María Teresa Ramírez, director of the Separ Health Care Quality Committee.
Improve the quality of care for Pulmonology services in Spain it has become a priority that the Spanish Society of Pulmonology and Thoracic Surgery seeks to promote (Separ). Maria Theresa Ramirezdirector of the Commission for the Quality of Health Care, says in Medical writing that “the intent is to produce a white paper of the basics that a pulmonology service should have to help establish minimal references which every service in Spain should have. The best way I can think of is to make these minimum standardssince each autonomous community has its own own health management system and resources are not evenly distributed”.
The impossibility of codifying numerous new diseases within pulmonology assumes in Spain that many pathologies cannot be addressed so specifically. This reality is condemned by Ramírez, who says that “we do not have specific systems for the treatment of specific pathologies within the specialty, known as GRD. It is a worldwide problem, because we are now gathering patients with chronic obstructive pulmonary disease (COPD) in an elderly person suffering from pneumonia. Measuring our specific activities becomes impossible, and some treatments such as mechanical ventilation in hospitalized patients are still not coded and are classified as simple pneumonia”.
What is the accreditation of health units in Spain?
The accreditation of all those for whom Separ is responsible is in the period in which we reformulate the method of accreditation after the amendment of the regulations, and in January, with the changes we made, they will be reactivated and renewed again. , opening places for new units that want to be accredited. With the coronavirus, there was a reduction in activity in the monographic units, and this meant that we had a year of reserve for the reopening of accreditation places in 2023. We hope that there will be an increase in units that want to be accredited.
What are the problems with respiratory coding and how do you solve them?
Coding, as in almost everything, is based on a system, GRD, which is an international nomenclature in which pathologies are grouped based on the resource consumption they will involve. This implies that we may have placed a patient with chronic obstructive pulmonary disease (COPD) admitted with pneumonia and another with pneumonia in the same DRG. This is due to the fact that the consumption it carries with it is a way of grouping as a management system. This means that we do not have specific systems for specific pulmonary pathologies, so coding is practically impossible and measuring our very specific activity becomes impossible. This is not a problem only in Spain, but in the whole world. There are new diseases such as mechanical ventilation in hospitalized patients that are still not coded and are still classified as simple pneumonia.
How can the quality of care of pulmonology services in Spain be improved?
The most serious problems we have must be identified. It is not the same to work in Madrid with many nearby hospitals than maybe in one of Logroño, where the patient has to travel many kilometers. Depending on the territory, it is difficult to access resources. We need to have a precise map of the resources we have in Pulmonary Services, both human and material, and consider improvements thereon. Each autonomous community has its own health management system and resources are not evenly distributed. A few years ago, Separ tried to draw up a map of this situation in order to identify the differences as a starting point for each manager and hospital in defense of achieving the minimum. The intention of the Separ quality group is to prepare a white paper on the basics that all services must have in order to help establish the minimum references that every hospital in Spain should have. This is the best way to work out these minimum standards.
How do you collaborate with the Ministry of Health and the autonomous communities themselves to achieve these improvements?
From the quality group, we do not work directly with them, the group for institutional relations is in charge. When we have projects that may need this contact, we talk to them. Regarding mechanical ventilation, we strive to ensure that this activity establishes appointments to achieve DRG. After the society agrees to the request, its president is obliged to forward it to the Ministry and the autonomous communities for their acceptance. Without a doubt, this is the most complex part.
There are projects supported by Separ, such as lung cancer screening or the new anti-smoking plan, which are still awaiting approval from the Ministry of Health. How would these initiatives improve care for respiratory patients and professionals?
These projects would make it possible to impose recognition at the national level that this need exists. If no one tells them what our patient’s needs are, the projects will hardly start. The fact that these projects are run by a national society allows the Ministry of Health and Community to be looked at, because that is the only way to bring about change. If all pulmonologists are progressing along a common path, it is reasonable for the Ministry to make changes. It is our duty as specialists not to forget the patient and to put pressure on the institutions to improve. As far as experts are concerned, the fact that these initiatives are being implemented is a matter of satisfaction. Every project that everyone accepts, if implemented, allows us to do better.
Is it necessary to recruit more pulmonologists in the workforce in Spain?
Globally, yes. The coronavirus has punished us badly, leaving large groups of patients who had to be redeployed and who cannot be made to disappear. There is a lot of residual symptomatology that builds on what we already had. Globally, it is necessary to increase the templates. There will be a lot of retirements soon and it will be complicated in a specialty like ours, which takes 65 percent of emergency cases from December to June, and the demands of primary care will be unsustainable with the current templates.
What is the importance and impact of recertification of competences in pneumology for achieving a better quality of care?
More than recertification, it is still not clear from the ministry to establish specific competencies for each specialty. That is a topic for discussion. It is vitally important that the complexity of medicine increasingly requires more subspecialties. A way must be found so that, after the residency period is over, there are minimums or training that is maintained through recertification courses. It serves solely to ensure that you maintain your training and education. More than recertification, the first thing that needs to be done is certification, since we do not certify in pulmonology and in almost no specialty. The level of complexity demands it.
One of the commission’s functions is to advise on professional issues and defend partners in competition problems that may arise with other specialties. Were there any problems in this last phase?
At the time I was in Separ, I did not know that we had received any complaint about the intrusion. The human body is not divided into closed parts, there can be friction and conflict with other specialties.
How to achieve consensus regarding care activities and clinical management within pulmonology?
Each community and hospital is a world and has some resources. Level 3 hospitals have more resources, and as they go down they get smaller. There is no global study where one can know the percentage to know if decision making creates more efficiency for the patient. HRM is more powerful at the third level than at the first level, making it more difficult to deal with. It turned out to be an unknown specialty with a potential in the treatment of respiratory pathology that no other specialty has, as evidenced by the coronavirus.
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