The NCAPC builds on evidence generated from established national perioperative audits and quality improvement programmes, notably the National Emergency Laparotomy Audit (NELA - https://www.rcoa.ac.uk/research/research-projects/national-emergency-laparotomy-audit-nela) and the Perioperative Quality Improvement Programme (PQIP - https://pqip.org.uk/content/home). These programmes have demonstrated substantial unexplained and unwarranted variation in perioperative processes and outcomes between providers, alongside evidence that national benchmarking, transparent reporting, and structured quality improvement support can lead to measurable improvements in patient outcomes.
Published national standards and frameworks from the Centre for Perioperative Care (CPOC) emphasise a whole pathway approach to perioperative care, spanning referral, shared decision making, optimisation before surgery, postoperative recovery, and rehabilitation. Despite this guidance, there is inconsistent implementation of evidence based perioperative practices across NHS organisations.
The audit will be delivered by a team at the Royal College of Anaesthetists (RCoA) with extensive experience in national clinical audit and perioperative care. This includes experience running and coordinating the Perioperative Quality Improvement Programme (PQIP) and the National Emergency Laparotomy Audit (NELA). The audit will also have a key strategic partner with the Centre for Perioperative Care (CPOC), with representation on both our governing Board and clinical reference group. CPOC will be able to harness its parent organisations, such as the Royal College of Surgeons of England, Royal College of Nursing and the Royal College of General Practice, to promote the audit and increase participation. CPOC’s active network of 191 perioperative care leads can provide a two-way communication channel and disseminate key findings from the audit. Drawing upon this experience will ensure that the audit achieves high quality outputs that lead to improvements in patient care.
The idea for the audit evolved from recognition of a critical gap: while specialty specific audits exist, there is no national audit focused on generic, cross cutting perioperative processes for adult elective surgery. The proposed audit responds to this gap by integrating pathway wide measurement, equity focused sampling using CORE20PLUS5, and real time feedback mechanisms to systematically reduce unwarranted variation and support sustained quality improvement across the NHS.
The NCAPC aims to drive improvements in surgical pathways by reducing unwarranted deviations from evidence-based practice, thereby lowering complication rates and enhancing patients’ health-related quality of life. Its objectives are to:
• Improve the quality of perioperative care
• Reduce variation in practice
• Identify and address health inequalities
• Promote best practice across health services in England and Jersey
The first year of the audit will be dedicated to defining healthcare quality improvement goals, identifying evidence-based standards of care likely to have the most impact on these goals, and defining a dataset to ascertain compliance with these standards. The second year of the audit will be focused on data collection, while the third year will see the first state-of-the-nation report issued.
All of the leadership and governances for the audit is in place via the RoCA and HQIP (Healthcare Quality Improvement Partnership). A strategic oversight board and clinical reference group is already being put together to provide the necessary governance framework around this audit.
In order to define and develop a set of perioperative standards for patients undergoing major elective surgery we plan to undertake a modified Delphi study and expert panel consensus with healthcare professionals and patients with lived experience. This is both a qualitative and quantitative technique that aims to build consensus to resolve uncertainty around perioperative clinical questions and enable the identification of the top 10 standards of perioperative care that will be benchmarked in NCAPC.
A/Prof Malcolm West and Dr Tim Baker are co-chief investigators and co-leads for NCAPC
The RoCA and CPOC are experts in providing perioperative medicine services for the NHS, however they are not experts in actually undergoing major elective surgery. Patients are essential stakeholders, so in accordance with COMET and CREDES guidelines we have sought patient involvement from an early stage in the design of this Delphi project so that they will have an important influence the selection of perioperative standards that will be benchmarked by data collection in year 1. We plan to recruit patient representatives through the RoCA (PatientsVoices@RCoA), CPOC’s patient network, Royal College of Surgeons and other stakeholder groups and known Patient and Public Involvement (PPIE) groups already in existence through the RoCA/ CPOC or charity partners e.g. Bowel Research UK and other cancer charities. Cancer charities or NIHR Biomedical Research Centres e.g. UCL and Southampton would be able to distribute the Delphi invitation widely within their PPIE groups to help us find additional patient representatives. Perioperative medicine healthcare professionals from NHS hospitals will be encouraged to invite appropriate patient representatives from their own institutions. Unfortunately, we do not currently have funding for professional interpreters, and we will also not be able to offer patients renumeration for their time. We anticipate that we will have difficulties in recruiting non-English speaking patient representatives, but this is a recognised limitation.
The lay representatives/ PPIE from CPOC have contributed to the development of this proposal especially the set-up of NCAP prior to the commissioning application process. This includes taking part in discussions to determine key elements and concepts to be included in the audit as well as reviewing responses to this application.
This Delphi study has been designed by the NCAPC leadership with expert support from RoCA, CPOC and PQIP in accordance with the Guidance on Conducting and Reporting Delphi Studies (CREDES) guidelines. In order to undertake a Delphi study a panel of experts are required. The RCoA and CPOC are a diverse national group of health care professionals from >250 NHS hospitals in England that provide perioperative medicine services, and aim to improve the results for patients undergoing major elective surgery. Therefore, all members of RoCA and CPOC as well as other key stakeholders e.g. Royal College of Surgeons, Association of Anaesthetists, British Dietician Association etc., will be invited to be involved in the study, generating, multi-professional, national representation.
Disease Category: Other
Disease Name: Perioperative medicine
Age Range: 18 - 120
Sex: Either
Nature of Intervention: Surgery
- Charities
- Clinical experts
- Consumers (caregivers)
- Consumers (patients)
- Patient/ support group representatives
- Core indicator set
- Consensus meeting
- Delphi process
- Literature review
This study will develop a consensus-based core set of perioperative audit standards for the National Clinical Audit of Perioperative Care (NCAPC) using a multi-round modified Delphi methodology, conducted in accordance with the COMET Initiative guidance, COS-STAP protocol items, COS-STAD development standards, and CREDES reporting recommendations. This study already has approval by the Faculty Research Ethics Committee at the University of Southampton (ERGO110645).
A multidisciplinary Steering Committee, including clinicians, methodologists, audit leads and patient representatives, will oversee study governance, confirm scope, approve candidate standards, and ratify consensus decisions. Patient and public involvement is embedded throughout to ensure relevance, clarity and acceptability of standards.
Candidate standards were identified through a structured scoping review of national and international guidelines, policy documents and perioperative audit outputs, supplemented by expert consultation and metric-mapping against established perioperative quality frameworks. A national, web-based Delphi survey will be conducted using Qualtrics, involving two stakeholder panels: healthcare professionals and patient representatives.
Participants will rate each candidate standard using a 9-point Likert scale aligned with GRADE importance categories. Structured feedback will be provided between rounds. Consensus criteria will be defined a priori and applied separately to each stakeholder panel, with progressively more stringent thresholds across rounds to support prioritisation. Standards meeting progression criteria and final consensus will be ranked to identify the final core set for NCAPC.
Analyses will follow COMET and COS-STAD recommendations, using descriptive summary statistics to assess the distribution of importance ratings for each candidate standard within and between stakeholder panels, with a priori consensus thresholds applied to determine retention, exclusion, and final prioritisation of items. Qualitative text analyse and apriori sub-group analyse will be carried out according to a published protocol.