The discipline of perioperative medicine provides a foundation for the consistent delivery of safe and good quality care to surgical patients. Its goals include the identification and optimal care of the high-risk surgical patient, fostering patient-centred decision making throughout the surgical perioperative pathway, and reducing unwarranted variation in practice. In turn, this should reduce preventable complications and improve patient satisfaction, long-term morbidity and survival. This review concludes a series of articles which have described the epidemiology of surgical disease, the growth in the objective means of risk assessment, and novel outcome measures. It describes shortcomings in current practice, and how perioperative care pathways may overcome these. It discusses the growth of enhanced recovery programmes, which exemplify many of the sub-specialty's principles of patient-centred and coordinated care. Reported initiatives to modify local health-care systems, such as the Perioperative Surgical Home, are presented. Consideration is given to how clinicians can use the philosophy and tools of quality improvement methodology, with important current examples. The article concludes by looking at obstacles to change when introducing new frameworks and the future horizons for the discipline.