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Background There is no low-risk surgery for frail, high-risk patients. Frailty screening helps identify these patients, enabling surgical teams to tailor treatment plans that align with patient values and mitigate risks. However, the way clinicians assess values and counsel older patients about surgical options is unclear. As part of a larger Veterans Administration (VA) quality improvement (QI) initiative to implement Surgical Pause, this pre-implementation qualitative assessment examined how outpatient surgical teams identify and use older adults’ goals, values and care preferences in elective surgery decision-making.Methods We triangulated pre-implementation interview, observational and focus group data to understand the clinical context, workflows and staff perspectives around preoperative goal clarification conversations. Using thematic analysis, we described clinicians’ attitudes towards integrating structured ‘What Matters’ conversations into routine preoperative care, mapped existing processes and identified barriers and opportunities for quality improvement.Results The final sample included 27 interviews, 75 observations and 7 focus groups across 18 outpatient clinics at four medical centres. Overall, clinicians supported discussing ‘What Matters’ with high-risk older patients considering elective surgery, but their practices varied. Participants reported inconsistent processes for integrating patient priorities into decisions. Key barriers included reliance on a ‘fix it’ care model, workflow integration and visibility, and time constraints. Facilitators included leveraging performance metrics, improving documentation and referral systems, and staff training.Conclusions Although surgical clinicians recognise the importance of discussing patient goals, explicit ‘What Matters’ conversations with patients rarely occurred. In contrast, frequently used implicit strategies include chart reviews, clinical assessment, discussion of treatment options, informed consent and referrals. Future work should enhance strategies to improve goal clarification and promote high-quality decision-making with frail older patients.