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

A quality framework for perioperative care: rapid review and participatory exercise | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search A quality framework for perioperative care: rapid review and participatory exercise View ORCID Profile Kristina Wanyonyi-Kay , View ORCID Profile Graham Martin , View ORCID Profile Sarah Ball , View ORCID Profile Paige Cunnington , View ORCID Profile Oliver Boney , View ORCID Profile S. Ramani Moonesinghe , View ORCID Profile Mary Dixon-Woods , The Perioperative Expert Contributor Group doi: https://doi.org/10.1101/2025.08.13.25333583 Kristina Wanyonyi-Kay 1 THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Strangeways research laboratory Cambridge CB1 8RN , United Kingdom PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Kristina Wanyonyi-Kay For correspondence: kristina.wanyonyi-kay{at}thisinstitute.cam.ac.uk Graham Martin 1 THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Strangeways research laboratory Cambridge CB1 8RN , United Kingdom PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Graham Martin Sarah Ball 2 RAND Europe, RAND Europe (UK) CIC , Eastbrook, Shaftesbury Road, Cambridge, CB2 8BF, UK PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sarah Ball Paige Cunnington 1 THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Strangeways research laboratory Cambridge CB1 8RN , United Kingdom MSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Paige Cunnington Oliver Boney 3 Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust , London, UK 4 Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London , UK 5 National Institute for Health and Care Research Central London Patient Safety Research Collaboration, University College London Hospitals NHS Foundation Trust , London, UK PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Oliver Boney S. Ramani Moonesinghe 3 Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust , London, UK 4 Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London , UK 5 National Institute for Health and Care Research Central London Patient Safety Research Collaboration, University College London Hospitals NHS Foundation Trust , London, UK (MD(Res) Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for S. Ramani Moonesinghe Mary Dixon-Woods 1 THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Strangeways research laboratory Cambridge CB1 8RN , United Kingdom PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mary Dixon-Woods Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background This study addresses the need for a comprehensive, evidence-informed conceptual framework to describe relevant dimensions of quality in perioperative care, moving beyond traditional phase-based models. Methods We used iterative synthesis of literature as well as consultation and participatory exercises with multidisciplinary professionals and patient representatives, who together formed an Expert Collaborative Group (ECG). The review included primary studies, guidelines, and grey literature identified through searches of PsycINFO, MEDLINE, CINAHL, and institutional websites. The findings were synthesised across studies using an inductive process to build a preliminary framework. Key concepts were identified, mapped, refined, and organised into an initial structure for further development. Fourteen ECG members evaluated a draft version of the framework via the Thiscovery online platform, focusing on relevance and coherence. Their feedback was used to refine the framework, in consultation with clinical experts. Results Through combination of rapid review of the literature and stakeholder engagement, we were able to develop a framework comprising ten domains that encapsulate structural and process-related features critical to high-quality perioperative care. Feedback from stakeholder exercises was important in improving early versions of the framework, including reordering domains to reflect their centrality and integrating patient and carer perspectives. The resulting perioperative-framework, termed P-Frame, includes domains such as environment and facilities, leadership and governance, organisational culture, shared decision-making, multidisciplinary working, patient optimisation, clinical protocols, post-operative support, staff education, and workforce planning. Importantly, the framework integrates the perspectives of patients and carers, ensuring relevance across clinical, operational, and experiential dimensions of care. Conclusions P-Frame, based on the available evidence and the perspectives of clinicians and patients, offers a valuable tool for monitoring and improving perioperative care quality as well as supporting research efforts. What is already known on this topic Perioperative care quality is typically defined within the pre-, intra-, and post-operative phases, restricting the development of broader based quality measurement. This has led to an excess of measures focused on clinical protocols, based on limited evidence and excluding the perspectives of patients and caregivers. What this study adds This study provides a balanced framework for understanding the domains of quality and safety across all perioperative care settings. How this study might affect research, practice, or policy It offers a foundation for the development of measures which can be used in audit, research, and targeted improvement initiatives. Introduction While there is no universally agreed definition of quality in health systems, it is generally recognised as a multi-dimensional construct. ( 1 – 3 ) The Institute of Medicine’s (IOM) six key domains of quality – namely safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity - have been of enduring value and influence, ( 4 ) but are generic. Understanding what comprises the relevant dimensions of quality and what they look like for specific areas of care is important to quality monitoring, improvement, and research. In perioperative care, which extends from the initial consideration of surgery through to recovery, a very large number (in excess of 600) of process and structure indicators are published or in use ( 5 , 6 ) ( 7 ) ( 8 ) but are typically organised around the temporal phases of care (pre-operative, intra-operative, and post-operative). This phase-based approach risks overlooking important dimensions of quality that cut across timepoints, such as those concerning patient experience and priorities, organisational culture, and care coordination across systems ( 7 ). An overarching quality framework is likely to be of benefit to care and to improvement efforts, for example by ensuring clarity about the relevant domains of quality in perioperative care and by supporting balanced and meaningful indicator sets across the domains ( 8 ) ( 9 , 10 ). To address this need, we aimed to develop a conceptually based framework to identify the quality domains of perioperative care, based on capturing the key concepts set out in the literature in a parsimonious way ( 4 ) and on stakeholder engagement and consultation. Methods An overview of the framework development process, which used rapid review of literature and evidence combined with a participatory exercise, is shown in Supplemental Material 1. We sought to ensure our framework would be evidence-informed, contextually relevant, and achievable through a combination of rapid review of the literature and stakeholder engagement. ( 11 , 12 ) Our approach was guided by Jabareen’s methods for constructing conceptual frameworks ( 13 ) and by recommendations for conducting Cochrane Rapid Reviews, including those relating to stakeholder involvement. ( 14 ) It involved an iterative process to identify, map, refine, and combine concepts from the literature and then to consult on them. Rapid review The rapid review (PROSPERO registration: CRD42023447192) of existing literature included academic articles from primary research studies, guidelines, standards, and reports and other grey literature sources. Three electronic databases—PsycINFO, MEDLINE, and CINAHL— were searched. Full search strategies are shown in Supplemental Material 2. Articles were screened in two rounds, beginning with titles and abstracts, using an iterative process to refine eligibility criteria and manage the review’s scope. Articles that met the round 2 criteria ( Table 1 ), based on titles and abstracts, were then subject to full-text screening. The grey literature search focused on the websites of key UK-based institutions and agencies. Additional searches were carried out using Google to capture supplementary information. Data were extracted from all included sources using a structured Microsoft Excel-based template, developed specifically for this review. The data extracted included: article details (including article/study type, aims, focus); details on the development and purpose of the domains described; reviewer reflections on study quality and limitations; details on the domains and indicators presented (including domain names and descriptions, sources of domains and how they were conceptualised, and the indicators covered). View this table: View inline View popup Table 1. Rapid review eligibility criteria Development of a preliminary conceptual framework Following data extraction, review findings were synthesised across studies to build a preliminary framework. This inductive process (in line with that proposed by Jabareen) ( 13 ) involved the identification and delineation of concepts and constructs identified in the literature, mapping their relationships to one another, combining and dividing them as appropriate, and putting them together into a putative framework for further refinement. Participatory exercise Once we had a preliminary framework, we turned to an online participatory exercise to gather feedback from an Expert Collaborative Group (ECG) consisting of 17 members. This diverse group included perioperative care specialists, anaesthetists, surgeons, nurses, healthcare managers, other healthcare professionals, patient representatives and carers, providing a range of perspectives. Using the Thiscovery online platform, each ECG member reviewed the draft framework (Version 1). They assessed the relevance (i.e. appropriateness in relation to perioperative care quality) of each domain, indicated whether domains should be “kept as is,” “kept but modified,” or “removed,” and provided an overall evaluation of whether the domains collectively constituted an adequate framework for quality in perioperative care. Participants submitted responses via multiple-choice questions with the option to add free-text explanations for their choices. Ethics approval was given by the Cambridge University Psychology Research Ethics Committee (PRE.2024.045). Synthesis and refinement After collecting feedback, the quantitative and qualitative data from the ECG’s responses were analysed (frequency tables were created to identify the extent of agreement between ECG members regarding whether each domain should be kept as is, modified or removed, and summative content analysis ( 15 ) was undertaken to identify common recommendations). The insights gathered were synthesised to inform revisions to the framework, adjusting domains as needed. Where ECG feedback revealed significant discrepancies or disagreements, the research team collaborated with clinical experts to discuss and resolve these differences, refining the framework to ensure its relevance, and coherence. Results Our rapid review and synthesis, combined with the findings of the participatory exercise, enabled the generation of a quality framework which we termed “P-Frame.” Rapid review and synthesis Searches of academic databases returned a total of 3010 academic publications. After removing duplicates, 2403 titles and abstracts of academic papers were screened against inclusion/exclusion criteria. In the first round of title and abstract screening, 1966 records were excluded; subsequently, to manage breadth and volume of evidence, the criteria were revised ( Table 1 ), and titles and abstracts of remaining academic publications were rescreened, excluding an additional 362 records. Full texts of the remaining 75 articles were screened against the revised inclusion/exclusion criteria and a total of 37 academic papers were included in the final review. In addition to academic papers, eight relevant grey literature sources were identified and included in the review. See PRISMA flow diagram ( Figure 1 ) for details. Download figure Open in new tab Figure 1. PRISMA Flow Diagram Characteristics of included sources In total 45 sources were included in the review. Of the 37 academic papers, ten were published between 2013-2015 ( 16 – 25 ), eighteen between 2016 and 2020 ( 8 , 26 – 42 ) and the remaining nine after 2021 ( 43 – 51 ). Most academic papers were on the US system ( 18 , 20 , 21 , 23 , 24 , 26 , 28 , 34 , 39 , 42 , 45 , 47 , 48 , 51 ) or Western Europe ( 16 , 22 , 27 , 32 , 35 , 36 , 38 ), including two in the UK ( 22 , 36 ). Two publications focused on Australia ( 25 , 46 ), one on Canada ( 41 ) and one on Pakistan ( 33 ); five had international focus ( 8 , 37 , 40 , 49 , 50 ) while the remaining six did not explicitly specify geographical focus ( 17 , 19 , 29 – 31 , 43 , 44 ). Fifteen academic publications were reports of empirical studies, including four quantitative ( 16 , 20 , 23 , 33 ) and five qualitative studies ( 22 , 35 , 36 , 38 , 47 ), and six mixed or multimethod studies ( 18 , 24 , 32 , 37 , 40 , 46 ). Eight publications were formal reviews of literature ( 8 , 21 , 25 , 27 , 30 , 31 , 39 , 49 ), five were discussion or perspective papers ( 28 , 34 , 44 , 48 , 51 ), six described the development process or characteristics of a framework, indicator set or measurement tool (including a conceptual framework for assessing surgical care quality, patient safety indicators, standards for surgical care of older adults and a measure of post-operative readmission) ( 17 , 19 , 26 , 29 , 43 , 50 ), two reported on quality improvement programmes ( 42 , 45 ) and one was a consensus statement ( 41 ). Six publications focused solely on perioperative care in adult populations ( 8 , 16 , 22 – 24 , 49 ), four considered children ( 18 , 42 , 43 , 48 ) and four elderly patients ( 26 , 39 , 50 , 51 ). One publication considered both paediatric and adult perioperative care ( 28 ); remaining articles did not specify the age-group of interest. Most publications focused on the whole perioperative period ( 16 , 17 , 19 , 21 , 25 – 30 , 32 , 39 , 40 , 43 , 44 , 49 ), five considered only postoperative care ( 22 , 34 , 36 , 37 , 46 ), one the surgery itself ( 24 ), and two both surgery and postoperative care ( 48 , 51 ); remaining studies did not specify their focus within the perioperative care period. Of all papers that explicitly stated the condition or surgery of focus, nine concentrated on general surgery including two focusing on a paediatric population ( 43 , 48 ), three on cardiac surgeries ( 24 , 30 , 51 ), two on gastrointestinal surgery ( 16 , 19 ), three on orthopaedic/trauma surgeries ( 31 , 44 , 50 ), and one on plastic surgery ( 45 ). Of the eight grey literature sources, seven were published between 2020 and 2023 ( 52 – 58 ) and one in 2013 ( 59 ). All grey literature sources concerned the UK system and consisted of standards ( 52 , 56 ), guidelines or guidance ( 53 – 55 , 57 , 59 ) and a report on the Getting it Right First Time (GIRFT) review of Anaesthesia and Perioperative Medicine ( 58 ). Existing frameworks used in the literature Within the reviewed literature relating to the conceptualisation of quality in perioperative care, the most frequently referenced model was the IoM model of healthcare quality, ( 4 ) which was referred to by nine articles in our sample of the academic literature. ( 8 , 20 , 29 , 30 , 34 , 43 – 45 , 48 ) Another frequently used framework, cited explicitly in four articles ( 29 , 31 , 43 , 47 ) and used more widely without explicit reference, was the Donabedian model, with its classic triad of structure, process and outcomes. Neither the IoM nor Donabedian frameworks are specific to the perioperative care context, although they have been used as a means of organising indicators, standards and recommendations relating to the quality of perioperative care – either separately, or in combination with each other ( 8 , 43 ). While these were the most commonly cited frameworks, we found that quality indicators, standards and recommendations related to perioperative care were grouped in a variety of other ways within the literature. There was little consistency in the ways in which indicators and standards were subdivided. For example, some were grouped according to broad temporal stages in the perioperative care pathway, along with general aspects or overarching concepts ( 26 , 27 , 51 ). Others were split by treatment topics (such as diagnosis and comorbidity management, discharge planning or pain management) ( 16 , 53 ) or by clinical versus system-related aspects ( 25 ). One article distinguished between different aspects of care, such as between communication with the patient or other providers, patient evaluation, and processes of care ( 19 ), while another used groups based on service features such as assurance, reliability and empathy ( 33 ). Some articles covered the full range of IoM domains, but others focused on one element of care quality such as patient safety ( 17 , 24 , 25 , 36 , 37 ) or equity ( 40 , 44 ), or more narrowly still, on defining quality in surgical palliative care ( 39 ) or on the impact of non-technical skills and team working on perioperative care quality ( 35 ). Within the grey literature documents we reviewed, recommendations and quality standards tended to be grouped according to structural categories such as leadership and management ( 54 , 56 ), workforce, staffing, education, training ( 54 , 55 , 57 ), environment, equipment and facilities ( 55 , 57 ). The Royal College of Anaesthetists accreditation approach, for example, mapped standards to the quality domains (safe, effective, caring, responsive and well-led) used by the Care Quality Commission ( 56 ), the care regulator for England. Draft quality framework based on review Through review of the existing literature described above, we identified a range of structural features 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 and care co-ordination; specific hospital-level characteristics; and structures to support audit, monitoring and research engagement. Similarly, a range of processes important to perioperative care were identified, including those relating to: patient assessment and documentation; planning and delivery of care; and communication, planning and co-ordination. Further, some aspects of quality might have both structural and process-related features. For example, having a safety protocol in place might be a structural aspect of care, while adherence to the protocol might be process-related. Based on our analysis, we constructed a preliminary draft quality framework (Supplemental Material 3). Participatory exercise Fourteen participants in our ECG, comprising ten healthcare professionals (surgeons, anaesthetists, nurses, healthcare managers and perioperative specialists) and four public contributors, with experience as patients or carers, took part in an online exercise on the online Thiscovery platform to review the draft framework. For each of the domains, respondents indicated: their level of agreement with the statement “This domain encompasses a coherent set of relevant features of quality and safety in perioperative care.” (from 1 – “strongly disagree” to 5 “strongly agree”); and their view on whether the domain should be “kept as is”, “kept but modified” or “removed”. Respondents were also asked “Taken together, do you think these domains make an adequate framework for quality in perioperative care?” indicating “yes”, “no” or “not sure”. Qualitative feedback was provided on the reasons for the responses given. Feedback on proposed domains Overall, a majority of the group agreed that the proposed domains provided a coherent and relevant framework for perioperative care quality. The participants’ level of agreement on whether each domain should be kept, modified or removed and on whether each domain encompasses a coherent set of relevant features are shown in Tables 2 and 3 respectively. View this table: View inline View popup Download powerpoint Table 2. Level of agreement on whether domains should be kept as is, modified or removed View this table: View inline View popup Download powerpoint Table 3. Level of agreement on relevance of proposed domains Eight participants considered that the domains collectively formed an adequate framework. All participants agreed on the relevance of four domains. However, free-text feedback raised concerns that the domains originally titled ‘preoperative care,’ ‘intraoperative care,’ and ‘postoperative care’ were overly narrow, lacked balance, and might not resonate with patients. One domain from the initial framework, ‘continuous monitoring and management,’ was deemed redundant, as participants felt that it was insufficiently distinct from the pre-, intra-, and postoperative domains. Consequently, other domains were adapted to incorporate the aspects of quality and safety originally covered by this domain. Additionally, participants recommended reordering the domains to prioritise ‘shared decision-making and partnership in care’ and ‘multidisciplinary working, teamwork, and care coordination’ to better reflect their central role in perioperative care quality. Final framework of quality for perioperative care The feedback from the participatory exercise was used to refine the quality framework including its constituent domains. The final 10-domain framework (“P-Frame”), with definitions and rationale, is shown in Table 4 . View this table: View inline View popup Table 4. P-Frame: Final quality framework for perioperative care Discussion This study expands characterisation of quality in perioperative care beyond the traditional phase-based approach covering preoperative, intraoperative, and postoperative care. Our rapid review confirmed that a conceptual framework specific to perioperative care was lacking, while also indicating that distinctive features of the perioperative pathway limit the usefulness of generic frameworks ( 7 , 8 ). The structured, collaborative process we used has resulted in a framework (P-Frame) that reflects both evidence from the literature and practical insights from experts and stakeholders in perioperative care, including patients and the public. Its ten domains provide a comprehensive overview of what is important in quality of perioperative care, and will have value in enabling systematic organisation of quality indicators for purposes of monitoring and research, facilitating identification of where indicators may be lacking (such as those relating to patient centredness and equity) ( 8 ) and supporting more coherent approaches to assessing and improving care. The methods we used allowed triangulation of the views of stakeholders with the existing literature, increasing the rigour and face validity of the framework and ensuring consensus on the domains covered. The rapid review was successful in identifying a large number of relevant sources. However, variations in terminology across the literature required interpretive judgment and an iterative synthesis process. For example, where shared decision-making was outlined in the literature, how it was operationalised varied, with some sources constructing it primarily in terms of consent while others took a more encompassing view. These varied views can pose challenges not only at a conceptual level but also in developing reliable quality indicators, which are crucial for meaningful comparisons across settings ( 60 ). The role of stakeholder review of rapid review evidence aligned with Cochrane Rapid Review recommendations, ( 14 ) and was important in affirming the relevance of the framework, with unanimous agreement on four domains and minimal disagreement on six others. One domain in the first iteration of the framework—‘continuous monitoring and management’—was dropped following consultation with the ECG, since it was seen as inappropriately isolating aspects of care that were better understood as integral parts of other domains. Some domains benefitted from refined definitions and terminology adjustments. Notably, patient and carer perspectives emphasised the importance of communication and their representation within all domains and subsequent quality measures, helping to address previous concerns about the lack of patient representation in expert panels during indicator development ( 7 , 8 ). Similarly, stakeholder engagement supported the emergence of culture as a critical domain for perioperative care quality, reflecting Bello et al.’s ( 61 ) finding that highlights challenges such as diverse professional groups, dynamic teams, high-stress environments, and conflicting interests. Their work underscores the need for resilient perioperative cultures that can adapt to crises. Similarly, governance was identified as a key pillar of surgical quality ( 62 ), alongside the essential role of multidisciplinary collaboration ( 63 ). Several limitations should be considered, however. The rapid review methodology has inherent constraints, including those relating to scope of searches ( 64 ) which, in this case, focused on UK-based grey literature. Consequently, some relevant studies might have been excluded, potentially limiting the framework’s applicability across different geographical and health systems. To address this, the participatory exercise engaged a broad, albeit UK-based, expert group to refine and validate the framework, aligning with Cochrane rapid review recommendations ( 14 ), which emphasise iterative stakeholder involvement. This approach helped mitigate gaps by integrating diverse expertise including patients and informal carers, ensuring that the framework was both conceptually rigorous and practically applicable. In conclusion, this study presents a quality framework (P-Frame) informed by stakeholder engagement that is likely to have significant value for perioperative care. Among other things, this framework can inform the review and creation of new indicators, help in ensuring indicator sets are balanced across domains, support clinical audits, drive research initiatives, facilitate the implementation of transferable quality improvement interventions, and ensure that efforts to improve and assure the quality and safety of perioperative care do full justice to the breadth of domains covered by these concepts. Statements Authors contributions KWK: design, conceptualization, analysis and interpretation of data, writing – first draft, writing – review and editing, critical revision of the manuscript for important intellectual content; GM : conceptualization, writing– review and editing, critical revision of the manuscript for important intellectual content; SB: data acquisition, analysis and interpretation of data, writing – review and editing, critical revision of the manuscript for important intellectual content; PC: writing – review and editing; OB: interpretation of data, writing – review and editing; SRM: writing – review and editing, critical revision of the manuscript for important intellectual content; MDW: funding, conceptualization, writing – first draft, writing – review and editing, critical revision of the manuscript for important intellectual content Data Availability The data are not publicly available as sharing this data could potentially compromise the participant privacy. Data requests can be made to the research team and any such requests will be considered based on data governance. Contributorship The Perioperative Expert Contributor Group: Zoe Brummell, Abi Dennington-Price, Jugdeep K Dhesi, Jennifer Dorey, Bob Evans, Michael P W Grocott, Carolyn L Johnston, Emma McCone, Scarlett McNally, Ian Keith Moppett, Zoe Packman, David Selwyn, Ravinder Vohra Conflicts of interest MDW is a founder and non-executive director of THIS Labs, which hosts Thiscovery. She receives no financial benefit from this role. SRM is National Clinical Director for Perioperative and Critical Care at NHS England. Funding This work was funded by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies (THIS) Institute (RG88620). THIS Institute is supported by the Health Foundation – an independent charity committed to bringing about better health and health care for people in the UK. The views expressed in this article are those of the authors and not necessarily those of the Health Foundation. The funder played no part in the conduct or writing of this review, or the decision to submit the report for publication. SRM and OB receive funding from the National Institute for Health and Care Research (NIHR) Central London Patient Safety Research Collaboration; SRM receives funding from the University College London Hospitals NIHR Biomedical Research Centre The views expressed are those of the authors and not necessarily the NIHR or the Department of Health and Social Care. Acknowledgements The authors would like to thank Jo Brand, for supporting with the rapid literature review. References 1. ↵ Donabedian A . Evaluating the Quality of Medical Care . The Milbank Memorial Fund Quarterly . 1966 ; 44 ( 3 ): 166 – 206 . OpenUrl CrossRef PubMed Web of Science 2. Institute of Medicine . Crossing the Quality Chasm: A New Health System for the 21st Century. 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Share A quality framework for perioperative care: rapid review and participatory exercise Kristina Wanyonyi-Kay , Graham Martin , Sarah Ball , Paige Cunnington , Oliver Boney , S. Ramani Moonesinghe , Mary Dixon-Woods , The Perioperative Expert Contributor Group medRxiv 2025.08.13.25333583; doi: https://doi.org/10.1101/2025.08.13.25333583 Share This Article: Copy Citation Tools A quality framework for perioperative care: rapid review and participatory exercise Kristina Wanyonyi-Kay , Graham Martin , Sarah Ball , Paige Cunnington , Oliver Boney , S. 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