The Scottish Hip Fracture Audit (1) was founded on Rikshoft, the Swedish hip fracture register (2), and since 1993 has documented case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care were updated by a multidisciplinary group in 2002(3). And hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004 (4).

Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A& E care, pre-operative delay, multidisciplinary care and audit participation are met.

Three national-level initiatives on hip fracture care have delivered: reliable and largescale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance and quality assurance, with methods for casemix-adjusted outcome assessment for hip fracture care also now developed.