The advantage of statutory regulations and institutional licensing as forms of assurance schemes is their visibility in that they mandate health care providers to change the way surgery is organized and practiced. For example, the surgical checklists introduced by the World Health Organization (WHO) , which were designed and implemented throughout the globe to help reduce surgical mortality and complications, have been part of many national regulations in the USA and Australia [10, 11]. Since 2012, the US Centers for Medicare & Medicaid Services (CMS) requires ambulatory surgery centers (ASC) to conduct quality reporting that includes the use of surgery checklists for all, not only Medicare, patients [12, 13].

Within voluntary schemes, it is worth noting that non-governmental, private sector regulators are rapidly gaining their influence in the way that surgery is practiced, billed and supervised [6]. For example, the Leapfrog Group [13] has become one of the most powerful forces in the private regulatory sector and provides excellent evidence on the impact of this sector on surgical care. Furthermore, specialty colleges or board and professional licensing bodies are key players in developing assurance schemes based on consensus into more uniform, regulated schemes . For example, there is a global trend in developing and implementing a scheme for physicians’ continuous professional development such as schemes to maintain physicians’ competence [14]. In Australia, as an example, the Royal Australasian College of Surgeons requires surgeons to maintain their skills, knowledge and competence by self-directed learning, teaching, researching, publishing scientific articles, and attending educational gatherings such as scientific meetings, workshops, and seminars. In most of western countries, surgeons must retain records to verify their competence and professional development [14].

The specialty colleges or boards can also potentially be the champions in closing the gap in the areas in need of regulations such as robotic surgery. Technology advancements in surgery are growing rapidly, for example, the scale and spread of 3-D organ and prosthetic printing. This growth creates an urgent need for assurance schemes to ensure the quality and safety of patients not being harmed from the technology. Currently, there are no standards, nationally or internationally, for assuring patients are not harmed during the use of robotic surgery. However, there is a growing consensus in this field, such as a consensus document produced by The Society of American Gastrointestinal and Endoscopic Surgeons [15, 16]. This consensus document provides guidance to surgeons wishing to perform robotic surgery to fulfill specific training prior to performing it.

Most surgical assurance schemes have a focus mainly on prescriptive, rather than performance-based frameworks. Whereas health care practitioners need assurance schemes that are performance-based to help them put systems thinking into practice. This is crucial to ensure that end-users receive the necessary treatment with the desired outcome. There remains an evidence gap forcing regulators to be ever vigilant about the safety and reliability of surgical services [9].