Quality improvement around the world Accreditation and the quality movement in France

Background As in many industrialised countries, the health care quality movement began in France because of rising health expenditure and the necessity to contain costs but, recently, the public has become more aware of issues relating to quality. Serious public health problems such as the contaminated blood scandal of 1984, when blood that was strongly suspected of being contaminated by HIV was knowingly transfused to haemophiliac patients, and greater visibility of routine medical practice through regular publications in the lay press has led to a crisis of public confidence in the ethics of the medical and political worlds and a strong demand for accountability and greater transparency. Important reforms in the organisation of health care and public health have therefore been undertaken, of which accreditation is one. Its objectives reflect this historical background—namely, “to assess the quality and safety of health care, to assess a health care organisation’s ability to ensure continuous improvement in the quality of overall patient care, to formulate explicit recommendations, to involve professionals at all stages of the quality initiatives, to provide external recognition of the quality of care in health care organisations, to improve public confidence”. Accreditation was enacted in France as part of the 1996 health care reform by ordonnance, a government decision that is taken without consulting Parliament. Governments in France under the Fifth Republic use ordonnances when they feel there is an urgent need for reform that could be delayed by parliamentary discussions. Many healthcare reforms have been enacted by ordonnance and, in 1996, it was felt that the magnitude of the deficit of the national health insurance fund and the public health situation was suYciently serious. The ordonnance of 24 April 1996 reforming public and private hospitalisation stipulates that “in order to ensure continuous quality and safety improvement of health care, all public and private health care organisations must submit to an external evaluation procedure named accreditation” (Article 710–5). Accreditation applies to public and private hospitals and healthcare networks but does not include general practice. However, in time the fields of application for accreditation are likely to be extended. Accreditation is new in France so we are not yet able to describe the implementation of the programme, the uses that will be made of the findings of the accreditation surveys, and the changes it will eventually bring about in the management of French hospitals and the quality of healthcare services. We will therefore limit ourselves to the description of the accreditation policy in France, evaluate its similarities and diVerences with other accreditation programmes, and try to estimate its chances of success.