Table 1.

The perioperative medicine for older people undergoing surgery (POPS) logic model

Inputs	Core components	Mechanism (process changes)	Contextual factors (which enable or hinder implementation)	Short-term outcomes	Long-term outcomes	Wider impact of POPS service
MDT POPS team Consultant with expertise in CGA in perioperative setting CNS OT Administrator	Deliver preoperative CGA and optimisation through multidisciplinary working.	Preoperative CGA and optimisation outpatient clinic. Effective screening and referral criteria. Evidence-based perioperative medicine. ‘Hands on’ delivery of clinical optimisation plan.	‘Buy-in’ from board, surgeons, anaesthetists and other key stakeholders. Skills and engagement of medical and AHP staff equipped to deliver CGA and optimisation in the perioperative period. IT infrastructure, technical support and physical space. Funding.	Improved quantification of perioperative risk. Improved shared decision making. Improved identification of underlying medical issues. Improved medical optimisation. Improved identification and management of barriers to early discharge. Reduced variation in patient care.	Patient outcomes Embedding of multidisciplinary and patient-centred shared decision making in clinical practice. Provision of timely surgical care. Avoidance of inappropriate procedures. Reduced postoperative morbidity and harm. Improved patient reported outcomes (short- and long-term). Service outcomes Improved quality of care. Reduced length of stay. Reduced same day cancellation of surgery. Reduced readmissions. Reduced financial cost. Implementation outcomes Acceptability of service to providers, patients and carers. Maintenance of fidelity while adapting service to the local context. Development of ‘big data’ through collation of audit and quality improvement work at POPS sites. Development of a workforce equipped to deliver perioperative medicine services for complex older patients.	Improved health literacy with consequently improved patient navigation of health services. Integrated healthcare. Improved health outcomes. Development of evidence base in perioperative medicine through big data. Influence on policy and funding streams for perioperative medicine services.
Other key stakeholders Trust executive/board Surgeons Anaesthetists Other AHPs Surgical pathway coordinators Evaluator Patients and relatives	Provide postoperative CGA on the surgical ward.	CGA and optimisation conducted using scheduled ward rounds, board rounds, multidisciplinary team meetings. Proactive communication between healthcare professionals, patients and families.	‘Buy-in’ from ward teams. Staff attitudes and behaviours. Skills and engagement of medical and AHP staff equipped to deliver CGA and optimisation in the perioperative period. IT infrastructure, technical support and physical space. Funding.	Fewer acute postoperative complications. Improved early identification of postoperative complications with standardised management. Safe and effective discharge planning.
Resources Funding Clinic space Office space Equipment Supporting pro formas (in paper or electronic format) Clinical reference guide Clinical guidelines/protocols	Ensure ownership of patient care.	Fostering an environment that promotes shared decision making with the patient at the centre.	Professional jurisdictions, norms and codes of behaviour. Readiness for change within the clinical team and the organisation (open to new ways of delivering collaborative patient-centred care).	Reduced number of specialist referrals. Single point of access: improved communication with patient and primary care to facilitate patient navigation of perioperative pathway. Improved shared decision making. Improved delivery of holistic care, with focus on perioperative and longer-term outcomes.
Education resources Doctor/CNS curriculum / competency framework Teaching schedules Teaching materials (eg slide-packs)	Facilitate proactive liaison with other teams.	Joint ward rounds, board rounds, clinic consults between surgery, medicine and anaesthetics. Joint audit meetings / teaching sessions between surgery, medicine and anaesthetics.	Buy-in from all stakeholders. Promotion of collaborative working (on individual, team and organisational level). Trusted informal and formal peer review and accountability with willingness to engage with feedback processes. Avoidance of silo working and poor communication (whether due to IT or other systems).	Informed and therefore improved clinical decision making. Reduced silo culture. Positive influence on behaviours and attitudes of junior medical and nursing staff.
	Provide education and training to POPS team and key stakeholders.	Predefined curriculum. Structured teaching programme.	Scheduled protected teaching sessions.	An ‘upskilled’ workforce able to provide care for complex older patients. Improved knowledge and skills in perioperative medicine (doctors and AHPs). Creation of teaching and mentoring opportunities.
	Establish governance structure and evaluation programme.	Structured quality improvement programme underpinned by robust clinical governance meetings.	Support from informatics. Access to expertise in quality improvement.	Ensure fidelity to the POPS model of care. Reduced unwarranted variation in patient care. Improved quality of care. Development of an evidence base in issues relevant to complex older surgical patients.

AHPs = allied health professional; CGA = comprehensive geriatric assessment; CNS = clinical nurse specialist; MDT = multidisciplinary team; OT = occupational therapist; POPS = perioperative medicine for older people undergoing surgery.