A quality framework for perioperative care: rapid review and participatory exercise

Why it matters

In the UK, almost 10 million people have surgery every year, and they will need good quality perioperative care. The perioperative period starts when a patient first considers surgery, through to their recovery.

The aim of good quality perioperative care is to provide safe, high-quality care which ensures the best possible outcome for patients.

There is no single agreed definition of high-quality in healthcare, but it is widely understood to have several dimensions. To plan services, monitor performance, improve care, and carry out research, it is important to understand what quality means in specific areas of care and how it can be recognised in practice.

There’s no shortage of measures looking at how care is organised (structure) and what actions are done (process) – in fact, hundreds of them exist – but there is no single agreed framework that sets out the key areas of perioperative care or to helps to organise these measures in a balanced and meaningful way reflecting what matters most to patients, carers and staff. 

With our review and participatory exercises, we wanted to address the need for a comprehensive, evidence-informed and conceptually based quality framework. This framework had to include both the structures and the processes involved in perioperative care.

What we found

The framework development formed the first phase of a multi-stage study from which we went on to develop a core set of perioperative process and structure indicators.

First, we carried out a rapid review of the existing evidence that included research papers, guidelines, and other documents found by searching databases and websites (grey literature). We looked at all the information, brought together insights from different sources and studies, and then organised these into an initial framework.

The review of the literature identified a range of structural features that were important to the delivery of high-quality perioperative care, including:

• characteristics of the care environment and facilities
• leadership, management, and culture
• staffing
• the systems, pathways, and protocols in place
• structures to support multidisciplinary working
• communication
• care co-ordination

We also identified a range of processes that mattered to the quality of perioperative care, including those relating to:

• patient assessment and documentation
• planning and delivery of care
• communication, planning and co-ordination

Some aspects of quality had both structural and process-related features. For example, having a safety protocol in place might be a structural aspect of care, while following the protocol might be process related.

Based on our analysis, we put together an initial draft of a quality framework, then we asked an expert collaborative group which included patients, carers, healthcare professionals, and managers to help us identify the ten areas that most impacted care quality before, during and after surgery. The group took part in a collaborative online exercise, hosted on the online Thiscovery platform.

The resulting framework, P-Frame, reflects both evidence from the literature and practical insights from key stakeholders, including patients, caregivers, and clinicians. It will help to set out the systems that need to be in place to prepare patients well for surgery, ensure a supportive culture for healthcare staff to be open about quality and safety concerns, that services are fair for everyone, and that patients and carers are properly supported in making their own decisions, based on the available evidence and views of UK clinicians and patients.

It has the potential to be a valuable tool for monitoring perioperative care as well as supporting research efforts and improvement initiatives.

With thanks to the perioperative contributorship group members:

Jugdeep K Dhesi, Abi Dennington-Price, Jennifer Dorey, Zoe Packman, Ravinder Vohra, Zoe Brummell, Carolyn L Johnston, Bob Evans, Michael P W Grocott, Scarlett McNally, Iain Keith Moppett