Framing quality in peri‐operative care

Kelly et al. provide a comprehensive and timely update on structure and process indicators in peri-operative care [1]. The decision not to include outcome indicators, whilst methodologically consistent with the stated aims, deserves scrutiny. Peri-operative care is defined explicitly as an inherently person-centred practice, and a growing body of evidence supports patient-reported outcome measures (PROMs) [2] as legitimate quality benchmarks in surgical and anaesthetic care. If indicator development is to genuinely incorporate the patient perspective, it seems paradoxical not to include the very measures that most directly reflect patient experience. We would encourage Kelly et al. to consider, in subsequent phases of their programme, an integrative framework positioning selected outcome indicators alongside structure and process measures. The conceptualisation of evidence supporting the reviewed indicators warrants greater granularity. The adopted approach aggregates highly heterogeneous forms of support, from use as an endpoint in a randomised controlled trial to expert consensus under a single label. This approach risks overstating the robustness of many measures. An indicator employed as a secondary endpoint in a trial, without any formal assessment of its measurement properties, may not be methodologically equivalent to one developed explicitly and validated according to established standards. Future iterations of this work would benefit from distinguishing between evidence of indicator validity and the clinical practice the indicator is designed to capture. The review does not fully interrogate the mechanisms driving indicator proliferation, nor does it propose explicit criteria for retiring redundant or poorly validated measures. The number of peri-operative indicators has grown from 261 to 615 [3], yet this expansion appears to reflect accumulation rather than refinement. Without principled exclusion criteria, the core set development phase risks compounding rather than resolving the entropy it seeks to address. Frameworks developed in the field of healthcare de-implementation [4], which focus on identifying and phasing out low-value or poorly supported interventions, may offer useful methodological guidance on how to discontinue redundant or weak peri-operative quality indicators. Kelly et al. expose unresolved methodological tensions in how peri-operative quality indicators are designed, classified and evidenced. Addressing these issues is essential if the long list generated by this review is to translate into a parsimonious, actionable and conceptually coherent measurement system for peri-operative care. Without methodological consolidation, the expansion of peri-operative indicators risks undermining rather than strengthening the safety and quality systems it aims to support.