Quality indicators for structure and process in perioperative care: a systematic review

Why do we need to study quality indicators for perioperative care?

Quality indicators help track how well perioperative care – the care people receive before, during, and after surgery – is carried out. The quality of perioperative care patients receive has a major impact on whether they recover well from surgery, and with around 10 million operations each year in the UK, even small improvements can affect many people.

To improve care, healthcare teams can draw on quality indicators. These are simple measures that show whether the right things are happening at the right time. They cover three areas:

1. Structures – the resources and systems that are in place in a healthcare setting.
2. Processes – actions that are taken during the procedure.
3. Outcomes – the impacts of the care for patients, such as better health or quality of life.

Good quality perioperative care is likely to benefit from having the right indicators, and it is important to measure not only outcomes, but also structure and process. There have been reviews in the past; a 2018 study found over 260 different structure and process quality indicators, but many of them were found to be:

• poorly defined
• not backed by strong evidence
• not shaped by what matters to patients

Even after the list was narrowed to 95, it was still too large and lacked clarity and consistency, which made it hard for hospitals to know which measures were best for assessing and improving safety and quality.

This new review provides the groundwork needed to build a core set of reliable, meaningful measures that can guide safer, more effective perioperative care.

How we carried out a systematic review into quality indicators for perioperative care

We looked at research and guidance published since the 2018 review and used this to map all the available structure and process indicators and assess how well each one is supported by evidence.

Our review found a total of 615 indicators, including 380 that were new. These measures were grouped into:

• 324 process indicators
• 248 structure indicators
• 43 indicators that were relevant to either process or structure

Most of these indicators had evidence behind them (82%), which was higher than in the previous review, but only a few (around 12%) had been properly validated (been tested to confirm whether they truly measure what they claim to). Many were defined differently across sources. Patients or carers weren’t routinely involved in developing the indicators.

Why this matters for patients and healthcare staff

• Our findings underline the importance of better‑designed indicators, leading to more transparent, patient‑centred care.
• More consistent, validated indicators are likely to support fairer benchmarking, clearer expectations, and more meaningful quality improvement.
• Reducing the number of overlapping measures is likely to free up time for healthcare staff and reduce administrative load.
• Involving patients and carers in indicator development could help to ensure that measures reflect what matters to them.

Key takeaways

1. We found many indicators – but not enough clarity. We uncovered a large, overlapping, and sometimes confusing set of measures. Many indicators used different terminology for the same concept, or applied different thresholds, making comparison and implementation difficult.
2. Evidence is improving, but validation is lagging behind. Although more indicators are now evidence‑supported, very few have been tested for validity. Without validation, it’s hard to know whether these measures genuinely show what they are supposed to show.
3. Patients and carers need to be involved. Most of the existing indicators were created without meaningful patient or carer input, despite perioperative care being crucial for patients.
4. There was a need for standardisation. The review highlighted a clear need for consistent naming, definition, and reporting standards to make indicators more usable and trustworthy.