Colonoscopy is central to colorectal cancer (CRC) prevention, and its effectiveness is determined by the quality of mucosal inspection and lesion detection. The adenoma detection rate (ADR) remains the most widely validated quality benchmark due to its strong inverse association with interval CRC. However, reliance on ADR alone is increasingly recognized as insufficient, particularly given the growing understanding of the serrated neoplasia pathway, which contributes up to one-third of sporadic CRCs. This has driven the emergence of complementary metrics, such as the sessile polyp detection rate (SPDR) and adenomas per colonoscopy (APC). Although SPDR offers important advantages for capturing serrated pathology, challenges persist, including interobserver variability, inconsistent pathology thresholds, limited endoscopist training, and the absence of standardized benchmarks. Alongside these evolving metrics, technological advancements such as image-enhanced endoscopy, computer-aided detection, high-definition optics, and distal attachment devices have demonstrated measurable improvements in detecting subtle lesions and reducing operator-dependent variability. Large real-world registries, including GIQuIC, now support the development and validation of composite models that integrate ADR, SPDR, and APC to better reflect the full spectrum of neoplasia detection. As the field advances, redefining colonoscopy quality will require reconciling established metrics with newer indicators that more comprehensively address both conventional adenomas and serrated lesions.