Hervé Leteurtre, Quality Advisor for the Fédération Hospitalière de France
The ruling of April 24, 1996, completed by the decree of April 7, 1997, forms the framework for legal proceedings for the accreditation of French hospitals.
Following several other countries, hospitals and clinics in France were able to independently organise their own evaluation system. However, under the terms of the law of July 31, 1991,
this system became standardised (single reference) in 1996.
The subtle mix of voluntary service and obligatory commitment contained in the official texts is not a hindrance. In fact, the development of the quality of hospitals, and their evaluation right up to the organisation of a benchmarking system allowing the comparison of their performance, are necessary. Up until now, the performance of French hospitals was only tackled based on their activities, quantitatively evaluated thanks to the PMSI tool (the medicalisation programme for information systems).
The introduction of accreditation in France will allow the intersection of a quantitative and a qualitative
approach, and enable the French hospital system to be viewed in its entirety. It will be possible to evaluate its global performance.
A complimentary tool to PMSI, accreditation was born of a solid conceptual approach worthy of credit. The accreditation manual used by external auditors to carry out the evaluation of hospitals is particularly solid. Put together by professionals for professionals and experimentally tested in 40 hospitals, it has proven to be a particularly complete tool encompassing the reality of how hospitals are run in a vertical (hospital functions) and transversal (chain of activities) manner, in ten reference systems.
Furthermore, accreditation has been accepted by the different players in the health system. It has appeared as a consensual evaluation tool. It may have been necessary to simplify the commitment of hospitals by decree (January 31, 2001), but despite this simplification, not all hospitals completed their applications by April 2001 (cut-off date). By September 2001, however, almost all hospitals concerned had respected the law.
A Slow Rise in the Step Towards Accreditation
However, five years after being set-up, the accreditation reform is not free from criticism. This mainly concerns its effectiveness and content. The last report of the Court of Auditors is overpowering and stigmatises, in particular, the “very slow” rise in the production load of the Agence Nationale d’Accréditation et d’Evaluation en Santé (ANAES).
As of summer 2002, in fact, fewer than 200 hospitals had been subjected to an auditor’s report, and the official minutes of the board of directors of ANAES voiced echoes of real concerns about the respect of the workload announced by the institution.
For this reason, bearing in mind the weakness of the number of hospitals subjected to a report, it is impossible to draw truly edifying conclusions which can be extrapolated to the entire hospital population. Generally, it appears that the relative weight of public hospitals is superior to that of private hospitals. Within public hospitals, the Centres Hospitaliers Universitaires (CHU) have committed themselves to the accreditation process more quickly than other hospitals.
With regard to points of improvement, we note that:
• The number of improvements requested of public hospitals is greater than that of private hospitals.
• The most noted reference point in terms of improvement is that of the organisation of the responsibility for patients, closely followed by the surveillance, prevention and control of infectious risk.
With regard to decisions, we note that:
• 16% of hospitals obtained a five-year accreditation, with no recommendations or reservations, the vast majority being private hospitals.
• Close to 50% of hospitals obtained a five-year accreditation and were subjected to an accreditation report with recommendations.
• Just over 37% of hospitals were subjected to an accreditation report with recommendations, reservations and/or major reservations.
• The total number of major reservations is 10, that is, 1% of decisions. The 10 major reservations can be divided into nine major reservations for public hospitals and one major reservation for private hospitals.
With regard to the structure of the reports, it is interesting to note that there is an almost perfect alignment of public and private hospital reports in terms of requests for improvement.
Subsequently, if this trend were to be confirmed, it may be interesting to ask oneself why such a parallelism exists. Two hypotheses seem possible at present: the hospitals are similar in terms of organisation, or the accreditation reports are written based on a collective prejudice shared by the external auditors.
ANAES’s Real Reaction
To rectify the dysfunctions surrounding the entire general evaluation procedure, ANAES is permanently improving its accreditation system. It is also moving towards the idea of offering assistance to hospitals by project leaders, which will provide better support to hospitals. The reinforcement of the responsibility of external auditors in concluding the accreditation process will, moreover, allow more time to be saved, although probably not enough in order for all hospitals to be accredited by 2006.
Finally, there are plans to modify the accreditation reports, which, by making them more concise, will probably guarantee greater homogeneity of compilation and fairer conclusions.
A Mission Which Remains to be Fulfilled
If ANAES has shown that it is able to undergo reforms, doubts remain over the total consideration of its mission as defined by the ruling of 1996, which envisaged in particular that this institution should “appreciate the quality of a hospital with the aid of indicators (...) relating to good clinical practice and the results of the hospital’s different services and activities.” However, after being questioned by the former Minister for Health on the accomplishment of these missions, ANAES proposed:
• To neglect the service approach
• To ask learned societies and professional authorities to develop evaluation systems for professional practices under the methodological supervision of ANAES, with ANAES ensuring, during its accreditation visits, that such evaluation structures have been set-up in hospitals.
• To encourage different professions to formalise the re-certification of professionals, to develop the role of assuming responsibility for patients via networks, after validation by the learned societies.
Furthermore, it recently gave up short-term proposals to introduce a series of performance indicators common to hospitals, thus preventing any form of benchmarking between hospitals.
While reform is essential, accreditation might not provide the best results in the short-term. However, the progress that it represents for the development of the continued improvement of quality in French
hospitals calls for the hospital players to contribute to its organisation, with vigilance but confidence.