Quality assurance in surgery—a moral obligation

Abstract

Summary Background Quality assurance (QA) in surgery is crucial, ensuring patient safety, improving outcomes, and maintaining the highest standards of care. Structured medical documentation is a key component in generating valid data that can be used to achieve QA goals. Unfortunately, digital systems for surgical documentation that are simultaneously clinically oriented, appropriately comprehensive, and user friendly are currently lacking. Methods For this reason, the Department of Visceral, Transplant, and Thoracic Surgery at the Medical University of Innsbruck has established its medical documentation platform as a quality-controlled registry (qcRegistry). Results This paper gives an overview of quality assurance measures in medicine, especially in surgery. It describes the essential requirements for the data of a registry, the tools to achieve quality-controlled data, and its implementation in routine without significantly disturbing the daily clinical routine. Conclusion Despite complex conditions inherent to medical quality-controlled documentation, it has been shown that a quality-controlled, audit-capable registry (qcRegistry) can be successfully implemented across all aspects of surgical practice in a tertiary care surgery department.