European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Spain

7.6 Health care quality and safety

The SNS draws on a long tradition in development and implementation quality and safety initiatives. Many of the current lines of work can be regarded as stemming from the 2010 Quality Plan, notably the 10 national health strategies focused on the most relevant health problems (MSSSI, 2017i), the extension of GuíaSalud (the national network for development and implementation of clinical guidelines) (GuíaSalud, 2017), the development of the National Strategy for Patient Safety (MSSSI, 2016d), the aforementioned Scientific Societies Commitment for SNS Quality (MSSSI, 2017o) or the National Plan for Antibiotic Resistance (AEMPS, 2014b).

Despite the efforts in raising awareness and creating a culture of quality and safety, the outcomes are debatable. Except in the case of in-hospital mortality after acute myocardial infarction, after coronary revascularization (percutaneous coronary intervention plus coronary artery bypass graft) and after fracture repair showing an average decline, the remaining indicators either hold or increase, particularly in the case of safety events (a registration bias may be still possible in this case). Finally, readmissions follow the same pattern: except in readmission after an acute myocardial infarction episode, those readmissions after surgery, psychiatric acute admissions and asthma do not show any particular trend (Table7.1).

However, the massive variation in quality and safety across hospitals is more concerning. Recent figures show that, for example, in thromboembolism and deep vein thrombosis after surgery, there is a 1.9-fold variation across hospitals, in-hospital mortality after coronary artery bypass graft varies 2.2 times and in-hospital mortality after percutaneous coronary intervention exhibits a 3.5-fold variation.31 The impact that low quality might have on excess costs is worth highlighting – a study showed that thromboembolism after surgery increased average length of stay by 1.74 days (Comendeiro-Mälloe et al., 2015).

When it comes to the use of appropriate treatments in nosocomial infection, the ENVIN-UCI study (SEMICYUC, 2016) revealed that in intensive care units in 2016, 14.4% of patients with pneumonia associated with mechanical ventilation and 18.8% of patients with bacteraemia associated with catheter did not receive the appropriate antibiotic, clearly worsening the 2011 findings (5.9 and 6.8 of inappropriateness, respectively).

Lastly, the rates of potentially avoidable hospitalizations for chronic conditions, also a proxy measure on how appropriately the whole system manages chronic care patients, showed an ambivalent trend between 2009 and 2013. While chronic obstructive pulmonary disease and short-term complications of diabetes were observed to decrease (from 254.1 admissions per 100 000 inhabitants to 194 per 100 000 inhabitants in 2013 in the former, and from 64.4 admissions per 100 000 inhabitants to 52.3 admissions per 100 000 inhabitants in the latter), potentially avoidable hospitalizations in congestive heart failure increased (from 191.7 admissions per 100 000 inhabitants to 206 admissions per 100 000 inhabitants) and pulmonary arterial hypertension in asthma remained stable, with 42 admissions per 100 000 inhabitants (OECD, 2017e).

Patients’ view

Every year, the Healthcare Barometer provides a view on patients’ satisfaction with the SNS. In 2016, most declared having received good or very good care – 85.8% in primary care and hospital care, 79.5% in specialized outpatient settings and 75.8% in emergency departments. However, if they had to choose, numbers are more ambiguous: 69.6% would use the public primary health care services, 68.1% would go to public hospital settings, 57% would visit public specialized premises, and 66.4% would go to public emergency departments. Most respondents declare that the system has neither improved nor worsened between 2011 and 2016; however, the number of individuals that think that the system has worsened reached 21.2% when referring to primary health care, 28.7% when referring to specialized outpatient care and 27.3% when referring to hospital care. This is consistent with the assessment that respondents gave to waiting times: 5.7 (out of 10) in the case of diagnostic tests referred from primary health care, 5 for the first visit to specialists and 4.8 in the case of waiting times for surgery. 30% of women and 25% of men think that the SNS needs profound reforms. Nevertheless, the overall satisfaction has not shown any change since 2006, not even in the worst years of the economic crisis (MSSSI, 2016k).

31 Own source (2017): Ad hoc estimation with data from the Atlas of Variation in Medical Practice in the Spanish SNS (

The 2017 Health Barometer analysing citizens’ satisfaction with the Spanish National Health System (SNS) was recently released.
Citizens gave the SNS an overall score of 6.7 (out of ten), maintaining the improving trend since 2003, when the score was 6.05. Primary care obtained a score of 7.3 and both hospital and outpatient specialized care, a score of 6.8. When asked about health services utilisation, most of respondents declared having received good or very good care: 87% in primary and hospital care, 83.5% in specialized outpatient settings and 78% in emergency departments.

Nonetheless, 26.2% of respondents declared that the SNS would require in-depth reforms. Moreover, when choosing between public or private providers, 68% would use public primary care, 67% would go to public hospitals, 65% would go to public emergency departments and only 55% would visit public specialized settings.
Notably, waiting lists remain the main concern for citizens, with 29% observing a worsening in the last year; in fact, the percentage waiting up to two months for an appointment in specialised care reached 20% in 2017.

More information (in Spanish):

The Ministry of Health is hosting three programmes within the National Strategy for Patient Safety, which aim to reduce infections in Intensive Care Units. The three projects - Bacteraemia Zero, Pneumonia Zero and Antibiotic Resistance Zero - are being led by the working group of infectious diseases and sepsis from the Spanish Society of Intensive Care and Coronary Care Units (SEMICYUC), in collaboration with all the regional health departments.

The ZERO infection projects are founded on the local implementation of strong evidence-based recommendations in virtually all public hospitals in Spain. The latest assessment report, released last week, exhibits 50% reduction of bacteraemia and pneumonia rates and 20% decrease in the rate of patients infected with multidrug resistant bacteria during their admission in intensive care units.

Noticeably, the implementation of these programmes has been observed to increase the awareness of the ‘safety culture’, boosting the coordination and communication across health care professionals.

More information (in Spanish):