Real time monitoring of risk-adjusted outcomes for adult cardiac surgery has been reported in the past and found to aid quality assurance efforts. Recent advances in terms of the available risk-adjustment methods for congenital heart disease and paediatric cardiac surgery, which go some way to reflecting the great complexity of this field, have opened up the opportunity to use Variable Life Adjusted Display (VLAD) charts for this context. This chapter explains what VLAD charts are, and how they differ to other retrospective methods of audit that may be familiar to readers. The chapter then provides an example of VLAD chart use for real time monitoring of risk-adjusted surgical outcomes in congenital heart disease from the United Kingdom thus illustrating how these charts may be used for quality assurance. The chapter then places this example into context covering some of the salient issues and previous experiences with VLAD for outcome monitoring.