Firstly, two focus groups were held, one with patients with PsA and the other with specialists (not rheumatologists, specifically: PC physicians, dermatologists, endocrinologists, cardiologists and nephrologists) involved in the care of these patients. They addressed the entire care process of patients with PsA in the Spanish healthcare system, from the onset of symptoms to treatment and follow-up. A typological box was created to identify the profiles of the participating patients that would guarantee their representativeness (associated and non-associated, different age groups, sex, with short and long disease courses). In the same way, another typological group specific to the specialists was created (different ages, sex and referral hospitals). A specific discussion map was drawn up for both groups, defining a series of priorities (the aspects of care that are especially important), as well as the barriers and facilitators that we face to provide maximum quality care. The participation of both patients and specialists from these focus groups in the QUANTUM Project was limited to this activity. The results of the focus groups were then considered by the experts(see below).

Subsequently, a literature review was undertaken that involved a search for documents in the area of care quality, such as consensuses,26 clinical practice guidelines and related projects, such as the international QUANTUM,27 2E,25 NEXUS,28 and ONLY TOOLS projects.29 The aim of this review was to compile quality indicators and standards relating to the management of patients with PsA. Medline was consulted from its creation to January 2017 using Mesh terms such as [Quality of Health Care], free-text terms, and the Clinical Queries tool was used.

All the information gathered in the previous sections (focus groups and literature review) was presented and discussed in a nominal group meeting, where a total of 15 experts consensually generated a series of quality criteria and formulae or quantifiable objective measures to be assessed. These criteria covered the entire care process of patients with PsA, from onset of symptoms to long-term monitoring, and other related elements, such as post-graduate training. They were grouped into 4 categories according to several general objectives: (1) shortening the time until diagnosis; (2) optimising management of the disease; (3) promoting multidisciplinary collaboration, and (4) improving monitoring. After that, using a Delphi method, the feasibility and priority of the quality criteria generated were analysed along with the level of agreement with them

With the collaboration of the Ad Qualitatem Foundation, experts in quality audits, the quality criteria were reformulated as quality standards to conform to one standard. A quality standard is a document established by consensus and approved by a recognised body (national or international), which provides for common and repeated use a set of rules, guidelines and characteristics for quality activities or their results, in order to achieve an optimal degree of order in the context of quality.

All these quality standards were developed with a common structure that includes: the requirement to be met, the justification for its selection, the quality standard indicator, the target level to be reached, evidence of compliance, a field of clarifications and the type of standard, which could be a mandatory compliance standard (essential requirement if a hospital later wishes certification) or non-compulsory (see results section). Standards with great impact on the quality of care of patients with PsA are considered compulsory, and that, in the opinion of the experts are “indispensable”.

All this was circulated among the 15 experts for their final comments and approval.

A descriptive analysis of the standard's quality standards was undertaken.

Six quality standards were included in this block (Table 1)—none of them mandatory—aimed at facilitating a reduction in time until diagnosis of PsA. They refer to the coordination and collaboration with PC, for example, by developing advisory or consultancy services in the health centres, with rotations of family residents and PC physicians in the area of rheumatology or other training activities. They also refer to 2 relevant processes towards facilitating an early diagnosis in the dermatology services, namely the implementation of screening protocols and protocols for referral to rheumatology if there is a suspicion of PsA.

In terms of possible accreditation, various documents will be consulted to assess whether the quality standards are being met, such as appointment records, service reports and other clinical and administrative records.

Twenty-six quality standards were generated (Table 2), 7 of mandatory compliance to optimise management of PsA, some relating to the resources that influence delivery of the service of both infrastructures and human resources, training of professionals, and patient information and care protocols.

As we mentioned earlier, part of these standards refers to the structure of the centre and the service, both in terms of materials, provision and their characteristics as human resources. In this regard, we highlight that a specific quality standard was generated on nursing which is of mandatory compliance and according to which the centre must have a nursing clinic with the necessary time and materials. With regard to provision, it is suggested, for example, that the clinic providing care for patients with PsA must have (or have access to) a computer, microscope, access to ultrasound or MRI, and that the centre's pharmacy catalogue must keep all the therapeutic targets authorised for PsA accessible at all times.

In relation to staff training, we must highlight that this standard includes a mandatory compliance standard that the services must participate in and develop exclusive and continuous activities in PsA (and continuous training programmes on PsA). Another will state that there must be a team specifically dedicated to the locomotor apparatus in the radiology departments where patients with PsA are treated, although this is not mandatory.

Neither are several of the quality standards mandatory that refer to the provision of care protocols for patients with PsA, to the information given to patients, to continuity of care (that patients are always assessed by the same rheumatologist) or to the minimum assessment times for first and subsequent consultations.

Furthermore, these two mandatory compliance standards indicate that the patient's medical record should contain certain information, from the date of diagnosis or the specific form of the condition to their family history, smoking habit, and the presence of comorbidities. In addition, periodic updating is required of treatment at the time of the consultation. Likewise, another 3 mandatory standards were generated that indicate that for patients with PsA, serologies for hepatitis B and C viruses should be recorded on diagnosis and when treatment is initiated, X-rays of hands/feet, pelvis, thorax and symptomatic joints should be taken, and specifically, in patients with peripheral PsA, the rheumatoid factor should be recorded on diagnosis.

The medical records will often be reviewed to check compliance with these quality standards. Other sources will be the records of the service and of the hospital, and various directories.

The level of exigency when checking compliance with the quality standard varied greatly depending on the standard; one was 50%, another was 100%, but several were 70%-80%, or were yes/no in type.

The quality standards that refer principally to the coordination and collaboration of rheumatology and dermatology services (other services as well, such as preventive medicine) were included in this block. There is a total of 9 (Table 3), 2 of which are mandatory in nature (if an accreditation is decided).

This multidisciplinary collaboration includes, for example, rotations of dermatology and rheumatology residents in rheumatology and dermatology services, respectively, during their training. Likewise, the development of joint workshops specific to PsA and joint clinical sessions is assessed (the latter form part of one of the mandatory quality standards). The other mandatory standard states that 2 specialists must collaborate in patient assessment and follow-up. Other forms of multidisciplinary collaboration include creating joint protocols on the biological therapies and the participation of both services in a common research project.

Finally, it should be noted that a quality standard has been included which will assess duplicated (unnecessary and unjustified) tests performed on patients.

Again, different sources can be consulted to assess compliance with the standards, such as clinical and administrative records, or the departments’ annual reports.

Eighteen quality standards were generated on monitoring patients with PsA (Table 4). Others were established relating to the number of publications, participation in clinical trials and patient satisfaction.

Several of these standards mean that data referring to patient assessment must be recorded in the clinical history, some with specific timing, both in dermatology and rheumatology. Quality standards, for example, are included in the general examination, skin or nail examination and locomotor apparatus symptom screening to be performed in the dermatology service, and the axial and peripheral examination for the rheumatologists (rheumatological examination is considered obligatory). Also included in this block are other actions that must be completed to improve patient monitoring, such as complementary tests (laboratory and radiological) and the use of questionnaires to evaluate pain, patient function and quality of life. It should be noted that a specific standard was generated for cardiovascular risk assessment. Half of the standards in this section were considered of mandatory compliance.

Moreover, in this block we selected 2 quality standards to evaluate the service's research activity. This measurement will be justified by a number of publications, articles in national journals, communications, posters at conferences and completed theses, as well as participation in clinical trials and PsA registers. In addition, there is a specific standard to assess patient satisfaction with the care received.

In most cases the medical records will be reviewed to evaluate compliance with these quality standards. Other sources will be the department's report and the literature search engines to establish the diffusion of the department's research papers. We highlight in this point the development and deployment of patient satisfaction surveys.

Finally, the level of exigency when considering a quality standard met will depend on the standard, but many require 70%–80% compliance.