ABSTRACT
Quality assurance is universally recognized as important and is a priority in nearly all areas of health care. Quality criteria have to be identied in order to aid in the development of practice guidelines, which are in place in most health-care systems. However, practice guidelines are intended for guidance, allowing for clinical judgment and patient preferences. In quality assurance, quantitative measures are used in a dynamic process of systematic and continuous monitoring in order to identify standards below which poor quality can be identied. e translation from treatment guidelines to identication of quality assurance metrics unfortunately is not straightforward; quality assurance can be summarized into eorts directed toward strategies to implement guidelines into daily routine practice [1,2]. In oncology, the quality of care in terms of standardization and improvement has been highlighted by several professional institutions, but has, to a lesser degree, been put into generalizable (community-based) use [3-6]. Quality assurance in surgery has been shown to be highly relevant. Notably, following a surgical risk study between 1991 and 1993, the National Surgical Quality Improvement Project (NSQIP) was introduced in 1994 to surgical services in the Veterans Health Administration in the United States [6]. In this program, presurgical risk factors and processes of surgical care are prospectively monitored in order to develop observed versus expected (O/E) ratios, which are reported back to participating institutions, allowing a process of continuous benchmarking. By 2004, as a result of these eorts, a 31% decrease in 30-day mortality and 45% decrease in 30-day morbidity had been reached [7]. Subsequently, the NSQIP has been introduced into a broader range of U.S. surgical services, and its introduction into use in gynecologic oncology has also been discussed [8-10]. A similar achievement of quality assurance in rectal cancer surgery has been reached in Europe. A quality assurance program
was launched in Norway in 1993 at the time when the importance of total mesorectal excision (TME) had been recognized and consensus reached about TME as the new surgical treatment standard. In parallel, a comprehensive quality registry within the Norwegian Cancer Registry was established, covering 99% of all patients operated for rectal cancer in Norway. As a result of training courses and master classes for renement of the TME technique in combination with institutional benchmarking against the national average, a remarkable increase of the performance of TME surgery from 78% to 92%, a reduction of local recurrence from 28% to 7%, and improved 5-year survival from 55% to 73% were achieved within the rst 4 years [11]. Subsequently, several other European countries have established similar successful programs for colorectal surgical audit, as well as a European international outcome-based quality improvement program has been initiated based on input from national registries [12,13].
