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Introduction The Neurocritical Care Society (NCS) launched its clinical practice guideline program in 2012 with the publication of “Guidelines for the Evaluation and Management of Status Epilepticus” [1]. Work on this guideline coincided with the development of standards for trustworthy clinical practice guidelines by the Institute of Medicine (now the National Academy of Medicine) in 2011 [2]. These standards highlighted the need for rigorous and consistent evidence-based methodology aimed at producing clear, actionable recommendations relevant to the individual patient encounter. The NCS Guideline Committee (GC) made the prescient decision to adopt and implement an emerging methodology, Grading of Recommendations Assessment, Development and Evaluation (GRADE) [3], which has since been adopted or endorsed by more than 100 organizations worldwide. In the past decade, the US GRADE Working Group has elaborated, refined, and extended this methodology in many publications. With the emergence of multiple GRADE-based guidelines since standards were developed, concerns were also raised about lack of adherence to published GRADE criteria in the development of these guidelines. In 2020, the US GRADE Working Group critically reviewed GRADE guidelines published in the National Guideline Clearinghouse [4]. Of the guidelines studied in this sample, which included two from NCS, nearly half did not comply with one or more of the key GRADE criteria for appropriate application of the methodology. Most commonly lacking were GRADE evidence profiles and evidence summaries, as well as explicit consideration of all four central domains required to move from evidence to recommendation. Those domains include certainty of evidence, balance of benefits to harms, patients’ values and preferences, and resource use and equity. Over the course of the past decade, NCS has produced a number of guidelines and related projects, the majority of which used methodology derived from GRADE publications (see Table 1). However, as our understanding of the requirements of GRADE deepened, it became clear that our application of the methodology across projects was inconsistent and generally fell short of the necessary rigor in various ways. On the basis of this growing insight, the NCS GC developed and is implementing a number of significant improvements in our guideline procedures. The aim of this article is to introduce and explain the basis for these changes. To that end, rather than reviewing in detail individual NCS projects with widely varying formats and objectives and rotating leadership, we chose to begin by setting forth the requirements *Correspondence: [email protected] 1 Center for Nursing Science, University of California Davis Health, 2315 Stockton Blvd, North Addition 3015, Sacramento, CA 95817, USA Full list of author information is available at the end of the article