The National Emergency Laparotomy Audit (NELA) was launched in England and Wales in 2013 on the back of data showing mortality figures of 15% and high complication rates together with disparities in care across the country. The aim was to improve the quality of care for Emergency Laparotomy patients but collecting and analysing data to guide quality improvement across the Nation. Over 30,000 emergency laparotomies were performed in the first year and a wide variation in outcomes between hospitals highlighted a need for better standards and care pathways. This benchmarked performance nationally and locally and provided data to improve decision-making, preoperative care and postoperative outcomes. It promoted adherence to evidence-based standards, especially timely surgery and consultant involvement and best-practice tariffs gave incentives to hospitals to improve performance. Delays to surgery, inconsistent consultant input and variation in access to post-operative critical care were highlighted as the biggest challenges but mortality has dropped to below 9% over the 12 years it has been active. NELA has significantly improved the landscape of emergency laparotomy care. It serves as model for national audit-led quality improvement and ongoing participation and engagement are essential for sustained progress.