Evidence Alignment and Implementation Content in Surgical Care Policies and Procedures: Supporting Evidence-Informed Practice in Complex Healthcare Environments.

Authors

Samuel Lapkin, Georgia Tobiano, Josephine Lovegrove, Sharon Latimer, Wendy Chaboyer, Joan Carlini, Jane Rodgers, Elizabeth McInnes, Karen Le Roy, Nipuna R Kuruppu, Chou Yew Stanley Thong, Brigid M Gillespie

Published in

International journal for quality in health care : journal of the International Society for Quality in Health Care. Nov 10, 2026. Epub Nov 10, 2026.

Abstract

Surgical care is delivered within increasingly complex and evolving healthcare environments, requiring organisational policies and procedures that support the translation of contemporary evidence into consistent clinical practice. Understanding the extent to which these documents align with contemporary evidence and incorporate implementation content is important for supporting evidence-informed surgical care. This study evaluated the alignment of organisational surgical care policies and procedures with contemporary evidence and examined the implementation content embedded within these documents.
A multisite qualitative document analysis was undertaken across four purposively selected tertiary public hospital, comprising three metropolitan hospitals and one large regional hospital. Surgical care policies and procedures were analysed using a structured document analysis approach. Data extraction focused on document characteristics, cited evidence sources, and implementation content. Analysis was informed by the Practical, Robust Implementation and Sustainability Model, and established implementation strategy frameworks. Reporting followed the Standards for Reporting Qualitative Research.
Thirty-seven organisational surgical care policies and procedures were screened, of which 19 met the inclusion criteria. Most included documents aligned with recognised standards and referenced clinical practice guidelines, regulatory requirements, and organisational sources. However, the type, level, and currency of evidence varied considerably, with relatively few documents incorporating recent systematic reviews or primary research. Implementation content primarily addressed on governance, audit, monitoring, education and competency requirements, with comparatively less emphasis on strategies supporting contextual adaptation, implementation planning, feedback processes and sustainability.
Organisational surgical care policies and procedures varied in the extent to which they reflected contemporary evidence and incorporated implementation content supporting evidence-informed practice. Strengthening routine policy review, evidence integration, and implementation-focused policy content may enhance evidence translation, promote more consistent evidence-based surgical care, and reduce unwarranted variation in practice. In increasingly complex and evolving healthcare environments, maintaining evidence-informed organisational policies and procedures is important for supporting consistent clinical decision-making and the delivery of high-quality surgical care.

PMID:
43006880
Bibliographic data and abstract were imported from PubMed on 10 Nov 2026.

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