Journal Information
Vol. 57. Issue 10.
Pages 637-647 (October 2021)
Vol. 57. Issue 10.
Pages 637-647 (October 2021)
Special Article
Full text access
Health outcomes: Towards the accreditation of respiratory medicine departments
Resultados de salud: hacia la acreditación de los servicios de neumología
José Manuel Álvarez-Dobañoa,c, Gerardo Atienzab, Carlos Zamarrónc, María Elena Toubesc, Lucía Ferreiroa,
Corresponding author

Corresponding author.
, Vanessa Riveiroc, Ana Casalc, Juan Suárez-Anteloc, Nuria Rodríguez-Núñezc, Adriana Lama-Lópezc, Carlos Rábade-Castedoc, Carlota Rodríguez-Garcíac, Tamara Lourido-Cebreiroc, Jorge Ricoyc, Romina Abelleirac, Antonio Golpea,c, Beatriz Paisb, Francisco Javier González-Barcalaa,c, Luis Valdésa,c
a Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
b Unidad de Calidad y Seguridad del Paciente, Subdirección de Calidad, Área Sanitaria de Santiago de Compostela y Barbanza, Santiago de Compostela, Spain
c Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
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Table 1. Proposed quality indicators for a respiratory medicine department.

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

Clinical management
Health outcomes
Respiratory medicine

Los sistemas nacionales de salud deben garantizar a los ciudadanos el cumplimiento de unas condiciones básicas como la equidad, la eficiencia, la calidad y la transparencia. En aras del derecho que tiene la sociedad a conocer los resultados de salud de su área sanitaria, el objetivo de este artículo es elaborar una propuesta de acreditación de los servicios de neumología desde el punto de vista asistencial, docente e investigador, midiendo sus resultados de salud a través de indicadores de calidad en la atención. Para mejorar estos, deberíamos utilizar unas herramientas de gestión (que se desarrollan en el artículo) y que, sin duda, nos ayudarían a conseguir los objetivos propuestos. La mejora del nivel de acreditación puede servir como estímulo para perfeccionar la gestión clínica y para que los profesionales ejerzan una capacidad de dirección cada vez mayor y adopten medidas para reforzar los resultados en la atención a sus pacientes.

Palabras clave:
Gestión clínica
Resultados de salud
Full Text

National health systems must meet the basic needs of their citizens, including equity, efficiency, quality, and transparency1. As such, they must ensure universal access to quality medicine, regardless of economic level and social background; they must also resolve health problems at the appropriate level of care, avoiding medical interventions that do not improve health care processes. They must generate data on health activity and outcomes using indicators to identify dysfunctional areas2 and provide citizens access to this information. Health systems must integrate new technological resources, exploit information systems, promote networking at different levels of care, and ensure the clinical implementation of diagnostic and therapeutic advances3 in order to achieve maximum efficiency and the quality of care that they are obliged to provide.

The challenges facing health systems today mean that the health sector must be remodeled to improve quality and efficiency and boost sustainability4. If health outcomes are to be improved, strategies must be rethought, and processes for implementing and evaluating these strategies must advance. To address these challenges, respiratory medicine departments must be managed from a cross-sectional perspective; both inpatients and outpatients must be seen; chronic care must be guaranteed; different types of care processes must be coordinated; various care levels must be integrated; a plan for renewing and implementing technological resources must be in place; robust quality indicators must be developed; and teaching and research activities adapted to available resources must be implemented.

In Spain, the Quality of Care and Innovation Committee of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) is responsible for the accreditation of healthcare units, but that does not mean that the different departments meet the same quality standards. To date, evaluation of the quality of care, teaching and research in respiratory medicine departments has not been addressed, and the indicators that should be used for this purpose remain undefined.

In the context of the organizational changes demanded by the COVID-19 crisis, we propose a new respiratory medicine care circuit model for Spain, based on a strategy aimed at maximizing quality by using indicators that measure health, teaching, and research outcomes, thus giving the general access to information on the health outcomes achieved in their health area. To this end, tools (process mapping, care processes, scorecard, etc.) should be used to identify opportunities to improve clinical practice and decision-making in health management.

Current overview of health systems (how we want to be)

To implement such a proposal, all professionals with management responsibilities should be trained and equipped to lead their respective teams and organizations5 toward the required transformation of the system. We believe that to achieve this goal, we need 1) a health outcomes-oriented system, 2) capacity to create value and 3) new procedures for measuring and evaluating cost and outcomes.

The focus on health outcomes is here to say, and these outcomes must be achieved at the least complex level of care, thus combining two elements that are often neglected: efficacy and sustainability. To achieve this, we must take into account two critical factors: the culture change required by decision-makers (politicians, managers, and health professionals), and the definition of a clear strategy that can be applied in this setting.

In the current context of health, economic and social crises, doing a good job no longer suffices: we must maximise quality given that achieving good health outcomes is the fundamental mission of any health system. The approach should therefore be to generate not more volume (“do more”), but more quality (“do better”)6, because this concept cannot be dissociated from patient interests.

Some of the barriers we face in the current model are a sub-optimal evaluative culture, due to the use of a model that is poorly adapted to measuring outcomes, and a lack of coordination and clinical integration between levels. We must therefore be able to incorporate a system that facilitates the documentation and analysis of the outcomes of our departments in order to obtain data on success and costs. Follow-up would also help adapt care processes, improve the quality of care and reduce expenditure, as has already been observed in several areas of respiratory medicine7–10.

Management tools

One of the keys to the accreditation of respiratory medicine departments11 would be to determine health outcomes using pre-established quality-of-care indicators. To improve these outcomes, we must apply management tools that can help us achieve our goals.

Process mapping Process mapping is the graphical representation of the procedures implemented by a given organization12 (in this case, a respiratory medicine department). It consists of a diagram that contains strategic lines and care, operational and support processes; it provides a global view of the department and positions each factor in the value chain. This diagram should summarize all the processes and subprocesses of the department and how they interrelate (Fig. 1).

Figure 1.

Process mapping of a respiratory medicine department.

COPD: chronic obstructive pulmonary disease; HR: human resources; ICU: intensive care unit; ILD: interstitial lung disease; IT: information technology; OC: outpatient clinics; PC: primary care; PE: pulmonary embolism; SERGAS: Galician Health Service.


Strategic lines highlight the organization’s relationship with its setting and how decisions on planning and institutional improvements are made. They are often established by management and show how the organization operates and creates value for the patient and the healthcare system. They establish the general guidelines, directives, and intervention levels for each department. Each department must integrate its strategic plan with those of general management and the health system. Operational processes are directly linked to the delivery of services to the patient. Finally, support processes, despite not being directly linked to meeting user needs, are those that complement the operational mechanisms; without them, it would be impossible to achieve objectives. This includes, for example, IT support for all departments.

Healthcare processes Care processes systematically define how clinical practice should be, based on available scientific evidence. They integrate the care that is received at different levels and facilitate coordination among professionals, improving the continuity of care, and offering the patient integral care. These processes, therefore, help define care circuits by enabling access to health resources and avoiding delays in diagnostic confirmation or treatment13,14.

In a respiratory medicine department there are at least 6 healthcare processes that we could define as priority, given their high prevalence or their high impact or complexity: chronic obstructive pulmonary disease (COPD), bronchial asthma, lung cancer, diffuse interstitial lung disease (ILD), pulmonary embolism (PE), and sleep-disordered breathing. The aim of the care processes in these diseases would be reach a consensus in clinical practice to decrease clinical variability, to ensure continuity of care between levels, to improve control and health-related quality of life, to achieve early diagnoses with easy access to diagnostic techniques, to ensure early treatment and improve adherence, to reduce exacerbations, and to promote health education for patients and caregivers.

Fast track Fast-track care was developed by adapting certain documents used in quality management in industry (standard working procedures)15 in order to maximise the use of resources by completing tasks within a set time. A fast track can be defined as an outpatient care plan that is suitable for a group of patients with a certain disease and a predictable clinical course. Implementing this strategy reduces time of care and diagnosis, but does not necessarily lead to an improvement in survival, as observed in lung cancer16.

Its objectives are to reduce variability in clinical practice, assign responsibilities, provide legal support to professionals, speed up the organization’s registration processes, promote clinical research, improve quality of care, especially with regard to “adverse events” and “complications”, and adapt the available resources to the prevailing needs. A clinical pathway must be designed and developed according to certain criteria: the diseases treated must be common within the department/hospital, clearly defined, and must follow a predictable, largely consistent clinical course that allows for standardized care; it must be possible to reach a professional consensus in the department/hospital to help implement a multidisciplinary approach to the diseases; and the diseases must represent a significant risk to the patient and a significant cost to the institution. In our department, three fast tracks have been implemented: lung cancer, ILD (Fig. 2) and pleural effusions.

Figure 2.

Fast track model for diffuse interstitial lung diseases.

CHUS: University Hospital Complex of Santiago; EBUS: endobronchial ultrasonography; ECG: electrocardiogram; FB: fiberoptic bronchoscopy; HRCT: high-resolution computed tomography; ILD: diffuse interstitial lung disease; LFT: lung function tests; PA: pathological anatomy; RDL: radiology; Rheu: rheumatology; RM: respiratory medicine; Rx: radiography; ThS: thoracic surgery; VATS: video-assisted thoracoscopic surgery.


Remote visits Moving some processes to outpatient care (fast tracks), as well as the use of certain resources to reduce the number of admissions (one-stop clinics, day hospital, etc.), has led to a progressive increase in the number of respiratory medicine outpatient visits. This has led to the launch of remote consultations (e-consultation) in some hospitals, in which primary care physicians, after recording all relevant clinical information, seek advice from the pulmonologist17. The latter decides which patients might benefit from hospital care and which ones should continue in primary care, and specifies the action to be taken. The outcomes of this system have been excellent.18

E-consultations provide a number of benefits to patients (reduced waiting time compared to the traditional pathway; more agile care; prioritization of waiting times based on defined clinical criteria; access to specialist opinion while avoiding travel to other centers; simple procedures in case of referral; care delivered at the patients’ own health center; availability of a legible written report; primary care and hospital physicians working with the patient’s medical history and using the same clinical guidelines). Physicians also benefit, whether they work in primary care (receiving hospital reports with advice on follow-up and indications whether referral is required; fluid communication; training and continuing professional development), or in the hospital (receiving requests that include patient history, current episode, diagnosis, treatment, and reason for inter-departmental consultation according to the criteria of the clinical guidelines; access to laboratory results and reports; fluid communication via a data system with secure access and transmission). Fig. 3 shows the referral procedure from primary care to respiratory medicine in our hospital. The pulmonologist responds in less than three days. The estimate is that approximately 40% of patients will be able to continue in primary care, and the rest should be seen in the respiratory medicine department within a maximum of 3 weeks, after performing the basic tests (chest X-ray, spirometry or respiratory polygraphy) as required.

Figure 3.

General procedure for referral from primary care to respiratory outpatient clinics.

LFR: lung function tests; PCP: primary care physician; RM: respiratory medicine; RPG: respiratory polygraphy; Rx: chest X-ray.


Telemedicine One of the priority objectives in the treatment of patients with chronic respiratory conditions and advanced neuromuscular diseases, in addition to improving quality of life and life expectancy with the increasingly generalized use of ventilatory support19, is to try to maintain stability and avoid exacerbations. This is to avoid the increased risk of death in these situations and to reduce emergency visits, prevent readmissions20, decrease the demand for hospital beds for acute patients21, and reduce the cost of care.

In chronic diseases, it is very important to determine the health status of patients and to anticipate possible episodes of exacerbation of their underlying disease. Telemonitoring at home could undoubtedly help in this area (Fig. 4). So far, most experience is available in COPD, probably because it is both a chronic and a highly prevalent condition. The results of home telemonitoring in COPD patients are good, but exceptions have been reported. Some studies showed fewer hospital admissions and lower mortality during a 1-year follow-up22, a decrease in mortality or readmission rate at 12 months23, and a reduction in hospitalization rates and emergency visits, although no effect on mortality was observed24. However, other authors found no significant differences in these variables25.

Figure 4.

Architecture of home telemonitoring of patients from the hospital or health center.


Balanced scorecard The balanced scorecard is a document containing a set of previously established indicators that provide information on the attainment of the proposed objectives and targets - information that can also permit comparison with results obtained by other departments26. The application of this tool can serve as a stimulus to improve clinical management and encourage managers to use all kinds of resources to improve patient care27,28. This information can enable professionals to take on increasing leadership responsibilities and to take steps to improve outcomes in patient care29.

Proposal for the control of care quality

Measuring the quality of health care is, in our view, one of the best methods of implementing a protective health policy. What is not measured does not exist and therefore cannot be improved. We must therefore select indicators that, when regularly measured, help determine the quality and efficiency of our care activity, identify the opportunities for improvement in our departments, and compare our outcomes with those of the reference centers in our specialty. These indicators can also highlight any significant differences relative to the outcomes obtained in other areas, even those that have the same resources, allowing managers to immediately remedy shortcomings and identify unjustified duplication of tasks, and compelling us to implement integrated healthcare networks.

We propose below a series of indicators that will reflect the efficiency of our systems and, based on health outcomes obtained, will lead to the accreditation of respiratory medicine departments. Our proposal aims merely to stimulate reflection and discussion, and it must be the SEPAR Quality of Care and Innovation Committee, guided by external experts in the organization, evaluation, and audit of clinical management, who have the last word in selecting the indicators that best assess the quality of the healthcare provided within each health area.

Table 1 shows the proposed indicators, in absolute numbers and measurement intervals. It is intended for tertiary hospitals, but a more appropriate approach may be to express the numbers by proportions adapted to each organization to avoid placing departments with a smaller volume of patients at a disadvantage. We leave the final selection to the evaluation committee, who must also determine accreditation levels (e.g., 1, 2, and 3) based on the degree of compliance with the set of indicators agreed upon by the authors of this article and grouped according to the different care areas of a respiratory medicine department.

Table 1.

Proposed quality indicators for a respiratory medicine department.

Indicator  Standard  Measurement frequency   
Conventional hospitalization
Number of admissions  >1300  Quarterly 
Frequency (no. admissions/1000 inhabitants)  <6  Yearly 
Number of programmed admissions  <10%  Quarterly 
Mean stay  <9 days  Quarterly 
Readmissions within 8 days  <5%  Yearly 
Readmissions within 30 days  <10%  Yearly 
Death  <5%  Six monthly 
Complaint rate (no. complaints/no. admissions)  <1%  Yearly 
Intermediate respiratory care
Number of admissions  >200  Quarterly 
10  Mean stay  <7 days  Quarterly 
11  Death  <8%  Yearly 
12  Available standardized procedures/protocols adapted to the IRCU  Yes  Yearly 
13  Skin ulcers derived from interface use  <10%  Quarterly 
14  Pressure ulcers in patients receiving non-invasive ventilation  <10%  Quarterly 
Intensive respiratory care
15  Number of admissions  >100  Yearly 
16  Mean stay  <10 days  Yearly 
17  Death  <10%  Yearly 
18  Available standardized procedures/protocols adapted to the ICU  Yes  Yearly 
19  Pneumonia associated with invasive ventilation  <7 episodes/1000 days of ventilation  Quarterly 
20  Bacteremia associated with central venous catheter  <4 episodes/1000 days of central venous catheter  Quarterly 
General consultations
21  Number of annual e-consultations  >3500  Quarterly 
22  Average waiting time for e-consultation  <4 days  Quarterly 
23  Percentage of e-consultations referred to primary care  <30%  Quarterly 
24  Number of first face-to-face consultations per year  >2000  Quarterly 
25  Number of total consultations  >10,000  Quarterly 
26  Ratio successive/first  <4  Quarterly 
27  Mean waiting time for first face-to-face consultation  25 days  Quarterly 
28  Mean waiting time to first consultation (single visit)  15 days  Quarterly 
29  Complaint rate (no. complaints/total no. consultations)  <1.5%  Yearly 
Pulmonary embolism
30  Number of patients admitted to RM per year due to PET scan  >50  Yearly 
31  Mean annual hospital stay  <8 days  Yearly 
32  Existence of specific intervention protocols  Yes  Yearly 
33  Number of patients with PESI/simplified PESI  <75%  Yearly 
34  In-hospital deaths; n (%)  <10 %  Yearly 
35  Readmissions within 30 days  <8%  Yearly 
36  Number of new patients per year in outpatient visits  >50  Yearly 
37  Patients followed in specialist clinics  >75% admitted  Yearly 
38  Non-fatal major bleeding at 30 days  <4%  Yearly 
39  All-cause mortality at 30 days  <10%  Yearly 
Pulmonary hypertension
40  Accredited pulmonologist  Yes  Yearly 
41  Specialist clinic  Yes  Yearly 
42  Multidisciplinary hospital unit  Yes  Yearly 
43  Mean delay for first consultation  <21 days  Yearly 
44  Number of patients seen per year (new/total)  10/50  Yearly 
45  Availability of echocardiography  Yes  Yearly 
46  Availability of right heart catheterization  Yes  Yearly 
47  Availability of medication administration on an outpatient basis  Yes  Yearly 
48  Pulmonologist with accredited training in COPD  Yes  Yearly 
49  Number of patients admitted to RM per year for COPD  >350  Yearly 
50  Mean annual hospital stay  <9 days  Yearly 
51  Existence of specific intervention protocols  Yes  Yearly 
52  Specialist clinic  Yes  Yearly 
53  Number of patients seen per year (new/total)  >100/>1000  Yearly 
54  Availability of a nurse case manager (coordination with other units, management of procedures and appointments, etc.)  Yes  Yearly 
55  Possibility of urgent care in the Unit for an exacerbation  Yes  Yearly 
56  Availability of immediate spirometry  Yes  Yearly 
57  Availability of immediate chest X-ray  Yes  Yearly 
58  Number of patients seen per year  >500  Yearly 
59  Possibility of urgent care for an exacerbation  Yes  Yearly 
60  Number of exacerbations seen per year  >50  Yearly 
61  Multidisciplinary hospital unit  Yes  Yearly 
62  Specialist clinic for difficult-to-control asthma  Yes  Yearly 
63  Immediate spirometry  Yes  Yearly 
64  Nonspecific bronchial challenge test  Yes  Yearly 
65  Specific bronchial challenge test  Yes  Yearly 
66  Exhaled nitric oxide  Yes  Yearly 
67  Induced sputum with inflammatory cell count  Yes  Yearly 
68  Availability of skin prick test in the Unit  Yes  Yearly 
69  Administration of biologics for asthma in the Unit  Yes  Yearly 
Respiratory rehabilitation
70  Number of new patients per year  >75  Yearly 
71  Days between discharge and first consultation  <30 days  Yearly 
72  Admitted COPD patients referred to an RR program  >80%  Yearly 
73  Ability to treat exacerbations after RR session  Yes  Yearly 
74  Protocol for respiratory rehabilitation in COPD patients  Yes  Yearly 
Non-invasive ventilation at home
75  Accredited training in non-invasive ventilation  Yes  Yearly 
76  Home ventilation specialist clinic  Yes  Yearly 
77  Number of patients per year (new/total)  >0/>200  Yearly 
78  Possibility of urgent outpatient care  <15 days  Yearly 
79  Possibility of starting of home ventilation on an outpatient basis  Yes  Yearly 
80  Availability of home ventilation care protocols  Yes  Yearly 
81  Accredited training in smoking cessation  Yes  Yearly 
82  Number of patients per year (new/total)  ≥200/≥600  Yearly 
83  Number of co-oximetries per year  ≥600  Yearly 
84  Number of cotinine determinations  ≥40  Yearly 
85  Availability of nurse in the Unit  Yes  Yearly 
86  Availability of psychologist in the Unit  Yes  Yearly 
Oxygen therapy
87  Availability of nurse case manager for oxygen treatment cases  Yes  Yearly 
88  Patients with revision of oxygen therapy prescription after provisional prescription  >80%  Yearly 
89  Patients with oxygen titration at rest  >90%  Yearly 
Diffuse interstitial lung disease
90  Accredited training in diffuse ILD  Yes  Yearly 
91  Specialist clinic  Yes  Yearly 
92  Number of patients per year (new/total)  >40/>200  Yearly 
93  Number of bronchoalveolar lavages/transbronchial biopsies per year  >30  Yearly 
94  Number of cryobiopsies per year  >25  Yearly 
95  Number of VATS per year  >7  Yearly 
96  Availability of echocardiography  Yes  Yearly 
97  Availability of right heart catheterization  Yes  Yearly 
Bronchiectasis and cystic fibrosis
98  Accredited pulmonologist  Yes  Yearly 
99  Multidisciplinary CF unit in the hospital  Yes  Yearly 
100  Number of new patients per year (Bronchiectasis/CF)  >75/>10  Yearly 
101  Day hospital to treat exacerbations  Yes  Yearly 
102  Test of tolerance to antibiotics and hypertonic serum  Yes  Yearly 
103  Possibility of administering IV antibiotics in outpatient clinic  Yes  Yearly 
104  Ability to perform spirometry the same day  Yes  Yearly 
105  Physiotherapist  Yes  Yearly 
Sleep-disordered breathing
106  CEAMS-accredited sleep pulmonologist  Yes  Yearly 
107  Specialist clinic  Yes  Yearly 
108  Multidisciplinary sleep unit in the hospital  Yes  Yearly 
109  Number of polysomnographs per year  >150  Yearly 
110  Number of respiratory polygraphs per year  >300  Yearly 
111  Delay in non-urgent cases  <90 days  Yearly 
112  Delay in urgent cases  <15 days  Yearly 
113  Standardized education program  Yes  Yearly 
114  New CPAP indications per year  >25% of patients studied for suspected SAHS  Yearly 
115  Objective monitoring of hours of CPAP compliance  Yes  Yearly 
116  Time between performing the diagnostic test and starting CPAP  <60 days  Yearly 
117  Patients who use CPAP prescribed for SAHS at least 4 h of per day  >70%  Yearly 
118  Evaluation of PSI and CURB-65 on admission  >90%  Yearly 
119  Percentage of patients admitted with PSI I and II.  <10%  Yearly 
120  Time between arrival in the emergency room and starting antibiotic  <8 h  Yearly 
121  Blood cultures available in the first 72 h  100%  Yearly 
122  Existence of an antimicrobial use optimization program (AUOP) in the hospital  Yes  Yearly 
123  Sequential antibiotic therapy (switch to oral)  90%  Yearly 
124  Mean hospital stay  <7 days  Quarterly 
125  Specialist clinic  Yes  Yearly 
126  First outpatient consultation delay <72 h  90 %  Yearly 
127  Ability to quickly access clinic  ≤2 days  Yearly 
128  Multidisciplinary unit in the hospital  Yes  Yearly 
129  Specialist clinic  Yes  Yearly 
130  Number of new patients per year  >30  Yearly 
131  Rapid diagnostic capability (<3 h)  Yes  Yearly 
132  Nurse case manager  Yes  Yearly 
133  Accredited mycobacteria laboratory (bacilli, solid-liquid media cultures, MTB and some non-TB identification, MTB molecular tests, rapid molecular test for rifampicin resistance, antibiotic resistance testing for first-line drugs, genetic resistance tests)  Yes  Yearly 
Day hospital
134  Number of patients per year  >800  Yearly 
135  Ability to deliver outpatient treatment according to established protocols  Yes  Yearly 
136  Possibility of treating exacerbations in readmitted patients  Yes  Yearly 
137  On-demand telephone visits for patients included in the program     
Fast track lung cancer
138  Number of new patients per year  250  Six monthly 
139  Time to first consultation  <15 days  Six monthly 
140  Time to diagnosis (from first consultation)  <15 days  Six monthly 
141  Time to complete staging (from first consultation)  <25 days  Six monthly 
142  Multidisciplinary Tumor Committee  Weekly meeting  Yearly 
Fast track for diffuse interstitial lung disease
143  Number of patients/year (new/total)  50/200  Yearly 
144  Time to first consultation  2 weeks  Six monthly 
145  Waiting list time for cryobiopsy  <30 days  Six monthly 
146  Time to diagnosis  <45 days  Six monthly 
147  Diffuse ILD Committee Meeting  Monthly meeting  Yearly 
Fast track for pleural effusion
148  Number of patients/year (new/total)  >125/>400  Yearly 
149  Time to first consultation  ≤ 3 days  Yearly 
150  Interdepartmental consultation response time  ≤ 2 days  Yearly 
151  Time to diagnosis  ≤15 days  Yearly 
152  Pleura Committee Meeting  Monthly  Yearly 
Integrated care processes (developed at the hospital/AC) and implemented
153  COPD  Yes  Yearly 
154  Bronchial asthma  Yes  Yearly 
155  Lung cancer  Yes  Yearly 
156  Diffuse interstitial lung disease  Yes  Yearly 
157  Pulmonary thromboembolism  Yes  Yearly 
158  Sleep-disordered breathing  Yes  Yearly 
Bronchiectasis and cystic fibrosis
159  Accredited pulmonologist  Yes  Yearly 
160  Multidisciplinary CF unit in the hospital  Yes  Yearly 
161  Number of new patients per year (Bronchiectasis/CF)  >75/>10  Yearly 
162  Day hospital to treat exacerbations  Yes  Yearly 
163  Test of tolerance to antibiotics and hypertonic serum  Yes  Yearly 
164  Possibility of administering IV antibiotics in outpatient clinic  Yes  Yearly 
165  Ability to perform spirometry the same day  Yes  Yearly 
166  Physiotherapist  Yes  Yearly 
Palliative respiratory care
167  Structure of the composition of the interdisciplinary team  100%  Yearly 
168  Coordination protocol between hospitalization and home care in accordance with area resources  100%  Yearly 
169  Initial assessment of patient needs  100%  Yearly 
170  Define how to access the Unit in case of emergency  100%  Yearly 
171  The patient must have a defined drug treatment plan  >90%  Yearly 
Home care
172  Number of patients seen per year  >50  Yearly 
173  Number of home visits  1 a month  Quarterly 
174  Possibility of specialized emergency home care  Yes  Six monthly 
175  Possibility of urgent care in the department (non-emergency)  Yes  Six monthly 
176  The patient must have a defined drug treatment plan  >90%  Six monthly 
177  The unit must have written patient admission criteria  100%  Yearly 
Medical duty rosters
178  Respiratory medicine duty rosters  Yes  Yearly 
179  Medical area duty rosters with pulmonologist 24 h a day  Yes  Yearly 
Lung function tests
180  Number of forced spirometries per year  ≥2000  Yearly 
181  Number of diffusion tests per year  ≥500  Yearly 
182  Number of plethysomographies per year  ≥100  Yearly 
183  Number of FeNOs per year  ≥1000  Yearly 
184  Number of 6-minute walk tests per year  ≥200  Yearly 
185  Number of cardiopulmonary stress tests per year  ≥100  Yearly 
186  Number of nonspecific bronchial challenge tests per year  ≥100  Yearly 
187  Number of specific bronchial challenge tests per year  ≥20  Yearly 
188  Number of oscillometries per year  ≥20  Yearly 
189  Number of PIP/PEP determinations per year  ≥30  Yearly 
Bronchoscopy techniques
190  Number of flexible bronchoscopy procedures per year  ≥500  Yearly 
191  Number of ultrasound-guided bronchoscopy procedures per year  ≥200  Yearly 
192  Number of therapeutic endobronchial procedures per year  ≥10  Yearly 
193  Number of rigid bronchoscopies per year  ≥10  Yearly 
194  Number of cryobiopsies per year  ≥30  Yearly 
195  Written explanatory information on arrival  100%  Yearly 
196  Written information specific to the procedure to be performed  100%  Yearly 
197  Written instructions and recommendations  100%  Yearly 
198  Different rooms for different procedures  Yes  Yearly 
199  Lead-lined room  Yes  Yearly 
200  Operating room availability  Yes  Yearly 
201  Deaths  <0.05%  Yearly 
Pleural techniques
202  Number of diagnostic thoracenteses per year  ≥250  Yearly 
203  Number of therapeutic thoracenteses per year  ≥100  Yearly 
204  Number of closed pleural biopsies per year  ≥30  Yearly 
205  Number of chest drains per year  ≥50  Yearly 
206  Number of tunneled pleural catheters per year  ≥15  Yearly 
207  Number of pleurodesis with talc  ≥20  Yearly 
208  Number of transthoracic ultrasounds per year  ≥400  Yearly 
209  Number of annual medical pleuroscopies  ≥10  Yearly 
210  Written welcome information  Yes  Yearly 
211  Written information specific to the procedure to be performed  Yes  Yearly 
212  Written instructions and recommendations  Yes  Yearly 
213  Different rooms for different procedures  Yes  Yearly 
214  Operating room availability  Yes  Yearly 
215  Deaths  <0.05%  Yearly 
Lung transplantation
216  Lung transplant in the hospital  Yes  Yearly 
Teaching indicators
217  Resident training  Yes  Yearly 
218  Undergraduate clinical internships  Yes  Yearly 
219  Satisfaction surveys for internship students  Yes  Yearly 
220  Development of health protocols for patients, caregivers, etc.  Yes  Yearly 
221  Pulmonologists with SEPAR membership-professional development certification  ≥2  Yearly 
222  Medical doctors in the department  ≥4  Yearly 
223  Post-graduate courses  Yes  Yearly 
224  Annual doctoral thesis management (5 years)  ≥2  Yearly 
225  Associate lecturers in the department  ≥1  Yearly 
226  Department pulmonologists accredited as associate lecturer, doctor, permanent lecturer or professor  ≥2  Yearly 
227  Permanent lecturers in the department  ≥1  Yearly 
228  Professors in the department  ≥1  Yearly 
Research indicators
229  Communications at national/international conferences  ≥30  5 years 
230  Scientific publications in journals with IF  ≥30  5 years 
231  Competitive research projects  ≥3  5 years 
232  Participation in networks (PII, CIBERES)  Yes  5 years 
233  Research contracts  ≥1  5 years 
234  Clinical trials  ≥5  5 years 
235  Technological innovation/patents  ≥1  5 years 

AC: autonomous community; CEAMS: Spanish Committee for Accreditation of Sleep Medicine; CF: cystic fibrosis; CIBERES: biomedical research network in respiratory diseases; COPD: chronic obstructive pulmonary disease; CPAP: continuous positive airway pressure; CURB-65: confusion, urea, respiratory rate, blood pressure and age (>65 years); FeNO: exhaled fraction of nitric oxide; IF: impact factor; ICU: intensive care unit; ILD: interstitial lung disease; IRCU: intermediate respiratory care unit; MTB: Mycobacterium tuberculosis; PE: pulmonary embolism; PESI: Pulmonary Embolism Severity Index; PIP/PEP: Peak inspiratory and expiratory pressure; PSI: Pneumonia Severity Index; RM: respiratory medicine; RR: respiratory rehabilitation; SAHS: sleep apnea-hypopnea syndrome; SEPAR: Spanish Society of Pulmonology and Thoracic Surgery; TB: tuberculosis; VATS: video-assisted thoracoscopic surgery.


Respiratory medicine departments should also be evaluated from a teaching perspective, since, under the provisions of article 104 of the General Health Law, “the entire healthcare structure of the health system must be at the disposal of undergraduate and post-graduate teaching and continuing professional development”.

The areas that the authors of this article believe should be evaluated include the participation of respiratory medicine departments in the training of medical students; teaching clinical internships throughout different courses (undergraduate teaching); National Commission of Teaching accreditation of the training of specialists in respiratory medicine (postgraduate teaching); the number of annual doctoral theses directed (continuing training); and the number of associate lecturers, permanent lecturers and professors in each department. This, of course, is a proposal and, as mentioned above, it must be SEPAR and the evaluation committee who decide on the criteria to be included. In this regard, the European HERMES initiative seeks to ensure that all respiratory medicine training networks have the opportunity to obtain accredited certification for their educational programs30.


Research in a respiratory medicine department must be recognized as an essential part of professional development, as it clearly contributes to improving the quality of care provided not only by the pulmonologist, but also the department and the hospital. This is because research generates new knowledge, promotes continuing training and professional stimulus, can attract new economic resources, and contributes to improving the image of the institution and, consequently, to the pride of belonging to a prestigious center31. To perform research, we pulmonologists should subscribe to networking structures, such as SEPAR projects or the CIBER centers for biomedical research for respiratory diseases of the Instituto de Salud Carlos III. It is also important for hospitals to have the backing of a health research foundation, ideally with university support, that promotes research, and for the different research units of the hospital, health institutions and university to coordinate their efforts and encourage research careers. Furthermore, foundations can work together to improve their competitive edge when bidding for publicly funded research grants, and to reduce the cost of projects by making their structure or their own funds available to researchers and by making the necessary investments (Fig. 5).

Figure 5.

Research in a respiratory medicine department supported by the hospital, university, foundation, research consortium (Campus Vida) and networking structures (CIBERES and PIIs).

Fidis: Health Research Foundation Institute of Santiago de Compostela; USC: Universidad de Santiago de Compostela.


Society’s demand for high-quality health services and the right to know the health outcomes of its health area will continue to grow. All departments will be required to objectively demonstrate their competences, and, as such, will most likely have to be globally accredited. At present, one of the weaknesses of the health system is its failure to monitor existing indicators, thus generating unacceptable variability in our clinical practice. The demands of society may prompt the health system to respond to the need to measure outcomes using quality-of-care indicators, improve clinical management, and encourage professionals to strengthen their leadership roles.


This paper has not received any funding.

Conflict of interests

The authors state that they have no conflict of interests.

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Please cite this article as: Álvarez- Dobaño JM, Atienza G, Zamarrón C, Toubes ME, Ferreiro L, Riveiro V, et al. Resultados de salud: hacia la acreditación de los servicios de neumología. Arch Bronconeumol. 2021;57:637–647.

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