of Pittsburgh. For each PICO question, the librarians
developed the search strategies using PubMed’s command
language and appropriate search fields. Medical Subject
Headings terms and keywords were used for the main search
concepts of each PICO question. A data supplement that

includes search strings can be found following publication on
the IDSA website. Articles in all languages and all publication
years were included. Initial searches were created and
confirmed with input from the guideline committee chairs and
group leaders from February through mid-July 2013. The
searches were finalized and delivered between late July and
September 2013. After the literature searches were performed,
authors continued to review the literature and added relevant
articles as needed Barlam et al, 2016).
8. EVIDENCE SELECTION CRITERIA
Report the criteria used to select (i.e., include and exclude) the
evidence. Provide rationale, where appropriate.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Target population (patient, public, etc.) characteristics
· Study design
· Comparisons (if relevant)
· Outcomes
· Language (if relevant)
· Context (if relevant)
To evaluate evidence, the panel followed a process consistent
with other IDSA guidelines. The process for evaluating the
evidence was based on the IDSA Handbook on Clinical Practice
Guideline Development and involved a systematic weighting of
the quality of the evidence and the grade of recommendation

using the GRADE system. Unless otherwise stated, each PICO
comparator was usual practice Barlam et al, 2016).
9. STRENGTHS & LIMITATIONS OF THE EVIDENCE
Describe the strengths and limitations of the evidence. Consider
from the perspective of the individual studies and the body of
evidence aggregated across all the studies. Tools exist that can
facilitate the reporting of this concept.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Study design(s) included in body of evidence
· Study methodology limitations (sampling, blinding, allocation
concealment, analytical methods)
· Appropriateness/relevance of primary and secondary outcomes
considered
· Consistency of results across studies
· Direction of results across studies
· Magnitude of benefit versus magnitude of harm
· Applicability to practice context
Panel members were divided into 5 subgroups: (1)
interventions, (2) optimization of antibiotic administration, (3)
microbiology and laboratory diagnostics, (4) measurement and

analysis, and (5) antibiotic stewardship in special populations.
Each author was asked to review the literature, evaluate the
evidence, and determine the initial strength of the re-
commendations along with an evidence summary supporting
each recommendation in his/her assigned subgroup. The
evidence was graded based on the effectiveness of the antibiotic
stewardship intervention, not the underlying data that provided
the groundwork for the intervention. The panel reviewed all
recommendations, along with their strength and the quality of
the evidence. Discrepancies were discussed and resolved, and
all panel members are in agreement with the final
recommendations (Barlam et al, 2016).
10. FORMULATION OF RECOMMENDATIONS
Describe the methods used to formulate the recommendations
and how final decisions were reached. Specify any areas of
disagreement and the methods used to resolve them.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Recommendation development process (e.g., steps used in
modified Delphi technique, voting procedures that were
considered)
· Outcomes of the recommendation development process (e.g.,
extent to which consensus was reached using modified Delphi
technique, outcome of voting procedures)
· How the process influenced the recommendations (e.g., results
of Delphi technique influence final recommendation, alignment

with recommendations and the final vote)
The panel met face to face on 3 occasions and conducted
numerous teleconferences to complete the work of the
guideline. The purpose of the meetings and teleconferences was
to develop and discuss the clinical questions to be addressed,
assign topics for review and writing of the initial draft, and
develop recommendations. The whole panel reviewed all
sections. The guideline was reviewed and approved by the
IDSA Standards and Practice Guidelines Committee (SPGC),
the IDSA Board of Di- rectors, the SHE Guidelines Committee,
and the SHEA Board of Directors, and was endorsed by ACEP,
ASHP, ASM, PIDS, SAEM, SIDP, and SIS (Barlam et al, 2016).
11. CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that were
considered when formulating the recommendations.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 1
No information available.
· Supporting data and report of benefits
· Supporting data and report of harms/side effects/risks
· Reporting of the balance/trade-off between benefits and
harms/side effects/risks
· Recommendations reflect considerations of both benefits and
harms/side effects/risks
12. LINK BETWEEN RECOMMENDATIONS AND EVIDENCE

Describe the explicit link between the recommendations and the
evidence on which they are based.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· How the guideline development group linked and used the
evidence to inform recommendations
· Link between each recommendation and key evidence (text
description and/or reference list)
· Link between recommendations and evidence summaries
and/or evidence tables in the results section of the guideline
A powerful way to support antibiotic stewardship is to improve
the scientific basis for ASP interventions. As outlined in
Section XIII, ASPs can successfully intervene to reduce the
duration of therapy for many infections because well-
constructed, randomized controlled clinical trials have
demonstrated that clinical outcomes are equivalent. Rigorous
published evidence is often needed to convince clinicians to
alter well-established, albeit suboptimal, practice Barlam et al,
2016).
13. EXTERNAL REVIEW
Report the methodology used to conduct the external review
1
Strongly Disagree
2
3
4

5
6
7
Strongly Agree
COMMENTS: Rate 7
· Purpose and intent of the external review (e.g., to improve
quality, gather feedback on draft recommendations, assess
applicability and feasibility, disseminate evidence)
· Methods taken to undertake the external review (e.g., rating
scale, open-ended questions)
· Description of the external reviewers (e.g., number, type of
reviewers, affiliations)
· Outcomes/information gathered from the external review (e.g.,
summary of key findings)
recommendations (e.g., guideline panel considered results of
review in forming final recommendations)
To evaluate evidence, the panel followed a process consistent
with other IDSA guidelines. The process for evaluating the
evidence was based on the IDSA Handbook on Clinical Practice
Guideline Development and involved a systematic weighting of
the quality of the evidence and the grade of recommendation
using the GRADE system (Barlam et al, 2016).
14. UPDATING PROCEDURE
Describe the procedure for updating the guideline.
1
Strongly Disagree
2
3
4
5
6

7
Strongly Agree
COMMENTS: 7
· A statement that the guideline will be updated Explicit time
interval or explicit criteria to guide decisions about when an
update will occur
· Methodology for the updating procedure
At annual intervals, the panel chair, the SPGC liaison advisor,
and the chair of the SPGC will determine the need for revisions
to the guideline based on an examination of current literature. If
necessary, the entire panel will reconvene to discuss potential
changes. When appropriate, the panel will recommend revision
of the guideline to the IDSA SPGC and SHEA guidelines
committees (IDSA, 2015).
DOMAIN 4: CLARITY OF PRESENTATION
15. SPECIFIC AND UNAMBIGUOUS RECOMMENDATIONS
Describe which options are appropriate in which situations and
in which population groups, as informed by the body of
evidence.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: 7
· A statement of the recommended action
· Intent or purpose of the recommended action (e.g., to improve

quality of life, to decrease side effects)
· Relevant population (e.g., patients, public)
· Caveats or qualifying statements, if relevant (e.g., patients or
conditions for whom the recommendations would not apply)
· If there is uncertainty about the best care option(s), the
uncertainty should be stated in the guideline
The benefits of antibiotic stewardship include improved patient
outcomes, reduced adverse events including Clostridium
difficile infection (CDI), improvement in rates of antibiotic
susceptibilities to targeted antibiotics, and optimization of
resource utilization across he continuum of care (Barlam et al,
2016).
16. MANAGEMENT OPTIONS
Describe the different options for managing the condition or
health issue.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
· Description of management options
Population or clinical situation most appropriate to each option
17. IDENTIFIABLE KEY RECOMMENDATIONS
Present the key recommendations so that they are easy to
identify.
1
Strongly Disagree
2

3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Recommendations in a summarized box, typed in bold,
underlined, or presented as flow charts or algorithms
· Specific recommendations grouped together in one section
· Preauthorization and prospective review of antibiotics are
among the many recommendations to ensure antibiotic
stewardship programs are most effective, suggest new
guidelines from IDSA/SHEA.
· Antibiotic stewardship programs should be led by physicians
and pharmacists, including ID specialists, who have the
expertise and education to ensure the right drug is being
prescribed at the right time for the right diagnosis.
· Antibiotic stewardship programs must be based on the specific
problems identified by the healthcare facility and a realistic
examination of available resources to ensure interventions are
performed with consistency.
· These programs have been shown to improve patient
outcomes, reduce antibiotic resistance and save money (IDSA&
SHEA, 2016).
DOMAIN 5: APPLICABILITY
18. FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline’s
application.
1
Strongly Disagree
2
3

4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· Types of facilitators and barriers that were considered
· Methods by which information regarding the facilitators and
barriers to implementing recommendations were sought (e.g.,
feedback from key stakeholders, pilot testing of guidelines
before widespread implementation)
· Information/description of the types of facilitators and barriers
that emerged from the inquiry (e.g., practitioners have the skills
to deliver therecommended care, sufficient equipment is not
available to ensure all eligible members of the
· population receive mammography)
How the information influenced the guideline development
process and/or formation of the recommendations
Additional clinical trials that incorporate consideration of
antibiotic stewardship in their design are critically needed.
Another significant gap is the dearth of implementation re-
search in this area Wagner et al. 2014). Although the National
Action Plan for Combating Antibiotic-Resistant Bacteria will
require the institution of ASPs across healthcare facilities, little
effort and limited research funding have been allocated to study
how best to achieve large-scale implementation (The White
House, 2015).
Qualitative assessments that can examine the impact of factors
such as organizational culture, prescriber attitudes, and the self-
efficacy of the antibiotic steward (ie, the extent to which he/she
believes his/her goals can be reached) are lacking and are
important to establish the context in which ASP implementation

occurs (Pakyz et al, 2014).
19. IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be
applied in practice.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 6
Additional materials to support the implementation of the
guideline in practice. For example:
o Guideline summary documents
o Links to checklists, algorithms
o Links to how-to manuals
o
Solution
s linked to barrier analysis(see Item 18)
o Tools to capitalize on guideline facilitators (see Item 18)
o Out come of pilot test and lessons learned
Despite the recognition that much more research is needed, this

guideline identifies core interventions for all ASPs as well as
other interventions that can be implemented based on facility-
specific assessments of need and resources. Every healthcare
facility is able to perform stewardship, and institution of an
ASP is attainable and of great importance to public health
(Barlam et al, 2016).
20. RESOURCE IMPLICATIONS
Describe any potential resource implications of applying the
recommendations.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 6
· Types of cost information that were considered (e.g.,
economic evaluations, drug acquisition costs)
· Methods by which the cost information was sought (e.g., a
health economist was part of the guideline development panel,

use of health technology assessments for specific drugs, etc.)
· Information/description of the cost information that emerged
from the inquiry (e.g., specific drug acquisition costs per
treatment course)
recommendations
Support for these guidelines was provided by the Infectious
Diseases Society of America (IDSA) and the Society for
Healthcare Epidemiology of America (Barlam et al, 2016).
21. MONITORING/ AUDITING CRITERIA
Provide monitoring and/or auditing criteria to measure the
application of guideline recommendations.
1
Strongly Disagree
2
3
4
5
6
7
Strongly Agree
COMMENTS: Rate 7

· Criteria to assess guideline implementation or adherence to
recommendations
· Criteria for assessing impact of implementing the
recommendations
· Advice on the frequency and interval of measurement
· Operational definitions of how the criteria should be measured
The American Society of Health-System Pharmacists (ASHP),
the Infectious Diseases Society of America (IDSA), the Surgical
Infection Society (SIS), and the Society for Healthcare
Epidemiology of America (SHEA). Plus Centers for Medicare
and Medicaid Services (CMS), Joint Commission on
Accreditation of Healthcare Organizations (JACHO) and Center
for Disease Control and Prevention (CDC) (Barlam et al, 2016).
DOMAIN 6: EDITORIAL INDEPENDENCE
22. FUNDING BODY
Report the funding body’s influence on the content of the
guideline.
1
Strongly Disagree
2
3

4
5
6
7
Strongly Agree
COMMENTS: Rate 7
· The name of the funding body or source of funding (or explicit
statement of no funding)
· A statement that the funding body did not influence the
content of the guideline
Financial support for these guidelines was provided by the
Infectious Diseases Society of America (IDSA) and the Society
for Healthcare Epidemiology of America (Barlam et al, 2016).
23. COMPETING INTERESTS
Provide an explicit statement that all group members have
declared whether they have any competing interests.
1
Strongly Disagree
2
3
4
5
6

7
Strongly Agree
COMMENTS: Rate 7
· Types of competing interests considered
· Methods by which potential competing interests were sought
· A description of the competing interests
· How the competing interests influenced the guideline process
and development of recommendations
Potential conflicts of interest. A list of the reflection of what
was reported to IDSA was provided. To provide thorough
transparency, IDSA requires full disclosure of all relationships,
regardless of relevancy to the guideline topic. Evaluation of
such relationships as potential conflicts of interest is
determined by a review process that includes assessment by the
Standards and Practice Guidelines Committee (SPGC) chair, the
SPGC liaison to the development panel, and the board of
directors liaison to the SPGC, and, if necessary, the Conflicts of
Interest (COI) Task Force of the Board (Barlam et al, 2016).
Maximum possible score = 7 (strongly agree) x 3 (items) x 1

(appraisers) = 21
Minimum possible score = 1 (strongly disagree) x 3 (items) x 1
(appraisers) = 3
The scaled domain score will be:
Obtained score – Minimum possible score
Maximum possible score – Minimum possible score
OVERALL GUIDELINE ASSESSMENT
1. Rating the overall quality of this guideline. 6
1
Lowest possible quality
2
3
4
5
6
7
Highest possible quality
2. I would recommend this guideline for use. YES

Yes
Yes, with modifications
No
NOTES:
The overall quality of this guideline is 6 and I would
recommend them for use for Health Professionals in the
following areas: internal medicine, emergency medicine,
microbiology, critical care, surgery, epidemiology, pharmacy,
and adult and pediatric infectious diseases specialties.
I gave it a 6 because Nurses are kind of ignored or overlooked
or unrecognized /underutilized in the Antimicrobial Stewardship
Programs. My question is that, Are the staff nurses being
underutilized and not recognized as members of the
antimicrobial/antibiotic stewardship program team related to the
rise in health care associated c-diff? “Focused consideration to
empower and educate staff nurses in antimicrobial management
is needed to strengthen collaboration and build an inter
professional stewardship workforce” (Monsees, E. et al., 2017).

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“prescribing etiquette.”
Clin Infect Dis 2013; 57:188–96.
Infectious Diseases Society of America (IDSA) (2015).

Handbook on clinical practice guideline
development. Available at:
http://www.idsociety.org/uploadedFiles/IDSA/ Guidelines-
Patient_Care/IDSA_Practice_Guidelines/IDSA%20Handbook%
20on%20CPG%20Development%2010.15.pdf
Infectious Diseases Society of America (IDSA) and Society for
Healthcare Epidemiology of
America (SHEA) (2016). New Antibiotic Stewardship
Guidelines Focus on Practical Advice for Implementation.
http://www.idsociety.org/New_Antimicrobial_Stewardship_Gui
deline_2016/
Monsees, E., Goldman, J & Popejoy, L. (2017). Staff nurses as
antimicrobial stewards: An
integrative literature review. American Journal of Infection
Control 2017 August 1, 45 (8): 917-922
Pakyz, A., L., Moczygemba, L.,R., VanderWielen, L., M.,
Edmond, M., B., Stevens, M., P,
Kuzel, A., J. (2014). Facilitators and barriers to implementing
antimicrobial stewardship strategies: results from a qualitative
study. Am J Infect Control 2014; 42(suppl 10): S257–63.
The White House (2015). National action plan for combating
antibiotic-resistant bacteria, 2015.
Available at:
https://www.whitehouse.gov/sites/default/files/docs/
national_action_plan_for_combating_antibotic-

resistant_bacteria.pdf.
Wagner B, Filice GA, Drekonja D, et al. (2014). Antimicrobial
stewardship programs in
inpatient hospital settings: a systematic review. Infect Control
Hosp Epidemiol 2014; 35:1209–28.
Week 3 Assignment Instructions
Details:
While there are several tools to critically appraise practice
guidelines, the most comprehensively validated appraisal tool is
the AGREE II Instrument. The AGREE II Instrument can be
used by individual practitioners to critically appraise health
guidelines and by decision makers to inform policy decisions.
The purpose of the AGREE II Instrument is to provide a
framework to:
1. Assess the quality of guidelines.
2. Provide a methodological strategy for the development of
guidelines.
3. Inform what information and how the information ought to be
reported in guidelines.
Overall assessment includes rating the overall quality of the

guideline and whether the guideline would be recommended for
use in practice.
Items are rated on a 7-point scale from 1 (Strongly Disagree) to
7 (Strongly Agree). A score of 1 is given when there is no
information on that item or if it is poorly reported. A score of 7
is given if the quality of reporting is excellent and when full
criteria have been met (Score explanations found in the AGREE
II-GRS Instrument).
A quality score is calculated for each of the six domains, which
are independently scored. Domain scores are calculated by
summing up all the scores of the items in the domain and by
scaling the total as a percentage of the maximum possible score
for that specific domain.
For this assignment, you will choose a guideline and assess the
overall quality and whether the guideline would be
recommended for use in practice.
General Requirements:
Use the following information to ensure successful completion
of this assignment:
· Download the AGREE II instrument.
· Doctoral learners are required to use APA style for their
writing assignments. The APA Style Guide is located in the
Student Success Center. An abstract is not required.

· This assignment uses a rubric. Please Review the rubric prior
to the beginning to become familiar with the expectations for
successful completion.
· You are not required to submit this assignment to Turnitin.
Directions:
Perform the following tasks to complete this assignment:
1. Using the AGREE II instrument as your guide, create a table
that discusses a practice guideline in which you might have
questioned the recommendations. (Note: You may be able to
copy and paste the instrument into a new Word document and
complete the information.)
2. Each domain must have its own cell (similar to the one shown
in the manual) and add domain scores and an overall guideline
assessment. Be sure to include comments and additional
considerations that influenced your rating decision and cite any
sources used.
APPRAISAL OF GUIDELINES
fOR RESEARCH & EVALUATION II

INSTRUMENT
_____________________________________________________
______________________________
The AGREE Next Steps Consortium
May 2009
UPDATE: September 2013

ii
COPYRIGHT AND REPRODUCTION
This document is the product of an international collaboration.
It may be reproduced and used for educational purposes,
quality assurance programmes and critical appraisal of
guidelines. It may not be used for commercial
purposes or product marketing. Approved non-English
language versions of the AGREE II Instrument must be used
where available. Offers of assistance in translation into other
languages are welcome, provided they conform to the
protocol set out by The AGREE Research Trust.

DISCLAIMER
The AGREE II Instrument is a generic tool designed primarily
to
help guideline developers and users assess the
methodological quality of guidelines.
The authors do not take responsibility for the improper use of
the AGREE II Instrument.
© The AGREE Research Trust, May 2009.
© The AGREE Research Trust, September 2013.
SUGGESTED CITATION:
Brouwers M, Kho ME, Browman GP, Cluzeau F, feder G,
Fervers B, Hanna S, Makarski J on behalf of the AGREE
Next Steps Consortium. AGREE II: Advancing guideline
development, reporting and evaluation in healthcare. Can
Med Assoc J. Dec 2010, 182:E839-842; doi:

10.1503/cmaj.090449
FUNDING:
The development of the AGREE II Instrument was funded by a
grant from the Canadian Institutes of Health Research
(FRN77822)
FOR FURTHER INFORMATION ABOUT THE
AGREE CONTACT:
AGREE II Project Office, [email protected]
AGREE Research Trust Web site, www.agreetrust.org
AGREE
10th
Year
Anniversary:
2003

-‐
2013
iii
AGREE NEXT STEPS CONSORTIUM MEMBERSHIP
Dr. Melissa C. Brouwers
Principal Investigator, AGREE Next Steps Consortium
McMaster University, Hamilton, Ontario, Canada
Consortium Members:

Dr. GP. Browman, British Columbia Cancer Agency, Vancouver
Island, Canada
Dr. JS. Burgers, Dutch Institute for Healthcare Improvement
CBO, The Netherlands
Dr. F. Cluzeau, Chair of AGREE Research Trust; St. George’s
Hospital Medical School, London, UK
Dr. D. Davis, Association of American Medical Colleges,
Washington, DC, USA
Dr. G. Feder, University of Bristol, UK
Dr. B. Fervers, Cancer et Environement, Centre Léon Bérard,
France
Dr. I. Graham, Canadian Institutes of Health Research, Ottawa,
Ontario, Canada
Dr. J. Grimshaw, Ottawa Health Research Institute, Ontario,
Canada
Dr. SE. Hanna, McMaster University, Hamilton, Ontario,
Canada
Ms. ME. Kho, McMaster University, Hamilton, Ontario Canada
Dr. P. Littlejohns, National Institute for Health and Clinical
Excellence, London, UK
Ms. J. Makarski, McMaster University, Hamilton, Ontario,
Canada
Dr. L. Zitzelsberger, Canadian Partnership Against Cancer,
Ottawa, Ontario, Canada

NOTICE:
AGREE
II
Original
Public
Release
and
Publication
Date:
2009/2010
AGREE
II
Update:
September
2013

Please
see
the
Update
section,
at
the
end
of
the
Introduction,
following
the
References
section
iv

TABLE OF CONTENTS
I.
INTRODUCTION
I. Overview
..............................................................................................
.......................................
1
II. Applying
the
AGREE
II

..............................................................................................
...................
4
III. Key
Resources
and
References
..............................................................................................
.....
4
II.
USER’S
MANUAL:
INSTRUCTIONS
FOR
USING
THE

AGREE
II
.................................................................
6
I. Preparing
to
Use
the
AGREE
II
..............................................................................................
......
7
II. Structure
and
Content
of
the
AGREE
II

.......................................................................................
7
III. Rating
Scale
and
User’s
Manual
Sections
....................................................................................
8
IV. Scoring
the
AGREE
II
..............................................................................................
......................
9
V. Overall

Assessment
..............................................................................................
.....................
10
VI. Guidance
for
Rating
Each
Item
a. Domain
1.
Scope
and
Purpose
............................................................................................
11
b. Domain
2.

Stakeholder
Involvement
...................................................................................
15
c. Domain
3.
Rigour
of
Development
.....................................................................................
19
d. Domain
4.
Clarity
of
Presentation
......................................................................................
28
e. Domain

5.
Applicability
..............................................................................................
.........
32
f. Domain
6.
Editorial
Independence
......................................................................................
37
g. Overall
Guideline
Assessment
.............................................................................................
40

III.
AGREE
II
INSTRUMENT
..............................................................................................
.............................
1
I. Domain
1.
Scope
and
Purpose
..............................................................................................
......
2
II. Domain
2.
Stakeholder

Involvement
..........................................................................................
3
III. Domain
3.
Rigour
of
Development
.............................................................................................
4
IV. Domain
4.
Clarity
of
Presentation
..............................................................................................
.
7

V. Domain
5.
Applicability
..............................................................................................
.................
8
VI. Domain
6.
Editorial
Independence
...........................................................................................
10
VII. Overall
Guideline
Assessment
..............................................................................................
.....
11

1
I. INTRODUCTION
I. OVERVIEW
i) Purpose of the AGREE II Instrument
Clinical practice guidelines (‘guidelines’) are systematically
developed statements to assist
practitioner and patient decisions about appropriate health care
for specific clinical
circumstances (1). In addition, guidelines can play an important

role in health policy formation
(2,3) and have evolved to cover topics across the health care
continuum (e.g., health promotion,
screening, diagnosis).
The potential benefits of guidelines are only as good as the
quality of the guidelines themselves.
Appropriate methodologies and rigorous strategies in the
guideline development process are
important for the successful implementation of the resulting
recommendations (4-6). The quality
of guidelines can be extremely variable and some often fall
short of basic standards (7-9).
The Appraisal of Guidelines for REsearch & Evaluation
(AGREE) Instrument (10) was
developed to address the issue of variability in guideline
quality. To that end, the AGREE
instrument is a tool that assesses the methodological rigour and
transparency in which a
guideline is developed. The original AGREE instrument has
been refined, which has resulted
in the new AGREE II and includes a new User’s Manual (11).
The purpose of the AGREE II, is to provide a framework to:

1. assess the quality of guidelines;
2. provide a methodological strategy for the development of
guidelines; and
3. inform what information and how information ought to be
reported in guidelines.
The AGREE II replaces the original instrument as the preferred
tool and can be used as part of
an overall quality mandate aimed to improve health care.
ii) History of the AGREE Project
The original AGREE Instrument was published in 2003 by a
group of international guideline
developers and researchers, the AGREE Collaboration (10).
The objective of the Collaboration
was to develop a tool to assess the quality of guidelines. The
AGREE Collaboration defined
quality of guidelines as the confidence that the potential biases
of guideline development have
been addressed adequately and that the recommendations are
both internally and externally
valid, and are feasible for practice (10). The assessment

includes judgments about the
methods used for developing the guidelines, the components of
the final recommendations, and
the factors that are linked to their uptake. The result of the
Collaboration’s effort was the
original AGREE Instrument, a 23-item tool comprising 6 quality
domains. The AGREE
Instrument has been translated into many languages, has been
cited in well over 100
publications, and is endorsed by several health care
organizations. More details about the
original instrument and related publications are available on the
Web site of the AGREE
Research Trust (http://www.agreetrust.org/), the official body
managing the interests of the
AGREE Instrument.
2

As with any new assessment tool, it was recognized that
ongoing development was required to
strengthen the measurement properties of the instrument and to
ensure its usability and
feasibility among intended users. This led several members of
the original team to form the
AGREE Next Steps Consortium (Consortium). The objectives
of the Consortium were to further
improve the measurement properties of the instrument,
including its reliability and validity; to
refine the instrument’s items to better meet the needs of the
intended users; and to improve the
supporting documentation (i.e., original training manual and
user’s guide) to facilitate the ability
of users to implement the instrument with confidence.
The result of these efforts is the AGREE II, which is comprised
of the new User’s Manual and 23
item tool organized into the same six domains, described here.
The User’s Manual is a
significant modification of the original training manual and
user’s guide and provides explicit
information for each of the 23 items. Table 1 compares the

items of the original AGREE to the
items in the AGREE II.
Table 1. Comparison of original AGREE and AGREE II items.
Original AGREE Item AGREE II Item
Domain 1. Scope and Purpose
1. The overall objective(s) of the guideline is (are)
No change
2. The clinical question(s) covered by the guideline is (are)
The health question(s) covered by the guideline is (are)
3. The patients to whom the guideline is meant to apply
are specifically described.

The population (patients, public, etc.) to whom the guideline is
meant to apply is specifically described.
Domain 2. Stakeholder Involvement
4. The guideline development group includes individuals
from all the relevant professional groups.
No change
5. The patients’ views and preferences have been sought. The
views and preferences of the target population (patients,
6. The target users of the guideline are clearly defined. No
change
7. The guideline has been piloted among end users. Delete item.
Incorporated into user guide description of item
19.
Domain 3. Rigour of Development
8. Systematic methods were used to search for evidence. No

change in item. Renumber to 7.
9. The criteria for selecting the evidence are clearly
described.
No change in item. Renumber to 8.
NEW Item 9. The strengths and limitations of the body of
evidence are clearly described.
clearly described.
No change
No change

3
Original AGREE Item AGREE II Item
12. There is an explicit link between the recommendations
and the supporting evidence.
No change
13. The guideline has been externally reviewed by experts
prior to its publication.
No change
14. A procedure for updating the guideline is provided. No
change
Domain 4. Clarity of Presentation
15. The recommendations are specific and unambiguous. No
change
16. The different options for management of the condition

are clearly presented.
The different options for management of the condition or health
issue are clearly presented.
17. Key recommendations are easily identifiable. No change
Domain 5. Applicability
18. The guideline is supported with tools for application. The
guideline provides advice and/or tools on how the
AND Change in domain (from Clarity of Presentation) AND
renumber to 19
19. The potential organizational barriers in applying the
recommendations have been discussed.
The guideline describes facilitators and barriers to its
application.
AND change in order – renumber to 18
20. The potential cost implications of applying the

The potential resource implications of applying the
21. The guideline presents key review criteria for monitoring
and/ or audit purposes.
The guideline presents monitoring and/ or auditing criteria.
Domain 6. Editorial Independence
22. The guideline is editorially independent from the funding
body.
The views of the funding body have not influenced the content
of the guideline.
23. Conflicts of interest of guideline development members
have been recorded.
Competing interests of guideline development group members
have been recorded and addressed.

4
II. APPLYING THE AGREE II
i) Which guidelines can be appraised with the AGREE II?
As with the original instrument, AGREE II is designed to assess
guidelines developed by local,
regional, national or international groups or affiliated
governmental organizations. These include
original versions of and updates of existing guidelines.
The AGREE II is generic and can be applied to guidelines in
any disease area targeting any
step in the health care continuum, including those for health
promotion, public health, screening,
diagnosis, treatment or interventions. It is suitable for
guidelines presented in paper or electronic

format. At this stage, the AGREE II has not been designed to
assess the quality of guidance
documents that address health care organizational issues. Its
role in the assessment of health
technology assessments has not yet been formally evaluated.
ii) Who can use the AGREE II?
The AGREE II is intended to be used by the following
stakeholder groups:
• by health care providers who wish to undertake their own
assessment of a guideline
before adopting its recommendations into their practice;
• by guideline developers to follow a structured and rigorous
development methodology,
to conduct an internal assessment to ensure that their guidelines
are sound, or to
evaluate guidelines from other groups for potential adaptation
to their own context;
• by policy makers to help them decide which guidelines could
be recommended for use

in practice or to inform policy decisions; and
• by educators to help enhance critical appraisal skills amongst
health professionals and
to teach core competencies in guideline development and
reporting.
III. KEY RESOURCES AND REFERENCES
i) AGREE Research Trust
The AGREE Research Trust (ART) is an independent body
established in 2004 at the
conclusion of the activities of the original AGREE
Collaboration. ART endorses the AGREE II
and manages the interests of the AGREE enterprise, supports a
research agenda regarding its
development, and serves as the holder of its copyright.
The AGREE Research Trust web site http://www.agreetrust.org
provides:
• free downloadable copies of AGREE II
• links to the AGREE II on-line training tool
• reference lists citing AGREE II and the original AGREE

Instrument
• free downloadable copies of the original AGREE Instrument
• information about AGREE projects, the AGREE Next Steps
Consortium and the original
AGREE Collaboration
5
ii) How to cite the AGREE II
AGREE Next Steps Consortium (2009). The AGREE II
Instrument [Electronic version].
Retrieved <Month, Day, Year>, from http://www.agreetrust.org
.
iii) AGREE II On-Line Training Tool

For access to the AGREE II On-Line Training Tool, please visit
http://www.agreetrust.org .
iv) References related to the AGREE II
AGREE II: Advancing guideline development, reporting and
evaluation in healthcare.
Parallel publications in progress
v) Primary reference related to the original AGREE Instrument
AGREE Collaboration. Development and validation of an
international appraisal instrument for
assessing the quality of clinical practice guidelines: the AGREE
project. Qual Saf Health Care.
2003 Feb;12(1):18-23.
REFERENCES
1. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J.
Clinical guidelines: potential
benefits, limitations, and harms of clinical guidelines. BMJ.
1999;318(7182):527-530.
2. Committee to Advise the Public Health Service on Clinical
Practice Guidelines IoM. Clinical
practice guidelines: directions for a new program. Washington:

National Academy Press;
1990.
3. Browman GP, Snider A, Ellis P. Negotiating for change. The
healthcare manager as catalyst
for evidence-based practice: changing the healthcare
environment and sharing experience.
Healthc Pap. 2003;3(3):10-22.
4. Grol R. Success and failures in the implementation of
evidence-based guidelines for clinical
practice. Med Care. 2001;39(8 Suppl 2):1146-54.
5. Davis DA, Taylor-Vaisey A. Translating guidelines into
practice: a systematic review of
theoretic concepts, practice experience and research evidence in
the adoption of clinical
practice guidelines. CMAJ. 1997;157(4):408-16.
6. Grimshaw J,.Russell I. Effect of clinical guidelines on
medical practice: a systematic review
of rigorous evaluations. Lancet. 1993;342:1317-22.
7. Shaneyfelt TM, Mayo-Smith MF Rothwangl J. Are guidelines
following guidelines? The

methodological quality of clinical practice guidelines in the
peer-reviewed medical literature.
JAMA 1999:281(20):1900-5.
8. Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice
guidelines developed by specialty
societies: the need for critical appraisal. Lancet. 2000;355:103-
6.
9. Burgers JS, Fervers B, Haugh M, Brouwers M, Browman G,
Phillip T, Cluzeau FA.
International assessment of the quality of clinical practice
guidelines in oncology using the
Appraisal of Guidelines and Research and Evaluation
Instrument. J Clin Oncol.
2004;22:2000-7.
10. AGREE Collaboration. Development and validation of an
international appraisal instrument
for assessing the quality of clinical practice guidelines: the
AGREE project. Qual Saf Health
Care. 2003 Feb;12(1):18-23.
11. AGREE II: Advancing the guideline development, reporting
and evaluation in healthcare.

Parallel publications in progress.
UPDATE: September 2013
In 2013, the AGREE marked its 10th anniversary since the
original AGREE Instrument was first
published and made available for use. To mark this
anniversary, we provide a summary of
6
activities that have taken place over the past 10 years and an
update to the references originally
noted in the AGREE II 2009 version.
UPTAKE AND USE OF AGREE II

As with the original AGREE Instrument, uptake and use of
AGREE II has been significant.
Between 2010 (publication of AGREE II) and July 2013, a cited
reference search revealed a
total of 590 articles referencing the four core AGREE articles.
An analysis of the AGREE
Enterprise Website (www.agreetrust.org) showed much activity
with a total of 42,553 visits to
the website over a seven month period (January – July 2013). In
addition, to date nearly 2,000
users have registered accounts with the website. AGREE II
continues to be used as the basis
of PG development frameworks, academic course materials and
requirements, and PG
evaluation activities.
I. SUMMARY OF ACTIVITIES:
1. AGREE Website: Development Project www.agreetrust.org
• Using a user-centred development strategy and working with a
website
development group specializing in building evidence-based
healthcare sites

(www.minervation.com ), we redeveloped and redesigned the
AGREE website.
• The Website included various resources, including an online
platform to complete
and store individual AGREE II appraisals of PGs, “My
AGREE”.
• www.agreetrust.org is the AGREE Enterprise’s website and
the home for all
things AGREE.
2. *NEW* (2013) – “My AGREE PLUS”
• In response to user feedback and in recognizing a service gap,
we enhanced the
original “My AGREE” online platform to include the
functionality for completing
group (multi-rater) AGREE II appraisals of practice guidelines.
• New functions include the capacity to “Contribute” to a group
appraisal and to
“Coordinate” a group appraisal.

• To facilitate use of “My AGREE PLUS”, several “Help”
videos are available.
• Visit: www.agreetrust.org and click on top right tab, “My
AGREE PLUS”
3. AGREE II Training Tools (online)
• To facilitate the application and use of AGREE II, we
developed two innovative,
online training tools
i. AGREE II Overview Tutorial
ii. AGREE II Overview Tutorial + Practice Exercise
• Visit the Resource Centre of the AGREE website:
http://www.agreetrust.org/resource-centre/agree-ii-training-
tools/
4. AGREE II Language Translations
• As with the original AGREE Instrument, members of the
international PG

community have taken the initiative to translate the AGREE II
in various
languages. We extend our thanks to those members for
undertaking and making
available the translations.
• Completed translations:
i. Basques, Dutch, French, Italian, Korean, Portuguese,
Portuguese
(Brazilian), Slovakian, Spanish, Thai
7
• In progress translations:
i. Arabic, Chinese (Traditional), Chinese (Mandarin), Czech,
Farsi

(Persian), German, Greek, Japanese, Romanian, Russian,
Turkish
• If you would like to undertake a translation, please contact us
by emailing
[email protected] .
• Visit the Resource Centre of the AGREE website to access a
translation:
http://www.agreetrust.org/resource-centre/agree-ii-translations/
5. Ongoing Program of Research
• As an assessment tool, AGREE II evaluates the
methodological rigour used to
develop a particular practice guideline. It does not assess the
clinical validity of
practice guideline recommendations.
• To address the gap, the AGREE Enterprise is undertaking a
program of research
to develop a knowledge resource to direct the development,
reporting and

evaluation of practice guideline recommendation clinical
credibility.
• The knowledge resource will accompany the AGREE II.
• Please visit the website for updates to ongoing research work:
http://www.agreetrust.org/agree-research-projects/
As always, we welcome your feedback and suggestions. We
enjoy hearing from our users and
the PG community at large, so please contact us through our
website or by emailing us directly
via [email protected] .
II. AGREE II REFERENCES:
Listed below are the core references related to the AGREE II
and its training tools:
AGREE II: Non-Technical Paper (Main publication: Canadian
Medical Association Journal;
parallel publications in Journal of Clinical Epidemiology and
Preventive Medicine)

Fervers B, Hanna S, Makarski J on
behalf of the AGREE Next Steps Consortium. AGREE II:
Advancing guideline development,
reporting and evaluation in healthcare. Can Med Assoc J. Dec
2010, 182:E839-842; doi:
10.1503/cmaj.090449
reporting and evaluation in healthcare. J Clin Epidemol. 2010,
63(12): 1308-1311
reporting and evaluation in healthcare. Preventive Medicine,
2010, 51(5): 421-424
AGREE II: Technical Papers (Parts I and II)
Brouwers M, Kho ME, Browman GP, Burgers J, Cluzeau F,
Feder G, Fevers B, Graham ID,

Hanna SE, Makarski J, on behalf of the AGREE Next Steps
Consortium. Performance,
usefulness and areas for improvement: Development steps
toward the AGREE II – Part 1. Can
Med Assoc J. 2010, 182: 1045-52
8
Brouwers MC, Kho ME, Browman GP, Burgers J, Cluzeau F,
Feder G, Fervers B, Graham ID,
Hanna SE, Makarski J, on behalf of the AGREE Next Steps
Consortium. Validity assessment of
items and tools to support application: Development steps
towards the AGREE II – Part 2. Can
Med Assoc J. 2010, 182: E472-78

AGREE A3 Project, Stream 1 (Training Tools Development &
Evaluation)
Brouwers MC, Makarski J, Levinson A. A randomized trial to
evaluate e-learning interventions
designed to improve learner’s performance, satisfaction, and
self-efficacy with the AGREE II.
Implement Sci. 2010; 5:29
Brouwers MC, Makarski J, Durocher L, Levinson A. E-learning
interventions are comparable to
user’s manual in a randomized trial of training strategies for the
AGREE II. Implement Sci. 2011;
6:81
9

AGREE II:
USER’S MANUAL
10
II. USER’S MANUAL: INSTRUCTIONS FOR USING THE
AGREE II
This User’s Manual has been designed specifically to guide
appraisers in the use of the

instrument. We suggest reading the following instructions
before using the instrument.
I. Preparing to Use the AGREE II
i) Accompanying Guideline Documents
Before applying the AGREE II, users should first carefully read
the guideline document in full. In
addition to the guideline document, users should attempt to
identify all information about the
guideline development process prior to the appraisal. This
information may be contained in the
same document as the guideline recommendations or it may be
summarized in a separate
technical report, methodological manual or guideline developer
policy statement. These
supporting documents may be published or may be available
publicly on web sites. While it is
the responsibility of the guideline authors to advise readers on
the existence and location of
relevant additional technical and supporting documents, every
effort should be made by the
AGREE II users to locate and include them as part of the
materials appropriate for assessment.

ii) Number of Appraisers
We recommend that each guideline is assessed by at least 2
appraisers and preferably 4 as this
will increase the reliability of the assessment. Reliability tests
of the instrument are on-going.
II. Structure and Content of the AGREE II
The AGREE II consists of 23 key items organized within 6
domains followed by 2 global rating
items (“Overall Assessment”). Each domain captures a unique
dimension of guideline quality.
Domain 1. Scope and Purpose is concerned with the overall aim
of the guideline, the specific
health questions, and the target population (items 1-3).
Domain 2. Stakeholder Involvement focuses on the extent to
which the guideline was developed
by the appropriate stakeholders and represents the views of its
intended users (items 4-6).
Domain 3. Rigour of Development relates to the process used to

gather and synthesize the
evidence, the methods to formulate the recommendations, and to
update them (items 7-14).
Domain 4. Clarity of Presentation deals with the language,
structure, and format of the guideline
(items 15-17).
Domain 5. Applicability pertains to the likely barriers and
facilitators to implementation,
strategies to improve uptake, and resource implications of
applying the guideline (items 18-21).
Domain 6. Editorial Independence is concerned with the
formulation of recommendations not
being unduly biased with competing interests (items 22-23).
Overall assessment includes the rating of the overall quality of
the guideline and whether the
guideline would be recommended for use in practice.

11
III. Rating Scale and User’s Manual Sections
Each of the AGREE II items and the two global rating items are
rated on a 7-point scale (1–
strongly disagree to 7–strongly agree). The User’s Manual
provides guidance on how to rate
each item using the rating scale and also includes 3 additional
sections to further facilitate the
user’s assessment. The sections include User’s Manual
Description, Where to Look, and How
to Rate.
i) Rating Scale
All AGREE II items are rated on the following 7-point scale:
1

Strongly Disagree 2 3 4 5 6
7
Strongly Agree
Score of 1 (Strongly Disagree). A score of 1 should be given
when there is no information that
is relevant to the AGREE II item or if the concept is very poorly
reported.
Score of 7 (Strongly Agree). A score of 7 should be given if the
quality of reporting is
exceptional and where the full criteria and considerations
articulated in the User’s Manual have
been met.
Scores between 2 and 6. A score between 2 and 6 is assigned
when the reporting of the
AGREE II item does not meet the full criteria or considerations.
A score is assigned depending
on the completeness and quality of reporting. Scores increase
as more criteria are met and
considerations addressed. The “How to Rate” section for each
item includes details about

assessment criteria and considerations specific to the item.
ii) User’s Manual Description
This section defines the concept underlying the item in broad
terms and provides examples.
iii) Where to Look
This section directs the appraiser to where the information in
the guideline can usually be found.
Included in this section are common terms used to label
guideline sections or chapters. These
are suggestions only. It is the responsibility of the appraiser to
review the entire guideline and
accompanying material(s) to ensure a fair evaluation.
iv) How to Rate
This section includes details about assessment criteria and
considerations specific to each item.
• The criteria identify explicit elements that reflect the
operational definition
of the item. The more criteria that are met, the higher the score
the
guideline should receive on that item.

• The considerations are aimed to help inform the assessment.
As in any
evaluation, judgments by the appraisers are required. The more
the
considerations have been taken into account in the guideline,
the higher
the score the guideline should receive on that item.
It is important to note that guideline ratings require a level of
judgment. The criteria and
considerations are there to guide, not to replace, these
judgments. Thus, none of the AGREE II
items provide explicit expectations for each of the 7 points on
the scale.
12

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