Repetitive Transcranial Magnetic Stimulation in Stroke: A Literature Review of the Current Role and Controversies of Neurorehabilitation Through Electromagnetic Pulses.

Repetitive transcranial magnetic stimulation (rTMS) is an effective method used for the treatment of various neurological diseases, including stroke, epilepsy, and movement disorders. The pathophysiological mechanism for the effect of TMS is not clear. In this literature review, we conducted a detailed search regarding the effect of rTMS on neurotransmission and neuronal plasticity through the modulation of neuronal excitability. Evidence suggests that intramolecular subatomic mechanisms, including genetic changes related to neuronal prevention and death, play an important role. We also discuss the use of rTMS in the rehabilitation of patients with stroke and its main complications, as well as alternative mechanisms related to recovery, emphasizing the findings of available evidence and touching on possible controversies and limitations of the method.

[Design, implementation and evaluation of a management model of patient safety in hospitals in Catalonia, Spain]. / Diseño, implantación y evaluación de un modelo de gestión de la seguridad del paciente en hospitales de Cataluña.

Since its inception in 2006, the Alliance for Patient Safety in Catalonia has played a major role in promoting and shaping a series of projects related to the strategy of the Ministry of Health, Social Services and Equality, for improving patient safety. One such project was the creation of functional units or committees of safety in hospitals in order to facilitate the management of patient safety. The strategy has been implemented in hospitals in Catalonia which were selected based on criteria of representativeness. The intervention was based on two lines of action, one to develop the model framework and the other for its development. Firstly the strategy for safety management based on EFQM (European Foundation for Quality Management) was defined with the development of standards, targets and indicators to implement security while the second part involved the introduction of tools, methodologies and knowledge to the management support of patient safety and risk prevention. The project was developed in four hospital areas considered higher risk, each assuming six goals for safety management. Some of these targets such as the security control panel or system of adverse event reporting were shared. 23 hospitals joined the project in Catalonia. Despite the different situations in each centre, high compliance was achieved in the development of the objectives. In each of the participating areas the security control panel was developed. Stable structures for safety management were established or strengthened. Training in patient safety played and important role, 1415 professionals participated. Through these kind of projects not only have been introduced programs of proven effectiveness in reducing risks, but they also provide to the facilities a work system that allows autonomy in diagnosis and analysis of the different risk situations or centre specific safety issues.

Diseño, implantación y evaluación de un modelo de gestión de la seguridad del paciente en hospitales de Cataluña / Design, implementation and evaluation of a management model of patient safety in hospitals in Catalonia, Spain

Desde su creación en 2006, la Alianza para la Seguridad del Paciente ha tenido en Cataluña un papel muy destacado para impulsar y dar forma a una serie de proyectos relacionados con la estrategia del Ministerio de Sanidad, Servicios Sociales e Igualdad para la mejora de la seguridad del paciente. Uno de estos ha sido el proyecto de creación de unidades funcionales o comisiones de seguridad en los hospitales con el objetivo de facilitar la gestión de la seguridad del paciente. La estrategia se planteó en un determinado número de hospitales de Cataluña seleccionados en función de criterios de representatividad. La intervención se basó en 2 líneas de actuación: una, para enmarcar el modelo y otra, para su desarrollo. En el primer caso se definió la estrategia de gestión de la seguridad basada en el modelo EFQM (European Foundation for Quality Management) con la elaboración de estándares, objetivos e indicadores de seguridad que se proponía implementar, mientras que la segunda línea supuso la introducción de herramientas, metodologías y conocimientos como soporte a la gestión de la seguridad del paciente y a la prevención de riesgos. El proyecto se desarrolló en las 4 áreas del hospital consideradas de mayor riesgo, asumiendo cada una de ellas 6 objetivos de gestión de la seguridad. Algunos de estos objetivos, como el cuadro de mando o el sistema de notificación de eventos adversos, fueron compartidos por las 4 áreas. Se adhirieron al proyecto 23 hospitales de Cataluña. A pesar de las diferentes situaciones de cada centro se alcanzó un alto cumplimiento en el desarrollo de los objetivos. Se elaboró el cuadro de mando de seguridad en cada una de las áreas participantes. Se crearon o reforzaron estructuras estables para la gestión de la seguridad. La formación en seguridad del paciente, que tuvo un papel prioritario, llegó a 1.415 profesionales. A través de este tipo de proyectos no solo se introducen y desarrollan programas de efectividad contrastada en la reducción de riesgos, sino que se dota a los centros de una sistemática de trabajo que les permite la autonomía en el diagnóstico y análisis de las diferentes situaciones de riesgo o problemas de seguridad propios de cada centro (AU)

Since its inception in 2006, the Alliance for Patient Safety in Catalonia has played a major role in promoting and shaping a series of projects related to the strategy of the Ministry of Health, Social Services and Equality, for improving patient safety. One such project was the creation of functional units or committees of safety in hospitals in order to facilitate the management of patient safety. The strategy has been implemented in hospitals in Catalonia which were selected based on criteria of representativeness. The intervention was based on two lines of action, one to develop the model framework and the other for its development. Firstly the strategy for safety management based on EFQM (European Foundation for Quality Management) was defined with the development of standards, targets and indicators to implement security while the second part involved the introduction of tools, methodologies and knowledge to the management support of patient safety and risk prevention. The project was developed in four hospital areas considered higher risk, each assuming six goals for safety management. Some of these targets such as the security control panel or system of adverse event reporting were shared. 23 hospitals joined the project in Catalonia. Despite the different situations in each centre, high compliance was achieved in the development of the objectives. In each of the participating areas the security control panel was developed. Stable structures for safety management were established or strengthened. Training in patient safety played and important role, 1415 professionals participated. Through these kind of projects not only have been introduced programs of proven effectiveness in reducing risks, but they also provide to the facilities a work system that allows autonomy in diagnosis and analysis of the different risk situations or centre specific safety issues (AU)

Indicadores de calidad asistencial de GESIDA para la atención de personas infectadas por el VIH/sida / No disponible

Los sistemas de garantía de calidad asistencial tienen una cierta tradición en España y mucho mayor en los países anglosajones, pero en el campo de la infección VIH es escasa su implantación. Aunque ello podía ser comprensible al inicio de la epidemia por la incertidumbre que rodeaba a la enfermedad, desde hace varios años existe suficiente solidez científica en muchos aspectos de su abordaje, concretada en numerosas guías de tratamiento y práctica clínica. Esto ha inducido a GESIDA a realizar los presentes indicadores de calidad asistencial para la atención de personas infectadas por el VIH/sida. Un comité de profesionales, con la asesoría del Instituto Universitario Avedis Donabedian, redactó un primer borrador, posteriormente evaluado por un equipo de asesores externos y expuesto en la página web de la Sociedad. Las sugerencias fueron en parte incorporadas al texto final, resultando un total de 66 indicadores (estructura: 5; proceso: 45; resultados: 16) en las siguientes áreas: Condiciones estructurales, Diagnóstico y evaluación, Seguimiento e intervenciones de prevención, Seguimiento de pacientes en tratamiento, Aspectos específicos en la mujer, Comorbilidades, Hospitalización, Índices de mortalidad, Formación e investigación. En cada indicador se especifican los apartados que garantizan su validez y fiabilidad: justificación, dimensión, fórmula, explicación de términos, población, tipo, fuente de datos, estándar y comentarios. Finalmente, se seleccionaron 22 indicadores considerados como relevantes y que GESIDA entiende que todas las unidades VIH deberían monitorizar para conocer en todo momento sus resultados en esos aspectos de la práctica asistencial y así poder introducir medidas de mejora

Spain has some tradition of quality assurance systems, although less than in Anglo-Saxon countries. However, there is scarce implantation of these systems in the field of HIV infection. While this scarcity could be explained by the uncertainty surrounding the disease at the beginning of the epidemic, for several years there has been solid scientific evidence on many features of the approach to this disease, established in the various treatment and clinical practice guidelines. Consequently, the AIDS Study Group [Grupo de Estudio del Sida (GESIDA)] designed the present quality of care indicators for persons with HIV/AIDS. The first draft was developed by a committee of health professionals, with the guidance of the Avedis Donebadian University Institute. This draft was then evaluated by a team of external reviewers and posted on the Web page of the Society's web page. Some of the suggestions were included in the final document, with 66 indicators (structure: 5, process: 45, results: 16) in the following areas: structural conditions, diagnosis and evaluation, follow-up and preventive interventions, follow-up of patients under treatment, specific aspects in women, comorbidities, hospitalization, mortality rates, training and research. In each indicator, the sections guaranteeing the indicators' validity and reliability are specified: justification of the indicator as a measure of quality, the healthcare dimension evaluated, mathematical formula, explanation of terms, population, type of indicator (structure, process result), data source, the standard to be achieved and commentaries on the validity of the indicator. Finally, 22 indicators deemed relevant were chosen. GESIDA believes that these indicators should be constantly monitored in all HIV units to identify their results at all times and thus be able to introduce improvement measures

[GESIDA quality care indicators for the care of persons infected by HIV/AIDS]. / Indicadores de calidad asistencial de GESIDA para la atención de personas infectadas por el VIH/sida.

Spain has some tradition of quality assurance systems, although less than in Anglo-Saxon countries. However, there is scarce implantation of these systems in the field of HIV infection. While this scarcity could be explained by the uncertainty surrounding the disease at the beginning of the epidemic, for several years there has been solid scientific evidence on many features of the approach to this disease, established in the various treatment and clinical practice guidelines. Consequently, the AIDS Study Group [Grupo de Estudio del Sida (GESIDA)] designed the present quality of care indicators for persons with HIV/AIDS. The first draft was developed by a committee of health professionals, with the guidance of the Avedis Donebadian University Institute. This draft was then evaluated by a team of external reviewers and posted on the Web page of the Society's web page. Some of the suggestions were included in the final document, with 66 indicators (structure: 5, process: 45, results: 16) in the following areas: structural conditions, diagnosis and evaluation, follow-up and preventive interventions, follow-up of patients under treatment, specific aspects in women, comorbidities, hospitalization, mortality rates, training and research. In each indicator, the sections guaranteeing the indicators' validity and reliability are specified: justification of the indicator as a measure of quality, the healthcare dimension evaluated, mathematical formula, explanation of terms, population, type of indicator (structure, process result), data source, the standard to be achieved and commentaries on the validity of the indicator. Finally, 22 indicators deemed relevant were chosen. GESIDA believes that these indicators should be constantly monitored in all HIV units to identify their results at all times and thus be able to introduce improvement measures.

[Clinical safety and patient oriented care: descriptive study of 113 Spanish hospitals and similarities in other European countries]. / Seguridad clínica y orientación al paciente: estudio descriptivo en 113 hospitales españoles y similitudes en otros países europeos.

OBJECTIVES: This study describes the stage of development of the Spanish acute care hospitals quality improvement systems. It also presents data on their achievement of some specific requirements related to clinical safety and patient oriented care. Additional data from seven other European countries are included, in order to provide a comparative reference for the analysis of results. MATERIAL AND METHODS: Cross-sectional descriptive study developed in acute care hospitals with more than 100 beds from 8 European countries. Data was gathered using an on-line questionnaire that had more than 500 close questions. In order to validate the responses, a sample of the hospitals that had answered the questionnaire received an evaluation by external assessors. RESULTS: A total of 113 public and private Spanish hospitals participated in the study, which represented 34% of the total group that met the inclusion criteria. Another 276 hospitals from 7 other countries also answered the questionnaire. The results associated with quality management, clinical safety and patient oriented care from both groups are presented. CONCLUSIONS: Improvements must be made in those areas where Spanish hospitals have a lower developmental level than the rest of the participating countries: public dissemination of results from external quality assessments, development of some key mechanisms to promote clinical safety and patient involvement in organisational management.

Seguridad clínica y orientación al paciente: estudio descriptivo en 113 hospitales españoles y similitudes en otros países europeos / Clinical safety and patient oriented care: descriptive study of 113 Spanish hospitals and similarities in other european countries

Objetivos: Describir el grado de desarrollo del sistema de mejora de calidad de los hospitales de agudos en España y la medida en que dan respuesta a algunos requisitos específicos de seguridad y orientación al paciente. Se presentan también datos agregados de otros 7 países de la Unión Europea, con el fin de disponer de datos de referencia que ayuden al análisis de resultados. Material y métodos: Estudio transversal descriptivo llevado a cabo en hospitales de agudos de más de 100 camas de 8 países europeos. La recogida de datos se realizó mediante un cuestionario compuesto por más de 500 preguntas cerradas, autoaplicado a través de internet, que posteriormente validaron evaluadores externos en una muestra por conveniencia de los centros participantes. Resultados: Participaron en el estudio 113 hospitales españoles públicos y privados, lo que representa un 34% de los que cumplen los criterios de inclusión. Además, 276 hospitales de otros 7 países respondieron al cuestionario. Se presentan los resultados de ambos grupos respecto al sistema de gestión de calidad, la seguridad y la orientación al paciente. Conclusiones: Se recomienda trabajar en las principales áreas en que los hospitales españoles tienen un grado de desarrollo menor que el de los demás países participantes: el acceso público a los datos de evaluaciones externas de calidad, la implantación de algunos mecanismos clave para la seguridad del paciente y la implicación del paciente en la gestión de la organización (AU)

Objectives: This study describes the stage of development of the Spanish acute care hospitals quality improvement systems. It also presents data on their achievement of some specific requirements related to clinical safety and patient oriented care. Additional data from seven other European countries are included, in order to provide a comparative reference for the analysis of results. Material and methods: Cross-sectional descriptive study developed in acute care hospitals with more than 100 beds from 8 European countries. Data was gathered using an on-line questionnaire that had more than 500 close questions. In order to validate the responses, a sample of the hospitals that had answered the questionnaire received an evaluation by external assessors. Results: A total of 113 public and private Spanish hospitals participated in the study, which represented 34% of the total group that met the inclusion criteria. Another 276hospitals from 7 other countries also answered the questionnaire. The results associated with quality management, clinical safety and patient oriented care from both groups a represented. Conclusions: Improvements must be made in those areas where Spanish hospitals have a lower developmental level than the rest of the participating countries: public dissemination of results from external quality assessments, development of some key mechanisms to promote clinical safety and patient involvement in organisational management (AU)

Making performance indicators work: the experience of using consensus indicators for external assessment of health and social services at regional level in Spain.

OBJECTIVES: To describe a methodology and the results of projects combining consensus processes for indicator development with methods of external assessment of health and social services. METHODS: Our methodology can be characterized by a four-step approach: (1) stakeholder involvement and creating an enabling environment, (2) using standardized consensus methods for indicator development, (3) using rigorous external evaluation methods to assess results and (4) developing and implementing quality improvement initiatives. We describe each step in detail and discuss factors of success and pitfalls based on our experience of applying the methodology in 648 health/social centres and reviewing overall 68,616 case records. RESULTS: We observe in four sectors (assisted living, elderly health care, care for people with drug abuse problems, and care for abused woman) improvements in overall quality improvement rates, ranging from 9.5% to 65.6%. Improvements in overall rates are accompanied by reduction in range of up to 48.8. CONCLUSIONS: The conscientious setting up of an enabling environment and the systematic involvement of professionals in designing indicators and setting standards is a key to improving performance. Our research may entail lessons for policy makers on the current debate on pay for performance models.

[Study of the healthcare background and psychosocial environment of the Maghrebian immigrant population in Catalonia [Spain]]. / El marco sanitario y el entorno psicosocial de la población inmigrante magrebí en Cataluña.

INTRODUCTION: The aim of this study was to gather information on the healthcare background and social environment of the Maghrebian immigrant population in Catalonia in order to guide the management and provision of social services and the work of the organizations supporting this collective. METHODS: To gather data, we used a questionnaire exploring healthcare and social variables, including stressors and social support. Data collection was performed by pollsters in Arabic. RESULTS: We performed 403 interviews. Most interviewees had a health card providing access to public healthcare and knew where to access healthcare. The most frequently used services were primary care and emergency departments. In primary care, almost all of the interviewees were provided explanations, but 30% were unable to understand them properly. Health professionals seemed to have inadequate awareness of cultural and religious differences. Work, housing, distance from the family, and legal status were stressful factors for more than half of this population. Social support was low. Three quarters of the interviewees felt lonely. More than half of this population had completely or partially fulfilled their expectations of migration, while 11% felt they were in a worse situation. CONCLUSIONS: The main areas for improvement are the provision of information on conditions of healthcare access, promotion of social interaction, the use of associations for immigrants especially during the first phases of the migration process and facilitating religious activities. Health professionals should be provided with training in intercultural issues.

El marco sanitario y el entorno psicosocial de la población inmigrante magrebí en Cataluña / Study of the healthcare background and psychosocial environment of the Maghrebian immigrant population in Catalonia [Spain]

Introducción: Este estudio pretende obtener información sobreel marco sanitario y el entorno psicosocial de la población inmigrantemagrebí en Cataluña, para orientar las actuacionesen planificación y provisión de servicios sociales y de las organizacionesque apoyan a este colectivo.Método: Se utilizó un cuestionario de creación propia queexplora aspectos sanitarios y psicosociales, incluidos los factoresestresores y de apoyo social. La recogida de datos serealizó mediante encuestadores y en lengua árabe.Resultados: Se realizaron 403 entrevistas. La mayoría delos encuestados tenían tarjeta sanitaria y sabían a dónde acudirpara recibir asistencia. Los servicios más utilizados sonlos de atención primaria y urgencias hospitalarias. En atenciónprimaria, casi todos los encuestados reciben explicaciones,pero un 30% no las comprende adecuadamente. Se percibeque los profesionales sanitarios no tienen muy en cuenta lasdiferencias culturales o religiosas. Trabajo, vivienda, alejamientofamiliar y legalización son factores estresores para más de lamitad de esta población. El apoyo social es bajo. Tres cuartaspartes de los encuestados se sienten solos. Más de la mitadde esta población ve cumplidas total o parcialmente sus expectativasmigratorias y un 11% considera estar peor.Conclusiones: Las principales áreas de acción pasan por reforzarla información sobre condiciones de acceso al sistemasanitario, fomentar la interacción social y el asociacionismoentre los inmigrantes, especialmente durante las primeras fasesdel proceso migratorio, y facilitar las actividades religiosas. Pareceimportante formar a los profesionales sanitarios sobrelas culturas de origen(AU)

Introduction: The aim of this study was to gather informationon the healthcare background and social environment ofthe Maghrebian immigrant population in Catalonia in order toguide the management and provision of social services andthe work of the organizations supporting this collective.Methods: To gather data, we used a questionnaire exploringhealthcare and social variables, including stressors and socialsupport. Data collection was performed by pollsters in Arabic.Results: We performed 403 interviews. Most interviewees hada health card providing access to public healthcare and knewwhere to access healthcare. The most frequently used serviceswere primary care and emergency departments. In primarycare, almost all of the interviewees were provided explanations,but 30% were unable to understand them properly.Health professionals seemed to have inadequate awarenessof cultural and religious differences. Work, housing, distancefrom the family, and legal status were stressful factors for morethan half of this population. Social support was low. Three quartersof the interviewees felt lonely. More than half of this populationhad completely or partially fulfilled their expectationsof migration, while 11% felt they were in a worse situation.Conclusions: The main areas for improvement are the provisionof information on conditions of healthcare access, promotionof social interaction, the use of associations for immigrants—especially during the first phases of the migrationprocess— and facilitating religious activities. Health professionalsshould be provided with training in intercultural issues(AU)

Improving quality at the hospital psychiatric ward level through the use of the EFQM model.

OBJECTIVE: To describe the implementation of the European Foundation for Quality Management (EFQM) model as a quality framework for improving a psychiatric hospital ward. METHODOGY: Two self-assessments were conducted using the EFQM model. The self-assessment methods combined two approaches proposed by the EFQM: the award simulation approach and the questionnaire approach. Work groups were set up to improve the areas for improvement identified on the self-assessment. RESULTS: The EFQM was a useful framework for self-assessment at the ward level and a good system for identifying areas for improvement. Only one of the 32 sub-criteria did not apply at the ward level. The self-assessment score was 209 points in 2003 and 311 points 2 years later (an increase of 48.8% from the initial score). DISCUSSION: The main difficulties were ensuring that clinical personnel understood the EFQM model, the extra effort demanded by the initial phase and the lack of decision-making capacity in certain relevant areas. Adapting the self-assessment methodology to the specific context facilitated the process, as did a high level of involvement of the part of manager and staff. CONCLUSIONS: It is possible to implement the EFQM model at the hospital was level and it has a positive influence on staff communication and involvement. It is important, when working at this level, to adequately focus the scope of the project on improving quality in those areas where there is decision-making capacity.

A proposed adaptation of the EFQM fundamental concepts of excellence to health care based on the PATH framework.

OBJECTIVE: The use of the European Foundation for Quality Management (EFQM) Model in health care has found that this model is useful in promoting quality improvement, but its use in health care organizations is challenging because being a generic model, it does not cover the clinical aspects or the specifics of this field. For that reason, this article aims to bring the EFQM fundamental concepts of excellence closer to health care, using a specific model as a reference to this field: the Performance Assessment Tool for quality improvement in Hospitals (PATH) conceptual framework, developed by the WHO Regional Office for Europe. METHOD: A content analysis was performed to independently identify the contents that defined the elements of both frameworks. Then, using defined criteria, two independent researchers compared the contents of the elements of both frameworks. The elements from both frameworks that were equivalent were aggregated. Several experts discussed the aspects with discrepancies between the two comparisons. Finally, the EFQM framework is adapted to health care by adding to those aggregated elements the aspects that were exclusive from one of the models. RESULTS: The EFQM framework has many correspondences to a health care-specific framework. The EFQM-health care-adapted framework has eight quality dimensions, two of them (customer focus and safety) being overlapped with the other six (staff, results orientation, responsive governance, leadership and constancy of purpose, clinical effectiveness, and partnership development). This model also has two methodological dimensions (management by processes and facts and continuous learning; improvement and innovation). CONCLUSION: This adapted model seems useful for health care organizations, but it needs to be further used to corroborate this preliminary finding.

Derechos de los pacientes en los principales sistemas de acreditación hospitalaria / Patients’ rights in the main healthcare accreditation systems

Objetivo: Analizar cómo se abordan los derechos de los pacientes en los principales sistemas de acreditación del mundo. Material y método: Estudio de los principales sistemas de acreditación hospitalaria existentes, empleando una metodología cualitativa de análisis de textos. Los estándares de derechos de pacientes de los distintos sistemas de acreditación son agrupados según el tema que tratan. Se establecen 9 temas principales: Información al paciente, Intimidad, trato y apoyo emocional, Protección del paciente, Protección de la autonomía, Donación de órganos, Código de derechos del paciente, Expresión de quejas y reclamaciones, Ética de la organización y Nuevos derechos. Resultados: No todos los sistemas de acreditación estudiados incluyen un capítulo sobre derechos de los pacientes. A pesar de las diferencias observadas en la cobertura que los sistemas de acreditación dan a los derechos de los pacientes, tanto por la profundidad de su análisis como por los aspectos concretos que cubren los estándares, todos los sistemas de acreditación estudiados tratan este tema, aunque no sea en forma de un capítulo independiente. Conclusiones: En la revisión realizada se evidencia la creciente importancia del tema de los derechos de los pacientes en los sistemas de acreditación

Objective: To analyze how the world's main healthcare accreditation systems approach issues concerning patients' rights. Material and method: The main hospital accreditation systems were studied, using a qualitative methodology for text analysis. Patients' rights standards from several accreditation systems were grouped and organized on the basis of the subject they covered. Nine main subjects of study were established: patient information, privacy, care and emotional support, patient protection, protection of autonomy, organ donation, code of patients' rights, expression of complaints and legal claims, the organization's code of ethics, and new rights. Results: Not all the accreditation systems studied include a chapter on patients' rights. Despite the differences observed in the way accreditation systems cover issues concerning patients' rights, both in the depth of their analysis and in the specific aspects covered by the standards, all the accreditation systems studied cover this issue, although not always in an independent chapter. Conclusions: The review performed illustrates the growing importance of issues concerning patients' rights in accreditation systems

[Local evaluation of quality using generic measurement tools]. / La evaluación local de la calidad mediante instrumentos de medida genéricos.

Performance measurement and accountability are the most frequently encountered concepts across healthcare systems, although the tools used to put these concepts into practice vary. The aim of the present article was to discuss the tools (e.g., indicators) and user expectations (e.g., quality versus performance) of these tools in fulfilling healthcare's accountability mandate. In particular, the developments within the Spanish health system are discussed to illustrate how Spain has addressed, in a stepwise manner, the determinants of a national accountability model. Finally, a multinational project, The Maryland Quality Indicator Project, is presented as a popular framework for measuring performance.

La evaluación local de la calidad mediante instrumentos de medida genéricos / Local evaluation of quality using generic measurement tools

La medición de calidad y la responsabilidad son dos de los conceptos más utilizados en los sistemas sanitarios, aunque los instrumentos para poner en práctica estos conceptos varían. El objetivo de este artículo es analizar las herramientas (p. ej., los indicadores) y las expectativas de los usuarios de estas herramientas (p. ej., la calidad frente al rendimiento) al desempeñar el imperativo de responsabilidad en el sistema sanitario. Concretamente, presentamos la evolución del Sistema Sanitario Español en esta materia para analizar cómo se han ido constituyendo paso a paso los principios del modelo nacional de responsabilidad. Por último, se presenta un sistema internacional, el Maryland Quality Indicator Project®, como marco de referencia para la evaluación del rendimiento. (AU)