A welcome new perioperative care standard—but why does the new standards rely on an outdated safety framework?

Summary

At the beginning of this month, the National Institute of Health and Care Excellence (NICE) published a new quality standard for perioperative care in adults. This standard covers the care of adults around surgery during the preoperative (before), intraoperative (during) and postoperative (after) periods. In this blog, Dr Tim Jackson shares reflections on this new standard and highlights where it currently does not join up with the National Safety Standards for Invasive Procedures (NatSSIPs) 2.

Tim is the NatSSIPs lead for St Bartholemew’s hospital and a key member of the Barts Health Group NatSSIPs Committee. He is also a member of the Safer Surgery and Invasive Procedures Network, a group of over 1000 healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures.

If you are interested in joining the Safer Surgery and Invasive Procedures Network, you can do so by signing up to the hub today. When putting in your details, please tick ‘Safer Surgery and Invasive Procedures Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. 

Content

NICE’s recent publication of a new quality standard for perioperative care in adults is welcome. Composed of six quality statements, it seeks to describe high quality in priority areas for improvement.

Its first five statements provide a clear framework for continuity of care, risk assessment, clinical assessment, shared decision making and preoperative optimisation. These are important priorities and should support more consistent perioperative care. However, the sixth statement on procedural safety (ensuring an activity is carried out according to established procedure to minimise risk) represents a significant missed opportunity.

Quality statement six says that adults having surgery should have the World Health Organization (WHO) surgical safety checklist completed for each procedure. It describes the familiar three stages: before induction of anaesthesia, before the first incision and before the patient leaves the operating room. NICE then proposes measuring the proportion of procedures for which checklist completion is recorded.

The WHO checklist is the core cornerstone and an important foundation for procedural safety. However, what is missed here is that this checklist on its own is no longer the complete national framework.

NatSSIPs 2 is the current national standard

The National Safety Standards for Invasive Procedures (NatSSIPs) 2 were published in January 2023 by the Centre for Perioperative Care (CPOC). They apply across England, Northern Ireland, Scotland and Wales and to invasive procedures both within and outside conventional operating theatres. NHS England describes NatSSIPs 2 as the national safety standards covering all invasive procedures, including those undertaken outside operating departments.

NatSSIPs 2 has effectively evolved and superseded the WHO checklist as a standalone national safety framework. The WHO checks remain within it, but they are now the basic building blocks of a wider system to deliver consistent quality by enhancing teamwork, communication, situational awareness and mutual support.

CPOC is explicit that the previous Five Steps to Safer Surgery (2015) are now regarded as basic checks as organisations advance to the 'NatSSIPs 8' (2023). The latter are eight sequential standards that should be performed through each patient’s invasive-procedure pathway and should form the basis of locally adapted WHO or specialty-specific checklists.

The NatSSIPs 8 are:

1. Consent, procedural verification and site marking.
2. Team brief.
3. Sign in.
4. Time out.
5. Safe and efficient use of implants.
6. Reconciliation of items.
7. Sign out.
8. Handover and debrief. 

These distinction matters. The new NICE quality standard presents the three-stage WHO checklist as the principal standard of surgical safety. However, NatSSIPs 2 presents procedural safety as a connected sequence, beginning before the patient reaches the operating room and continuing through handover, debrief and organisational learning.

A national quality standard published in 2026 should reflect the current national safety standard.

More than three pauses

The WHO checklist focuses mainly on Sign in, Time out and Sign out. NatSSIPs 2 retains these safety-stop moments but also closes several important gaps around them.

• 'Consent and procedural verification' are linked together. This means that the proposed procedure is checked against the patient, clinical records, consent documentation, investigations and imaging. This creates a more robust check than simply confirming what appears on an operating list.
• It also includes a separate step on implant safety: ‘safe and efficient use of implants’. This is important because availability, suitability, compatibility, expiry and traceability cannot safely be assumed.
• Equipment reconciliation or ‘reconciliation of items’ is also a distinct step. This supports the safe, consistent and efficient practice in accounting for all items used during an invasive procedure, reducing the risk of them being retained unintentionally. This extends beyond traditional swab and instrument counts to guidewires and components used in interventional procedures.
• Finally, ‘handover and debrief’ are recognised as a specific step as safety-critical processes, rather than optional additions at the end of a checklist.

Both NatSSIPs 2 and wider national thinking, reflected in Health Services Safety Investigations Body (HSSIB) reports and the awaited consultation on Never Events, point towards moving away from using Never Events as a simple measure of quality in invasive procedures. However, the 'big three' risks remain: wrong-site surgery, wrong implant and retained foreign objects.

The sequential steps in NatSSIPs 2 provide multiple opportunities to identify and mitigate these risks, and were developed from learning drawn from real incidents. The NatSSIPs 2 standards are particularly relevant in catheter laboratories, interventional radiology, endoscopy, maternity, emergency departments, wards and outpatient settings where the WHO surgical checklist has not been embedded as they are not surgical areas. NatSSIPs 2 deliberately covers these environments, while the NICE quality statement is framed more narrowly around adults having surgery.

Brief and debrief are not checklist components

Reviewing the new quality standard, NICE’s description of Team brief and Debrief could benefit from a greater degree of clarity.

The quality standard states that the three WHO checklist components should be completed as a minimum, “including a team brief and team debrief”. However, Team brief and Debrief are not simply parts of the three-stage WHO checklist. They are separate steps with separate functions:

• Team brief—this creates a shared plan before a list or procedural session begins. It should identify patient-specific risks, equipment requirements, staffing concerns, anticipated difficulties and pressures affecting the whole session.
• Debrief—this should capture what went well, what created difficulty and what requires action. Done properly, it provides a route from frontline experience into governance and service improvement.

By appearing to combine the Team Brief and Debrief into the three checklist stages, the NICE quality standard currently risks unintentionally weakening both. A provider may record completion of sign in, time out and sign out without reliably delivering a meaningful brief or debrief.

Completion is not the same as quality

There are also some limitations when it comes to the proposed quality measures included in the NICE standard.

One proposed measure concerns the proportion of surgical procedures for which the WHO surgical checklist is completed. Counting how often a checklist is documented as complete is straightforward; however, it tells us little about how the checks were performed.

For example, a Sign in may have occurred before the anaesthetic team was present. A Time out may have happened too early while team members continued other tasks. Responses may have been read from the record rather than actively confirmed. A concern may have been raised but not resolved. However, all of these processes could still appear as 'completed' in an electronic record.

Recognising this complexity, NatSSIPs 2 deliberately moves away from an excessive emphasis on tick boxes. Instead it gives importance to engaged teams, human factors, psychological safety, patient participation, qualitative assessment and organisational conditions that allow staff to carry out the standards properly. It also states that checklists are not a solution in themselves.

Procedural safety should, therefore, be assessed not only by recorded completion, but also by correct timing, appropriate participation, team engagement, observed behaviours, and evidence that concerns and debrief actions lead to improvement.

A missed opportunity

NICE’s new quality standard is strong on perioperative assessment and optimisation. However, on procedural safety, its current statement reflects the WHO checklist but misses subsequent advances in invasive procedures safety that are incorporated into NatSSIPs 2.

This is more than a missing citation. It risks unintentionally sending the message that three documented checklist stages constitute the current national expectation, rather than NatSSIPs 2.

Moving forward, it is important that this new quality standard is updated to reflect the latest guidance in this area. This means it explicitly stating that the WHO checklist is incorporated within NatSSIPs 2, and that organisations should deliver the NatSSIPs 2 organisational standards and sequential steps proportionately across all invasive procedure settings.

The WHO checklist transformed surgical safety, but safety practice has moved on—national guidance should move with it.

About the Author

Dr Tim Jackson is a consultant cardiothoracic anaesthetist at St Bartholomew’s Hospital, a patient safety specialist, and the site lead for the National Safety Standards for Invasive Procedures. He also leads work on perioperative debriefing, mortality review and learning from harm, with a particular interest in human factors, team behaviours and how frontline learning can improve procedural safety.