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Quality in Health Care 2001;10:111–116 111

Quality improvement around the world

Accreditation and the quality movement in France


A Giraud

Background management of French hospitals and the qual-


As in many industrialised countries, the health ity of healthcare services. We will therefore
care quality movement began in France limit ourselves to the description of the
because of rising health expenditure and the accreditation policy in France, evaluate its
necessity to contain costs1 but, recently, the similarities and diVerences with other accredi-
public has become more aware of issues tation programmes, and try to estimate its
relating to quality. Serious public health prob- chances of success.
lems such as the contaminated blood scandal
of 1984, when blood that was strongly
suspected of being contaminated by HIV was Key messages
knowingly transfused to haemophiliac patients, + Accreditation in France is a government
and greater visibility of routine medical prac- sponsored initiative.
tice through regular publications in the lay + In France accreditation is compulsory,
press2 has led to a crisis of public confidence in patient centred, and orientated to con-
the ethics of the medical and political worlds tinuous quality improvement.
and a strong demand for accountability and
greater transparency. Important reforms in the
organisation of health care and public health The policy
have therefore been undertaken, of which The instruments of accreditation in France
accreditation is one. Its objectives reflect this consist of an agency, a manual, and surveyors.
historical background—namely, “to assess the
quality and safety of health care, to assess a health THE ACCREDITATION AGENCY
care organisation’s ability to ensure continuous In order to implement accreditation the 1996
improvement in the quality of overall patient care, ordonnance created what it defined as “an inde-
to formulate explicit recommendations, to involve pendent and professional organisation”, a
professionals at all stages of the quality initiatives, national agency for accreditation and evalua-
to provide external recognition of the quality of care tion in health care, the Agence Nationale pour
in health care organisations, to improve public con- l’Accréditation et l’Evaluation en Santé
fidence”.3 (ANAES). The mission of the new agency is
Accreditation was enacted in France as part “to help develop quality assurance of medical prac-
of the 1996 health care reform by ordonnance, a tice, in public and private hospitals as well as in
government decision that is taken without con- private practice, and to implement the accreditation
sulting Parliament. Governments in France procedure” so that it manages both quality
under the Fifth Republic use ordonnances when assurance and accreditation.5 ANAES consists
they feel there is an urgent need for reform that of a Board, a Scientific Council, and an
could be delayed by parliamentary discussions. Accreditation College and is headed by a Gen-
Many healthcare reforms have been enacted by eral Director. Its members are appointed by the
ordonnance and, in 1996, it was felt that the Minister of Health and it is financed one third
magnitude of the deficit of the national health by the Department of Health, one third by the
insurance fund and the public health situation National Health Insurance fund, and the
was suYciently serious. The ordonnance of 24 remainder by the survey fees of the hospitals. A
April 1996 reforming public and private hospi- notable feature of ANAES is the importance of
talisation stipulates that “in order to ensure con- professional representation: the health profes-
tinuous quality and safety improvement of health sions comprise at least three quarters of the
care, all public and private health care organisa- board and more than half are medical doctors.
tions must submit to an external evaluation proce- The present Chairman of the Board is a
Hôpital Jean Verdier,
Assistance dure named accreditation” (Article 710–5). professor of neurology and the General Direc-
Publique-Hôpitaux de Accreditation applies to public and private tor of the agency is a professor of public health.
Paris, 93140 Bondy, hospitals and healthcare networks but does not Members of the Scientific Council are experts
France include general practice. However, in time the in the areas of quality assurance and accredita-
A Giraud, head of public fields of application for accreditation are likely tion, and/or belong to medical or other
health medical information to be extended.4 scientific societies. The Council is presided
Correspondence to: Accreditation is new in France so we are not over by a professor of intensive care and is
Dr A Giraud yet able to describe the implementation of the responsible for the scientific quality of all
alexandra.giraud@jvr. programme, the uses that will be made of the guidelines and other documents produced by
ap-hop-paris.fr
findings of the accreditation surveys, and the the Agency. In particular, it supervised produc-
Accepted 27 March 2001 changes it will eventually bring about in the tion of the accreditation manual. The

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112 Giraud

importance of professional representation is


intended to guarantee the Agency’s independ- I Patients and patient care
ence and credibility. + Patient rights and information (DIP)
A key feature is the Accreditation College + Patient records (DPA)
which is responsible for examining the survey + Organisation of patient care (OPC)
reports, attributing accreditation, defining
recommendations for improvement for every II Management and organisation in the
hospital, and publishing an annual report. It service of the patient
is composed of 11 members and a similar + Management of the healthcare organis-
number of deputy members. Members are ation and its activity sectors (MEA)
hospital managers, hospital doctors, pharma- + Management of human resources (GRH)
cists or allied health professionals, and two + Management of logistics (GFL)
medical doctors with recognised expertise in + Management of the information system
quality assurance and/or accreditation. All are (GSI)
experienced professionals who have been in
practice for at least 15 years. They are III Quality and prevention
appointed by the Minister of Health on the + Quality management and risk prevention
proposal of the Scientific Council of the (QPR)
ANAES, after approval by the Board. + Specific prevention programmes and
transfusion safety (VST)
THE ACCREDITATION MANUAL + Monitoring, prevention and control of
Two specialties (psychiatry and cancer) have the risk of infection (SPI)
developed their own accreditation manuals,
but there is only one oYcial manual that is Box 1 Structure and contents of the accreditation
applicable to all healthcare organisations. The manual (from the English version).
manual was compiled during 1998 by ANAES
with the help and contribution of 150 profes-
sionals, 57 of whom were medical doctors. The to use practice guidelines and protocols. It
working groups included nine patients’ repre- responds to the main principles of CQI—that
sentatives. The actual writing was preceded by is, involving everyone in the organisation, being
a literature search on the topic of accreditation, concerned with all the internal organisational
foreign experiences, and various manuals com- processes, and focusing on external needs (in
piled privately in France, in particular the this instance, those of the patient).8
accreditation manual of the National Federa-
tion of Cancer Hospitals.6 Foreign manuals A management system concerned with all the
were also examined, including those of the organisational processes
Joint Commission for the Accreditation of In France the hospitals are divided into
Healthcare Organisation, the Canadian Coun- specialised departments or firms (services),
cil on Health Facilities Accreditation, the Aus- each led by a medical chef de service who exer-
tralian Council on Health Care Standards, the cises complete power on its medical policies.
King’s Fund, and CASPE Research. A first Every service tends to pursue its own interests
version of the manual was tested in 12 with no real consideration for the hospital as a
hospitals, amended, and tested again before it whole. Departments compete for their fair
was ready for oYcial use in February 1999. share of the hospital’s global budget, and the
The whole procedure was supervised by the culture is more one of competing interests than
Scientific Council of ANAES.7 An English ver- of constructive solidarity.9 A further rift is the
sion of the manual is available online on the one which often exists between clinicians and
Agency’s website (http://anaes.fr). managers whose culture, objectives, and lan-
The manual is divided into three sections guage often diVer. The hospital has therefore
(box 1) and each section is subdivided into been compared to a “mosaic” of decentralised
chapters. Every set of standards begins with the decision centres.10 The accreditation manual
definition of a general policy concerning the takes the radically diVerent approach that
objective of the standard—for instance, on the quality is the product of the cooperation of
organisation of patient records (DPA): everyone in all the management processes. It is
DPA standard 1: The healthcare organ- not divided by departments but by processes:
isation formulates and implements a pa- implementing patients’ rights and information,
tient record policy for all its activity managing patient records, organising patient
sectors care, managing human resources, the infor-
and ends with the evaluation of the level of mation system, quality and risk prevention, etc.
quality achieved: The chapter on “organisation of patient care”
DPA standard 7: The patient record is (OPC) follows the patient’s route through the
the subject of a strategy of assessment and hospital from access, admission, assessment of
continuous improvement. the patient’s condition and needs, coordination
The standards concern management proc- of care, discharge, to quality assessment of the
esses and procedures. Outcome standards are patient’s care. It prescribes organisational
expected to be introduced at a later stage. The processes that can ensure continuity of care by
purpose of the manual is for all professionals in involving all concerned professionals:
the hospitals to implement continuous quality OPC standard 6: Patient care is coordi-
improvement (CQI) by means of an explicit nated within the various clinical activity
quality management system, and for clinicians sectors.

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Accreditation and the quality movement in France 113

OPC standard 7: Continuity of care is The procedure itself consists of self-


ensured. assessment followed by the survey visit and a
OPC standard 8: Health professionals report, the purpose of which is to assess the
involved in operating theatres, other inter- compliance of the hospital with the standards
vention sectors and clinical activity sec- defined in the accreditation manual. Self-
tors work together in formulating their assessment is considered to be the most impor-
operational procedures. tant part of the process and a special guide was
At this stage, only two standards address written by ANAES to help hospitals with it.
quality of care: Self-assessment is intended as a preparation for
OPC standard 14: Clinical and ancillary the survey visit during which the whole organ-
medical activity sectors use diagnostic and isation assesses (or discovers) its baseline state
therapeutic protocols. of compliance with the standards contained in
OPC standard 15: Clinical and ancillary the manual. At the end of the self-assessment
medical activity sectors assess profes- the hospital sends to ANAES a report in which
sional practices and their results. it estimates its degree of compliance with the
Assessment of professional practice is to be manual standards and defines what improve-
achieved through the definition and use of per- ment measures it has undertaken where neces-
formance indicators (OPC 15b) and sentinel sary. The actual accreditation survey follows
events (OPC 15c). It is the task of every hospi- the self-assessment by less than 3 months.
tal to define its own. Depending on the size of the surveyed organis-
The quality management and risk preven- ation, the survey team is composed of at least
tion section (QPR) focuses on the cross-cutting three professionals including a doctor, a mem-
prevention of the major risks (transfusion ber of the allied health professions, and a man-
(VST), infection (SPI)) at the hospital level: ager. The survey visit lasts a varying number of
QPR standard 1: The healthcare organ- days. The surveyed organisation must be able
isation initiates, leads and maintains a to answer the question “What do you do in
quality policy based on quality manage- order to comply with ... the concerned
ment and risk prevention. standard?” The hospital must then be able to
VST standard 1: The authorities and produce the documents proving that they have
professionals concerned are involved in the corresponding policy. Where any deficien-
drawing up and implementing the organi- cies have been noted during the self-
sation’s policy concerning specific preven- assessment, the organisation must be able to
tion programmes, including transfusion demonstrate what improvement measures they
safety. have undertaken to correct them. Surveyors
SPI standard 1: The healthcare organis- can also interview professionals and patients to
ation establishes and operates a coordi- verify the answers they have received.
nated infection control policy among After the survey visit is completed the
patients and professionals. surveyors write an expert report in which they
compare their own conclusions with those
THE SURVEYORS made by the hospital itself after the self-
All are experienced and active healthcare assessment. This is sent to the Accreditation
professionals who have been trained in accredi- College which examines both reports and then
tation procedures by ANAES. Training is both writes an accreditation report in which it
initial and ongoing. Surveyors are part time attributes an accreditation level, with or
and cannot spend more than one third of their without reservations, and eventually decides on
working time on accreditation. In order to recommendations for improvement. The Col-
ensure consistency of the accreditation surveys, lege also considers the methods used for
surveyors must follow the principles of the self-assessment and for the survey visit. A sum-
accreditation survey listed in an “accreditation mary of the accreditation report is made avail-
surveyor’s charter” planned to evolve as able to the public. At the time of writing about
experience of the procedure is acquired. Obvi- 200 hospitals are in the process of self-
ously, surveyors can have no professional ties or assessment and 10 have been accredited. All
interests of any kind with the organisation they completed survey reports are accessible on the
survey. ANAES website.

The procedure A CONTINUOUS PROCESS


Initially, accreditation was a private and volun- This is an important feature of the process.
tary procedure but, as its objectives evolve Hospitals are being made to understand that
towards public regulation, it is tending to accreditation is not a one time procedure and
become compulsory.11 In France the voluntary/ that it is not obtained once and for all. On the
compulsory issue was resolved as follows. The contrary, it is presented as a means of ensuring
1996 ordonnance instituted a 5 year period a continuous improvement process within the
(1996–2001) during which hospitals can apply hospitals, showing changes from the baseline
to enrol for accreditation. This is the “volun- quality estimated by self-assessment before the
tary” aspect of the procedure. However, if at survey visit and the progress as surveys are
the end of this 5 year period any hospital has repeated at least every 5 years, thus ensuring
not yet volunteered, it will be compulsorily the continuity of the improvement in quality.
enrolled by the local hospital authority so that Compliance with the standards will be as-
no hospital, public or private, can escape a pro- sessed by the College of Accreditation on the
cedure that is, in fact, compulsory. basis of the survey report. No one will fail, at

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114 Giraud

least this first time, but for hospitals with owned, an essential point is the involvement of
recommendations the next accreditation level professionals. We have described the
will depend on their implementation of the importance of professional involvement in the
recommendations. Survey visits will normally composition of ANAES. A similar multiprofes-
be repeated every 5 years but, for hospitals sional involvement is expected at the hospital
with reservations, a survey visit focused on level. This can sometimes prove more diYcult
deficient areas may take place at an earlier date where doctors are concerned; indeed, doctors
as decided by the College. A cyclical process is have often been the missing link in healthcare
thus being installed, instituting a systematic quality assurance systems because their defini-
and prospective risk prevention policy in hos- tion of quality in medicine diVers from the one
pital management which constitutes a funda- adopted by regulators and managers. For doc-
mental departure from the retrospective crisis tors, improvement in medical quality consists
management of quality problems that has pre- in the accomplishment of medical progress
vailed up until now in the healthcare system in through clinical research. The majority have
France. not participated up to now in the managerial
culture of audit and accreditation. In France, as
THE CENTRAL IMPORTANCE OF THE PATIENT elsewhere, quality assurance as medical audit is
An important objective of the current French viewed by many as an intrusion and a waste of
health policy is to refocus health care on its time. The diYculty is enhanced in France by
ultimate object—that is, the patient—rather the fact that the concepts used are all of Anglo-
than the process of care per se. Explicit concern Saxon origin and do not always find easy trans-
for the welfare of patients has been the object of lation into French and acceptance in the
many legal texts in recent years. In particular, French culture.17 The fact that concepts
in 1988 an important law defined the condi- relating to quality assurance and management
tions of the protection of patients in medical are not integrated in the medical curriculum
research.12 A Charter of the rights of the hospi- contributes to doctors’ disinterest. One reason
talised patient was issued in 1995.13 Symboli- why the structures of ANAES include so many
cally, the 1996 ordonnance’s first title is professionals, apart from their necessary tech-
“Patients’ rights”. It contains a whole array of nical contribution, is the importance of obtain-
measures aimed at providing greater attention ing professional legitimacy and credibility.
to the rights and needs of patients, and ensur- However, at the local level it often remains dif-
ing a greater participation of the patient in the ficult to obtain medical participation in meet-
life of the hospital; the patient’s Charter must ings, and the very time consuming work for the
be made public and included in the infor- self-assessment prior to the survey visit is
mation booklet that every patient is given on mostly carried out by nursing and management
admission. Professionals must recieve specific personnel.
training in patients’ rights and confidentiality.
Access for deprived populations and immi- Discussion
grants must be organised specifically.14 Repre- Does accreditation in France respond to the
sentatives of patients now sit on every hospital definition given by the ExPeRT project of an
board and on hospital committees such as the external quality mechanism: “a regional or
infection committee (Comité de Lutte contre (potentially) national process voluntarily entered
les Infections Nosocomiales, CLIN). Every by service provider organisations for the improve-
hospital must organise a commission de concilia- ment of organisation and delivery of health services
tion where conflicts between patients and the assessed against explicit, published standards by
hospital may tentatively be solved amicably peer group teams moderated by a non-partisan
before reaching the legal stage. Furthermore, authority involving (but impartial to) users,
although not an explicit reference of the providers, purchasers, and government”18? In
manual, the assessment of patient satisfaction France accreditation is a national process
is an important issue in the accreditation which healthcare providers enter with the view
procedure. The ordonnance requires that every of improving the management and delivery of
hospital should “proceed to regularly assess their healthcare services in their organisation by
patients’ satisfaction”. The results of these having them assessed by peer group teams
assessments will count for accreditation.15 against explicit published standards and mod-
Patients’ rights and information are the subject erated by an authority that involves govern-
of the first chapter in the manual (DIP) and ment (in France the main purchaser), provid-
management of patients’ complaints is the ers and, to a lesser degree, users. This process,
subject of a specific standard (DIP standard 8). however, is not voluntary but is made compul-
sory by law. Is the moderating authority
THE INVOLVEMENT OF ALL PROFESSIONALS non-partisan and is it equally impartial to gov-
Healthcare policy in France is characterised by ernment, providers, and users? How does
the strong influence of the State and the weak accreditation take its place in the quality move-
bargaining power of a divided medical profes- ment in France? Does it have a chance of suc-
sion.16 Most major reforms, such as national ceeding in improving the organisation and
health insurance, were introduced unilaterally delivery of healthcare services in France?
by the government against the opposition of The answer to these questions probably lies
the medical profession. Although the accredita- in the answer to the question: “Who wants to
tion policy was introduced in the same influence whom to achieve what?”19 The history
authoritative fashion, and despite the fact that of healthcare quality assurance in developed
the process is decidedly public and government countries can be roughly divided into three

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Accreditation and the quality movement in France 115

periods.20 The first took place in the USA both the organisation of healthcare delivery
around 1917 when, following the initiative of E that mainly concerns managers, and the more
A Codman, surgeons decided that they would professional aspects of medical practice—such
not operate in hospitals that did not provide as making informed decisions about patients
them with a minimum standard of quality in with the help of evidence based practice
their working conditions. Eventually this initia- guidelines—which essentially concerns doc-
tive developed into accreditation. It is impor- tors. In the UK these two aspects of medical
tant to point out that this first period of quality management have been united in the new con-
assurance was (a) the result of a professional cept of clinical governance.25 Undoubtedly,
initiative, private and voluntary, and (b) mainly accreditation will considerably improve pro-
structure orientated—that is, aimed at ensuring spective risk management in French hospitals
doctors with satisfactory working conditions. and therefore will hopefully reduce the hazards
At that time the question of the quality of of hospitalisation. But will the medical profes-
medical procedures was not an issue. It was not sion follow? Will its participation in accredita-
even a concept. Quality was “what we (doctors) tion go beyond a formal involvement in
do”,21 and the purpose of accreditation was to structures and surveys? Will they engage at the
provide doctors with an appropriate environ- local level in new behaviours that would result
ment to do it. In other words, doctors wanted in an improvement in the quality of medical
to influence providers (hospitals) to obtain sat- care and of patient satisfaction? Such behav-
isfactory working conditions. iour would, for instance, involve a systematic
When the economic crisis of the 1970s review of the quality of patient records, a
attracted the attention of Western governments systematic assessment of the organisation of
to the increasing costs of health care, econo- every patient stay, and an explicit policy for
mists, epidemiologists, managers, and regula- patient information in every service. In an ideal
tors (that is, the “external users” of health world doctors would want to influence them-
care22) started examining medical practices.23 selves or each other in order to improve the
With no evidence that health indicators quality of everyday practices as well as their
improved in parallel with health expenditures, participation in medical research and publica-
and comforted by the extent of unexplained tions. Does accreditation contain the necessary
variation that had started to be documented in incentives?
doctors’ practices,23 they developed a rhetoric At this stage of the procedure it is not known
for introducing so called “professionally led what the public authorities intend to do with
quality assurance of medical practice”. But the the results of accreditation in France. If the
“quality” argument was promptly viewed by oYcial theory is that accreditation is mainly
the medical profession for what it was— destined to encourage quality monitoring
namely, a method for rationalising medical systems in hospitals, a common fear is that
prescriptions through utilisation review, con- unsatisfactory scores would encourage authori-
sensus conferences, and practice guidelines. ties to close down hospitals in these times of
The focus had shifted from structure to process restructuring of the healthcare system (France
and, whereas the first period of quality supposedly has about 60 000 hospital beds in
assurance was induced by and for the medical excess) so that, if the process today is largely
profession (the “original users of health professionally driven, the continuity of profes-
care”24), the second one was initiated outside sional participation may depend on the nature
the medical profession and, one could say, of the utilisation of its results by government. It
against it: today’s quality assurance questions will also depend on the evolution of the content
doctors’ decisions and practices. So it is not of the standards: will they remain strongly
surprising that it never gained professional management orientated, in which case the
legitimacy in the eyes of the doctors—as doctors may not feel really involved (only two
opposed to other health professionals such as standards explicitly concern quality of care
nurses—and that the biggest diYculty in today), or will they evolve to include visitatie
implementing quality assurance of medical like procedures, thereby explicitly including the
practices in most industrial countries except, quality of medical practices in the evaluation of
perhaps, the Netherlands has been the doctors’ performance?18 Given the political system in
constant indiVerence at best and, more often, France, the main users of accreditation are
the outright opposition to it. During this likely to be, firstly, the government and,
second period of quality assurance purchasers secondly, if all goes well, the users. Whither the
and regulators wanted to influence providers provider?
(doctors) to achieve better quality care for less
money. However, in France, as in many other I thank Professor Philippe Loirat, Chairman of the Scientific
western countries, they largely failed because Council of ANAES, and Professor Ellie Scrivens for reading and
commenting on the manuscript.
they did not succeed in getting the medical
profession to feel concerned. Will accreditation
1 de Pouvourville G. Quality of care initiatives in the french
succeed where quality assurance failed? context. Int J Qual Health Care 1997;9:163–70.
Accreditation, although authoritatively in- 2 Spécial Urgences: 65% des services sont hors normes.
Sciences et Avenir, May 2000.
troduced in France by law, is characterised by 3 Agence Nationale pour l’Accréditation et l’Evaluation en
an explicit involvement of the medical profes- Santé (ANAES). Accreditation manual (English version).
February 1999, 9.
sion, both in the structures of the programme 4 Agence Nationale pour l’Accréditation et l’Evaluation en
and in its implementation which consists of Santé (ANAES). Accreditation manual (English version).
February 1999, 12–13.
peer review. It is mainly concerned with 5 Décret no. 97-311 du 7 avril 1997 relatif à l’organisation et
management, but management that includes au fonctionnement de l’Agence Nationale pour

www.qualityhealthcare.com
116 Giraud

l’Accréditation et l’Evaluation en Santé. Journal OYciel, 8 17 Giraud A. Medical audit in France: historical perspective.
avril 1997. BMJ 1992;304:426–8.
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February 1999, 27–30. 19 Klazinga N. Re-engineering trust: the adoption and adapta-
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1st Asia Pacific Forum on Quality Improvement in Health Care


Three day conference
Wednesday 19 to Friday 21 September 2001
Sydney, Australia

We are delighted to announce this forthcoming conference in Sydney. Authors are invited to
submit papers (call for papers closes on Friday 6 April), and delegate enquiries are welcome.
The themes of the Forum are:
x Improving patient safety
x Leadership for improvement
x Consumers driving change
x Building capacity for change: measurement, education and human resources
x The context: incentives and barriers for change
x Improving health systems
x The evidence and scientific basis for quality improvement.
Presented to you by the BMJ Publishing Group (London, UK) and Institute for Healthcare
Improvement (Boston, USA), with the support of the the Commonwealth Department of
Health and Aged Care (Australia), Safety and Quality Council (Australia), NSW Health
(Australia), and Ministry of Health (New Zealand).
For more information contact: quality@bma.org.uk or fax +44 (0)20 7383 6869

www.qualityhealthcare.com