Elsevier

Health Policy

Volume 90, Issues 2–3, May 2009, Pages 156-165
Health Policy

Accreditation at a crossroads: Are we on the right track?

https://doi.org/10.1016/j.healthpol.2008.09.007Get rights and content

Abstract

Objectives

By comparing Canada, where accreditation is optional, to France, where it is required, this study evaluates the extent to which the accreditation process acts as a tool for bureaucratic coercion as opposed to a tool for learning.

Methods

Our study consists of a qualitative meta-analysis of studies of French and Canadian accreditation experiences between 1996 and 2006. Using the conceptual framework of Adler and Borys [Adler P, Borys B. Two types of bureaucracy: enabling and coercitive. Administration Science Quarterly 1996;41:61–89], we assess the characteristics of accreditation in the French and the Canadian environments and distinguish between coercive and enabling modi operandi.

Results

Results show that accreditation has positive impacts in the two countries but is more coercion-oriented in France than in Canada. This is because in France: (1) the fact that accreditation is compulsory and certain standards are required by law limits participant’s opportunities to influence the process; (2) standards are not adapted to various clinical programs and as a result, participants contest their legitimacy; (3) ambiguity about the use of accreditation visit results has sullied global transparency. Despite differences between the French and Canadian systems, however, both systems are converging towards a mixed model that includes elements of both philosophies, with the Canadian model becoming more coercive and the French model becoming more flexible and learning-oriented.

Conclusion

Comparison of the two cases shows that current trends in the evolution of accreditation threaten the very purpose of the accreditation process.

Introduction

Quality of care is a key concern for industrialized healthcare systems [2], [3]. Reports from Canada [4], [5], [6] and France [7], the two tracers in our study, have deplored poor quality of care indicators and the lack of incentives for quality improvement in healthcare facilities. Patient safety procedures have come under strong criticism and waiting times, nosocomial infections, inappropriate care and the mistreatment of the elderly make frequent headlines.

In response, both Canada and France have turned to accreditation as a means to control management and quality in healthcare institutions by following the principles of continuous quality improvement. French law made the accreditation of healthcare institutions compulsory in 1996 and Canada is considering the introduction of compulsory elements to an accreditation process that has been elective for 50 years. At the same time that governments move towards closer regulation of accreditation, however, stakeholders in both countries have questioned the very usefulness of the accreditation process, described by one Canadian scholar as a “sterile administrative ritual” [8]. As a result, decision-makers in both countries are presently entertaining a variety of proposals to radically revamp their approach to accreditation. For that reason, an appraisal of the evolution of the two systems is relevant at this time.

Our study poses the following two questions: (1) Do the two national accreditation systems use accreditation as a tool of learning or as a bureaucratic tool of coercion? and (2) How does a bureaucratic approach versus a learning approach impact organizational practices? To answer these questions, our article analyzes how decisions taken in Canada and in France between 1996 and 2006 have influenced the role and usefulness of accreditation in each context. This comparison, the first of its kind, is expected to produce valuable insight into the consequences of two different philosophical approaches to accreditation.

This study is not an investigation of the differences between individual establishments. Rather, it aims to identify the principal differences between the experiences of each country in order to better understand the impacts of the two approaches and to ascertain where accreditation is headed at the present time.

We begin with an overview of the French and Canadian accreditation systems and their respective contexts. We then present our research framework and our sources of data. After describing our results, we analyze trends in the two systems in light of our theoretical framework. We conclude by discussing the implications of these trends.

Section snippets

Overview of accreditation in France and in Canada

In both Canada and France, accreditation is a rigorous peer review process comprised of self-assessment against a given set of standards, an on-site survey, the issuance of a report that sometimes includes recommendations and follow-up on those recommendations. In both countries, standards are applied on a national basis, allowing teams and organizations to benchmark and share best practices. The process occurs over a 3-year cycle in Canada and a 4-year cycle in France.

Theoretical framework

In the world of management, accreditation is an external tool that uses standards to evaluate the quality of health care and improve quality management in a given institution. In line with this thinking, we propose to analyze accreditation as a bureaucratic measure, that is, a measure used to formalize organizational behaviour. Our question is whether as a bureaucracy, accreditation has a positive or a negative impact.

Historically, bureaucracies have solicited a mixed response. Some associate

Methodology

Our methodology consists of a qualitative meta-analysis of studies of French and Canadian experiences with accreditation. We selected the accreditation programs of these two countries because the two programs are based on different philosophies (compulsory versus voluntary accreditation) and we expected the impacts of accreditation to differ between programs. We chose to evaluate the period between 1996 and 2006 on the grounds that France initiated accreditation in 1996 and both France and

Results

In this section, we present the results of our analysis of the impacts of accreditation in each country. Table 3, Table 4 summarize the commonalities and differences between the impacts of each country, and we discuss in greater detail the following elements: the degree of diffusion of the accreditation process, the legitimacy of the accreditation process, the levers of change, the impacts of accreditation on practices, power relationships, organizational culture, and user’s involvement.

Analysis

Analysis of the results presented above reveals a number of differences between the impacts of accreditation in Canada and in France. Some of these differences are probably related to the fact that accreditation is newer to France than it is to Canada: for example, inter- and intra-organizational collaboration has advanced further in Canada than in France. But other differences can be attributed not to the degree of maturity of the accreditation process but to a divergence in philosophy.

Because

Discussion and conclusion

In this analysis, we have attempted to discern the impact of two different philosophies of accreditation on professional’s perceptions of the accreditation procedure and the effects of accreditation itself. Despite their differences, both systems are now converging towards a mixed model that includes elements of each philosophy. In the Canadian province of Quebec [36], accreditation has become compulsory, and in most of Canadian provinces, institutions must be engaged in the accreditation

References (46)

  • P. Adler et al.

    Two types of bureaucracy: enabling and coercitive

    Administrative Science Quarterly

    (1996)
  • WHO. World Health Report. WHO 2000,...
  • The Institute of Medicine

    Committee on quality of health care in America. Crossing the quality chasm: a new system for the 21st century

    (2001)
  • Romanow RJ. Commission on the Future of Health Care in Canada. Shape the future of health care. Interim Report February...
  • The Standing Senate Committe on Social Affairs, Science and Technology (Chair: Kirby M; Deputy Chair: LeBreton M). The...
  • G.R. Baker et al.

    The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada

    Canadian Medical Association Journal

    (2004)
  • S. Sandier et al.
  • D. Lozeau

    Des rituels et des homes: la gestion de la qualité en milieu hospitalier au Québec (Of men and ritual: quality management in Quebec’s hospital environment [translation ours])

    Canadian Public Administration/Administration publique du Canada

    (1999)
  • J.P. Poullier et al.

    France Journal of Health Politics Policy and Law

    (2000)
  • Z. Or et al.

    French hospital reforms: a new era of public–private competition?

    Eurohealth

    (2006)
  • A. Letourmy et al.
  • Brousselle A, Fournier MA, Champagne F. Lessons from the provincial health care reforms in Canada: when the same...
  • Boothe P, Carson M. What Happened to Health Care Reform? Report C. D. Howe Institute 2003; n 193, ISSN...
  • V.A. Thompson

    Bureaucracy and innovation

    Administrative Science Quarterly

    (1965)
  • T. Burns et al.

    The management of innovation

    (1961)
  • S.E. Jackson et al.

    A meta analysis and conceptual critique of role ambiguity and role conflict in work settings

    Organizational Behavior and Human Decision Process

    (1985)
  • F. Damanpour

    Organizational innovation

    Academy of Management Journal

    (1991)
  • Pichoir-Drew M. CCHSA accreditation: a catalyst for change and a building block for social capital. Case study of...
  • A. Depaigne et al.

    First ANAES accreditation results in psychiatry

    Annales Médico-Psychologiques

    (2003)
  • C. Bruneau et al.

    Le point sur l’accréditation. Une enquête nationale auprès de diverses catégories de professionnels de santé (How accreditation stands: a national survey of different categories of health professionals [translation ours])

    Actualité accreditation. Gestions hospitalières

    (Janvier 2003)
  • C. Lachenay-Llamas et al.

    Management, évaluation des pratiques professionnelles et accréditation: de l’actuel au futur (Management, the evaluation of professional practices and accreditation: going forward [translation ours])

    Gestions hospitalières

    (Août/Septembre 2003)
  • Herreros G, Milly B. Les voies de la qualité à l’hôpital: entre procédures et coopération. Dynamique et horizons de la...
  • M.P. Pomey et al.

    Accreditation as a tool for organizational change

    International Journal of Health Care Quality Assurance

    (2004)
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    Part of the study on which this research is based was funded by an operating grant from the Canadian Institutes of Health Research. The authors wish to thank all the people who were interviewed part of this study. Marie-Pascale Pomey is supported in part by career awards from the Canadian Institutes of Health Research. We thank Jennifer Petrela for the editing of the paper.

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