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