Pomey Etal Accreditation Tool for Org Change Hosps

Accreditation: a tool fororganizational change inhospitals?

Marie-Pascale Pomey

Andre-Pierre Contandriopoulos

Patrice Francois and

Dominique Bertrand

The authors

Marie-Pascale Pomey is Assistant Professor, Faculty ofManagement, University of Ottawa, Ottawa, Canada.Andre-Pierre Contandriopoulos is Professor, Department ofHealth Administration, Faculty of Medicine, University ofMontreal, Montreal, Canada.Patrice Francois is Professor, Evaluation Unit, UniversityHospital Centre, Grenoble, France.Dominique Bertrand is Professor, Department of Public Health,Fernand-Vidal Hospital, Assistance Publique – Hopitaux de Paris,Paris, France.

Keywords

Quality management, Organizational change, Social change,France

Abstract

Examines the dynamics of change that operated followingpreparations for accreditation. The study was conducted fromMay 1995 to October 2001 in a university hospital center inFrance after the introduction in 1996 of mandatory accreditation.An embedded explanatory case study sought to explore theorganizational changes: a theoretical framework for analyzingchange was developed; semi-structured interviews, focusgroups, and questionnaires addressed to the hospital’sprofessionals were used and documents were collected; andqualitative and quantitative analyses were carried out.Professionals from clinical and medico-technical departmentsparticipated most. Preparations for accreditation provided anopportunity to reflect non-hierarchically on the treatment ofpatients and on the hospital’s operational modalities by creatinga locus for exchanges and collegial decision making. Thesepreparations also led to giving greater consideration to results ofexit surveys and to committing procedures to paper, and were akey opportunity for introducing a continuous quality program.

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In 1996, France embarked on a program of reform

in order to deal with the economic and societal

constraints weighing on its health care system

(Code of Public Health, 1996). Among the

measures adopted, all public and private hospitals

had to undergo in the five years following the

reforms a mandatory accreditation review

conducted by an agency created specifically for the

purpose, namely the National Agency for

Healthcare Accreditation and Evaluation

(ANAES) (Code of Public Health, 1997). The

National Agency for Healthcare Accreditation and

Evaluation (1999) defined accreditation as:

. . . an evaluation process carried out byindependent professionals external to the healthcare organization and its governing bodies,focusing on its functioning and practices as awhole. It aims to ensure that conditions regardingthe safety, quality of care and treatment of patientsare taken into account by the health careorganization [translation].

The accreditation process, which comprises a self-

assessment, a field survey and a report (Hayes and

Shaw, 1995), looks at the entire organization and

thus serves to arrive at a global appreciation of the

hospital. Compared with what is most often

encountered (Hayes and Shaw, 1995; Scrivens,

1995a, 1995b; Segouin, 1998), “French-style”

accreditation has a number of interesting

characteristics (Code of Public Health, 1996;

Bertrand, 2001):. it is mandatory every five years for all health

care and medico-social organizations;. it is performed by an independent government

agency funded by public medicare and health

care organizations;. during visits, the surveyors have the duty of

reporting to the Head of the ANAES all

instances of non-compliance with safety

standards;. the survey report is a public document which

is sent to the regional administrative

authorities, and a summary of the report is

made available to the public at the ANAES

website (National Agency for Healthcare

Accreditation and Evaluation, 2003); and. regional administrative authorities can use the

information contained in the report to modify

hospital budgets and plan activities.

Accreditation has been greeted with enthusiasm

internationally (Segouin, 1998; Scrivens, 1998,

Shaw, 2003) since seeing the light of day in the

United States in 1919 (Roberts et al., 1987).

International Journal of Health Care Quality Assurance

Volume 17 · Number 3 · 2004 · pp. 113-124

q Emerald Group Publishing Limited · ISSN 0952-6862

DOI 10.1108/09526860410532757

This study was made possible with the financial

support of the National Agency for Healthcare

Accreditation and Evaluation (call for projects 1999).

However, the opinions expressed in this article are

those of the authors alone.

113

However, few published studies have measured the

impact of accreditation on hospitals and on the

health care system where it is implemented.

Following the introduction of optional

accreditation in Australia (Duckett and Coombs,

1982; Duckett, 1983), an evaluation of its impact

documented major benefits in the six areas

examined (i.e. administration and management,

medical organization, critical review of cases,

organization of nursing care, safety, and hospitals’

definition and missions). These included

recognition of the contribution of nursing care to

the implementation of service quality processes

and improved communications thanks to the

creation of a committee with a more collegial

approach to debating and decision making.

However, accreditation had little effect on

physicians and did little to help hospitals better

meet the needs of the population. In the United

States, a study (Keeler et al., 1992) revealed no

evidence that accreditation did anything to

improve quality of care. This finding then led to

changes in the procedure proposed by the Joint

Commission on Accreditation of Healthcare

Organizations (JCAHO). Other studies conducted

in Quebec (Lozeau, 1996, 2002; Francois, 2001)

demonstrated that the introduction of new

standards in 1995 by the Canadian Council on

Health Services Accreditation (CCHSA;

Canadian Council on Health Services

Accreditation, 1995) had served to shift from

“quality assurance” processes to “continuous

quality improvement” (CQI) processes. This

made it possible to involve more professionals in

the process, to identify the organization’s

weaknesses, and to implement corrective measures

as a function of the user’s point of view. In Canada,

studies have demonstrated that accreditation on

the one hand (Beaumont, 2002) served to improve

communication processes and, to a lesser extent,

clinical practices, but on the other hand that

indicators developed by self-assessment groups did

not allow organizational performance to be

monitored (Lemieux-Charles et al., 2000).

These studies examined accreditation above all

as an exercise aimed at introducing quality

processes such as CQI or total quality

management (TQM) (Richardson and Gurtner,

1999). However, accreditation can also be

considered as an agent of change affecting all areas

of the organization and all actors. In France, where

hospitals were obliged to prepare for an

accreditation visit and implement strategies to

meet the requirements of the ANAES

accreditation manual as well as possible, we sought

to explore the dynamics of change that operate

during self-assessment (accreditation

preparations) by examining those dynamics of

change that occurred specifically in a university

hospital center.

Setting

The study was conducted in a university hospital

center (UHC) with a staff of 4,500 professionals, a

budget of e0.3 billion, and 2,113 beds across five

geographical sites (two short-stay, two medium-

and long-stay, and one psychiatric). The hospital

chose to make accreditation preparations a

participatory process. To this end, the following

measures were taken:. accreditation awareness lectures were held on

all of the hospital’s sites;. a cross-sectional professional standards

manual (Segouin, 1998) specific to the

hospital was developed for clinical and

medico-technical departments, based on

standards available in France and elsewhere,

with the aim of enabling professionals to gain a

better awareness of quality processes;. training-action sessions were organized

comprising a clinical audit and training for

self-assessment teams on how to complete the

hospital’s standards manual: accreditation

awareness sessions were also organized to

emphasize the links between continuous

improvement processes and accreditation;

and. articles were written for publication in the

hospital’s internal newspaper, and a monthly

quality newsletter was created to provide an

update on the accreditation process.

Method

Study design

Our research protocol consisted of a longitudinal

explanatory single-case study with embedded units

of analysis (Yin, 1994; Stake, 1997). Six levels of

analysis relative to the study of accreditation

preparation implementation processes were

identified:

(1) Departments (vertical level).

(2) Thematic self-assessment groups (TSAGs),

created specifically to complete the

accreditation manual’s standards (cross-

sectional level) (in all, ten such groups were

formed, one for each chapter of the manual).

(3) Operational.

(4) Strategic.

(5) The hospital as part of the community of

hospitals.

Accreditation: a tool for organizational change in hospitals?

Marie-Pascale Pomey et al.


Volume 17 · Number 3 · 2004 · 113-124

114

(6) Administrative bodies at the local and regional

levels (public medicare and health

authorities).

Both quantitative and qualitative data were

gathered at the different levels (Table I) from the

following sources (Downey and Ireland, 1979;

Fielding and Fielding, 1986; Carey, 1993;

Creswell, 1994):. semi-structured interviews;. questionnaires;. documents; and. observation of means.

The data as a whole were then triangulated.

Population and data collection

Data collection took place over a six-year period

from May 1995 to July 2001. In all, 67 interviews

were conducted with people involved in the self-

assessment (Table I). The questionnaires were sent

out to all of the hospital’s full-time professionals

(3,248 people) (Table II) and to the members of the

quality commission and/or of the TSAGs (114

people), which amounted to 73.3 percent of the

total hospital population. This population wasmade

up mostly of women (80 percent) who worked as

nurses or nursing assistants (44 percent) in

departments targeted by the standardsmanual (81.6

percent) and in the UHC’s two short-stay units

(78.6 percent). The response rate for the

questionnaires was 52 percent, and the respondents

were representative of the hospital population

(Table III). All the documents distributed within the

context of the self-assessment were gathered

exhaustively, as were all documents pertaining to the

hospital’s policies. Physical surveys of the

departments were conducted to ascertain the

resources allocated to self-assessment.

Data analysis

The interviews were transcribed and processed

using the Atlas TI software (version 4.1, Windows

95) and the questionnaires were processed using

the SPSS (version 10.0). Chi-squared tests and

ANOVAs were run on the questionnaires as a

function of occupation and gender. The qualitative

and quantitative data set was examined based on a

framework of analysis (Figure 1) developed

following the triangulation of the different

theoretical currents regarding change and an

analysis of the literature regarding the

implementation of quality processes in healthcare

Table I Characteristics of data sources according to level of case analysis

Level

Nature of

data Categories of people

Number

expected

Number interviewed

or responded

Departments Interviews Heads of clinical departments 40 35

Questionnaires People working full-time in departments targeted

by hospital standards manual and in

departments not targeted by the manual 3,248 1,693

Documents Documents issued for departments and drafted

by departments in connection with self-assessment All All

TSAGs Interviews Presidents 10 9

Questionnaires TSAG members excluding presidents 114 62

Documents Documents issued for TSAGs and drafted

by TSAGs All All

Operational Interviews Quality directors and members of quality

bureau 8 7

Documents Documents issued for quality directors and

the quality bureau and drafted by

them All All

Strategic Interviews Hospital head, director of nursing care

services, CME president, quality committee president,

union representative, users’ representative, communications director 7 6

Documents Documents issued for the strategic level

and drafted by this level All All

Community of Interviews Quality directors 8 8

hospitals Documents Documents issued within the context of

the community of hospitals in connection

with self-assessment All All

Local and regional Interviews Hospital directors 3 2

administrative

authorities

Documents Objectives and means contract All None




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hospitals (Pomey, 2003). The results of these

analyses are presented and discussed below.

Results

Professionals’ perception of self-assessment

The questionnaire survey enabled us to

understand how the hospital’s professionals

experienced self-assessment and what it gave

them. The data presented in Tables IV-VII

compare the responses given according to four

categories of professionals: caregivers, medics,

non-caregivers (secretaries and technicians), and

administrative staff.

Accreditation preparations represented an

important stage in the hospital’s evolution

according to 82.7 percent of the non-caregivers,

77.4 percent of the caregivers, 71.9 percent of the

administrative staff and 65 percent of the medics

(p , 0:005). The strategy to mobilize

professionals was qualified as being well adapted to

the hospital by 36.4 percent of the respondents,

the most positive of the professionals being the

administrative staff (42.9 percent). For 71.8

percent of the staff, the process touched all of the

hospital’s fields of activity. Moreover, 67 percent

also considered that the process touched all of the

hospital’s personnel. The accreditation

preparation process was experienced essentially as

“bureaucratic” by 80.9 percent of the caregivers,

77.3 percent of the administrative staff, 76.1

percent of the non-caregivers and 65.2 percent of

the medics (p , 0:005). Furthermore, the process

was qualified as being “rigid” (55.3 percent),

“participatory” (52.5 percent), “consensual”

(46.4 percent) and finally “concrete” (45.4

percent) (Table IV).

Knowledge gained over the course of self-

assessment regarded above all the modalities for

conducting the accreditation process (45.8

percent), especially where medics were concerned

(57.5 percent, p , 0:05), and quality processes

(44.8 percent). Respondents said they had learned

much less about their own departments (29.5

percent), the hospital (22.6 percent), other

professionals (25 percent), themselves (18.2

percent) and other departments (13 percent)

(Table V).

Caregivers were the group that had most

impression of having learned about themselves

(p , 0:05). Also, 69.6 percent of those surveyed

believed that irreversible changes occurred at the

level of the hospital. Caregivers (72.6 percent) and

non-caregivers (71.2 percent) provided the bulk of

the opinion (p , 0:05). As for the changes made

within their departments, 52.4 percent of the

respondents believed that these were irreversible

(Table VI). The changes in question were

concerned primarily with the discussion of new

subjects (39 percent), the implementation of

changes in the organization of care (3 percent), the

definition of indicators (32.8 percent) and the

introduction of changes in practice (30.4 percent).

Finally, the respondents expected that the

accreditation process would primarily serve to

better meet the expectations of the administrative

authorities (75.8 percent), to improve the

management of patients (73.3 percent), to acquire

more resources (73.1 percent), and to better

realize the hospital population’s expectations

(Table VII). They also recognized that the

accreditation process helped them to develop

shared values (68.9 percent), to develop

networking with other partners in the health care

system (67.8 percent), to enable improvements in

the utilization of inpatient resources (67.8

percent), and to meet the expectations of other

health professionals (61.8 percent). In almost all

questions, the answers were given primarily by

Table II Characteristics of the population surveyed by questionnaire according tooccupation

Occupation Number Percentage

Caregivers: assistants and operatives,

paramedics, nurses and midwives 2,083 62

Medics 185 5.5

Non-caregivers: secretaries, engineer technicians

and workers 999 29.6

Administrative 95 2.9

Total 3,362 100

Notes: In order to facilitate data processing, we grouped the various professionalsinto four categories: (1) caregivers: assistants and operatives (pharmacy assistants,radiology assistants, laboratory assistants, caregiver assistants, technical assistants,pharmacist aides, amphitheatre operatives, hospital maintenance operatives),paramedics (dieticians, dietician managers, social workers, social worker managers,occupational therapists, kinesiotherapists, kinesiotherapist managers, radiologytechnicians, radiology technician managers, speech therapists, sight therapists,psychologists, psychomotor therapists, pedicure-podologists and trainers in traininginstitutions), and nurses and midwives (general nurses, psychiatric nurses, psychiatricnurse managers, nurses, nurse managers, midwives, midwife managers); (2) medics(physicians and pharmacists); (3) non-caregivers: secretaries (medical secretaries andnon-medical secretaries), engineer technicians and workers (technicians, includingthose working in EEG, radiology and laboratories, technician managers, computertechnicians, engineers, radiophysicists, workers (including laundry workers),ambulance workers, drivers, chaplains, telephone operators, hostesses); and (4)administrative (directors and management personnel).

Table III Representativeness of questionnaire respondentsrelative to population surveyed

Questionnaire addressed to

full-time professionals

Questionnaires x2 df p

Sex 0.00 1 ,0.05

Hospital 4.125 2 ,0.05

Occupation 7.763 4 ,0.05




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administrative staff (p , 0:05), except for (1) thedevelopment of networking with other partners,

where the opinions were provided primarily by

non-caregivers (p , 0:001), and (2) allowing the

hospital to acquire resources, where medics mainly

provided this opinion (p , 0:001).

Conditions for implementation of change

At the national level, the external institutional

environment has created strong pressure through

the imposition of mandatory accreditation.

However, these constraints were not backed up by

the simultaneous implementation of positive

incentives. At the level of the organization, the

hospital’s obligation to embark on the process was

not accompanied by an awareness of how much

accreditation could eventually serve as an agent of

change. Only once the self-assessment was

completed did people at the strategic and

operational levels recognize the importance of the

Figure 1 The dimensions of change




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changes to be made and of the necessity of

implementing major changes. Meanwhile, the

actors had the perception that their hospital was in

a precarious situation as it recruited patients

primarily at the local level (owing in part to its non-

central geographic location), despite its university

status, and therefore called for the implementation

of a specific strategy for survival.

The general director’s involvement in the

accreditation process was limited to animating

information sessions and drafting a letter of

commitment to quality for the hospital. As for the

president of the hospital’s medical committee

(CommissionMedicale d’Etablissement, or CME)

and the director of nursing care services, at no time

were they directly involved in the self-assessment,

leaving personnel at the operational level to their

own devices. Moreover, it was possible at this level

to set up a constellation of complementary actors

(Denis et al., 2001). Thus, as well as a previously

created quality committee, five positions were

assigned specifically to self-assessment (one

administrative, one public health physician, one

nurse, one secretary and one top nurse manager)

and three structures were created (a quality

directorate, a unit for the assessment of quality of

care and accreditation, and a quality bureau).

However, these structures were never the subject

Table IV Manner in which accreditation preparations were experienced in the departments

“Yes” (percent)

Questions Caregivers Medics Non-caregivers Administrative Total x2 p

Completion of this process constituted a key moment

for the hospital 77.4 65 82.7 71.9 76.6 0.004 S

Strategy to mobilize professionals was adapted 35.6 35.5 38.8 42.9 36.4 0.764 NS

The process affected all of the hospital’s fields of activity 74.8 69.8 65.1 75 71.8 0.115 NS

The process affected all of the hospital’s professionals 70.5 62.9 61.0 59.3 67 0.072 NS

The process was participatory 51.3 60 50.3 58.6 52.5 0.283 NS

The process was rigid 56.2 51.5 54.5 60 55.3 0.811 NS

The process was concrete 47.4 40 41.1 55 45.4 0.274 NS

The process was bureaucratic 80.9 65.2 76.1 77.3 77.8 0.003 S

The process was consensual 46.8 43.2 46.2 56.3 46.4 0.788 NS

Table V Knowledge acquired during self-assessment

“Yes” (percent)

About Caregivers Medics Non-caregivers Administrative Total x2 p

Yourself 21.2 13.2 15.9 4 18.2 0.024 S

Other professionals 26.8 26.3 19 22.2 25.0 0.185 NS

Your department 30.6 28.8 26.4 28.6 29.5 0.721 NS

Other departments 12.8 14.4 12.1 18.5 13.0 0.781 NS

The hospital 23.7 19 21.2 25.9 22.6 0.638 NS

Quality processes 44.3 53.8 40.9 42.9 44.8 0.127 NS

Accreditation process 45.6 57.5 39 44.8 45.8 0.013 S

Table VI Changes enacted thanks to self-assessment

“Yes” (percent)

Questions Caregivers Medics Non-caregivers Administrative Total x2 p

This process brought about irreversible changes

at the level of the hospital 72.6 57.5 71.2 53.8 69.6 0.011 S

This process brought about irreversible changes at the level of

your department 54.6 44.8 51.6 41.7 52.4 0.226 NS

Organizational changes were implemented in the department 34.0 35.5 34.3 26.7 34 0.837 NS

Changes occurred in professional practice 30.9 25.2 32.3 25.8 30.4 0.497 NS

New functions were integrated by certain professionals 11.7 12.1 17.6 32 13.6 0.008 S

Professional practice evaluation studies were put in place 30.8 25.4 26.2 25 29.6 0.624 NS

New topics were discussed in the departmental board

in connection with the accreditation preparation process 42.6 45 54 6 39 0.007 S

Quality indicators were defined 32.2 27.1 38.4 28.6 32.8 0.273 NS

Results of exit questionnaires were taken into account

systematically 58.0 13.7 20.2 26.7 21.5 0.298 NS




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of debate among the hospital’s authorities, and

never fell within the development of a strategic

plan. The quality bureau, which was considered a

steering group, was created to conduct the self-

assessment in association with the people working

specifically to this end, namely two representatives

from the CME and one from the hospital’s

administration. However, this steering group had a

hard time positioning itself relative to the quality

committee because of the lack of transparency in

the process. At the level of clinical and medico-

technical departments, no new position or

structure was introduced, with nurse managers

essentially being the ones to get involved in the

process, as were physician department heads,

albeit to a lesser extent.

Redistribution of power

The difficult context of accreditation in France

and the repercussions of the accreditation visit

placed enormous pressure on the hospital’s

directors. Indeed, the results of the visit and its

consequences could have had an impact not only

at the hospital level (recruitment of patients, staff,

budget allocations, viability, etc.) but also at an

individual level on the directors themselves (i.e.

their future career within or outside the hospital).

The other professionals in the hospital, such as

physicians, whose careers were not dependent on

the results of the accreditation visit, were not under

this pressure. Moreover, management felt strongly

that it was legitimate for them to intervene in the

clinical sphere, as it was incumbent upon them to

ensure that nationally recognized standards were

properly respected. This was all the more

important, in that the hospital could be held

criminally responsible in the event of non-

compliance with certain safety standards taken

directly from applicable rules and regulations.

Furthermore, the fact that accreditation was

mandatory legitimized a heteronomous

supervision of professionals by the administration.

This meant that professionals were subject to

direct supervision and to routine administrative

checks. This represents a potential source of

conflict, and could provide a reason for medical

and paramedical professionals not to buy into the

process (Mintzberg, 1979).

This supervision also took place at the

operational level, where initially the three quality

referents were independent and had the capacity to

act alone. Over time, the autonomy of the medical

and paramedical actors diminished in the face of

the quality director’s will to centralize control,

thereby generating considerable tension. The lack

of trust that reigned among the various parties did

not make it possible to establish collaborative

relationships. Information regarding all the

measures taken was shared only to a small degree

between professionals at the strategic and

operational levels. For example, the quality

director alone entertained a close relationship with

the general manager. Also, the quality bureau,

which was supposed to facilitate exchanges across

the three quality referents, managed instead only

unidirectional exchanges (administrative

departments conveyed no information and clinical

and medico-technical departments had to produce

their self-assessment).

Positioning of physicians

Prior to self-assessment, quality processes were

conducted essentially by the hospital’s physicians

in conjunction with nurses. Physicians carried out

an across-the-board public health mission in

addition to being clinicians. The introduction of

accreditation gradually led the administration to

claim a larger role in this area, for the reasons

mentioned above. Thus, leadership, which was

initially ensured by the medical corps, was slowly

Table VII Spin-offs expected from accreditation

“Yes” (percent)

Questions Medics Caregivers Non-caregivers Administrative Total x2 p

Accreditation makes it possible to improve treatment of patients 73.1 59.7 81.5 81.8 73.3 0.000 S

Accreditation makes it possible to develop values shared by all of

the hospital’s professionals 69.9 56.0 72.6 80 68.9 0.005 S

Accreditation makes it possible to better utilize inpatient

resources in the hospital 68.7 48.3 72.6 78.1 67.0 0.000 S

Accreditation allows the hospital to better meet the population’s

expectations 72 53.8 77.8 81.8 71.3 0.000 S

Accreditation allows the hospital to better meet the expectations

of other health professionals 62 45.1 69.6 78.6 61.8 0.000 S

Accreditation contributes to develop networking with the other

partners of the health care system 69 54.1 73.4 70 67.8 0.000 S

Accreditation allows the hospital to better meet the expectations

of health authorities 77.9 62.9 78.8 79.2 75.8 0.015 S

Accreditation can allow the hospital to acquire more resources 77.8 52.6 73.9 60.0 73.1 0.000 S




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taken over by the administration. At first, the

hospital’s physician clinicians expressed interest in

accreditation by taking part in the awareness

conferences that were held in the hospital and by

contributing to drafting the internal standards for

self-assessment in the hope of thus regaining some

lost “clout”:

My participation here is sincere, voluntary andenthusiastic, but it is also practical and somewhatcynical in that I quickly realized that this is fordepartment heads an excellent means of winningback the authority that they are in the process oflosing [physician and department head].

Other motives for their participation were the hope

that accreditation could protect them against

eventual legal suits and the possibility of improving

their medical practice:

. . . for many doctors, subscribing to accreditationboils down to eliminating a goodmeasure of risk, orat least trying to eliminate it. All of this has to dowith the relationship between the health caresystem and the justice system, with complaints . . .Certain doctors figure that it’s in their interest tobuy into this system, to improve quality precisely inorder to diminish these risks [physician anddepartment head].

However, they soon realized that accreditation was

more an organizational than a professional matter.

Because of their training and their own interest,

physician clinicians perceive the organizational

and managerial spheres to be the preserve of nurse

managers rather than their own (Robelet, 2001),

all the more so as they have neither the skills nor

the time for these. Thus, they have had the natural

tendency to disengage from these activities and

leave them to health care managers. Here, their

participation in self-assessment by way of the

working groups gradually diminished without

them ever adopting behaviour intended to boycott

the process. In short, it seemed that major issues

relative to the power struggle between physicians

and health care managers in health care

organizations were at the heart of the behaviour of

the former.

Creation of social capital

The numerous meetings organized for the purpose

of self-assessment were a key point to emerge from

the interviews and questionnaires. A feature of

these meetings was that they brought together a

broad range of professionals and disciplines. For

the first time ever at an establishment-wide level,

meetings were held to discuss the organization of

duties and the treatment of patients:

During this period of dialogue and exchanges, wefound a high degree of cohesion within themultidisciplinary team: all of the department’soperatives spoke their mind, no one monopolizedthe floor and everyone paid attention to what the

others had to say, be it department heads or staff,bar none . . . Three words summed things up:participation, adherence and quality

Self-assessment has unquestionably mobilized thepersonnel as a whole in a new way [commentsdrawn from the questionnaires].

Working on the ANAES manual or on the

hospital’s set of standards softened the hierarchical

relationships that existed across the various

professionals, and thus gave those in a more

vulnerable hierarchical position (e.g. assistants and

operatives in clinical, logistical and administrative

departments) or those working in so-called less

prestigious structures (medium- and long-stay

units) the opportunity to speak out and share their

perception of the organization. Under normal

circumstances, these people are rarely given the

chance to express themselves or to be heard. These

meetings made it possible for people who would

otherwise never have met to get to know one other,

to appreciate one another, and thus to establish

formal and informal professional ties. These new

ties strengthened the sense of belonging to the

same institution and made it possible to access

certain people more easily. These new social ties

also had a positive impact on treatment processes

(better flow of information and co-ordination). In

short, self-assessment provided an excellent

opportunity to forge social relationships and thus

create “social capital”. Bourdieu (1980) defined

social capital as:

. . . the durable possession of a network of socialrelations or membership in a stable group that theindividual can mobilize as part of his actionstrategies. This capital varies in volume andpotentiality as a function of the relations concerned[translation].

However, in order to maintain such an atmosphere

at work, it is imperative that the CQI philosophy be

integrated in themanagement philosophy, and that

the hospital’s hierarchical structures evolve. In the

case of the hospital studied here, no changes in the

hierarchical structures occurred following self-

assessment, and this at times may have generated

expectations and frustrations among professionals.

Change in practices and learning

organization

During self-assessment, a tacit sort of learning

took place at the individual and institutional levels.

First, professionals acquired new models of

thought, i.e. new vocabulary, the development of a

sharper sensibility for the needs of patients and

their families, the discovery of self-assessment, and

an awareness of the interdependence between

professionals and departments. Professionals were

also capable of integrating new activities, i.e. the

drafting of treatment protocols at the institutional




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level (both department-specific and

interdepartmental), the implementation of

indicators for treatment follow-up, the adoption of

a standard patient file for the hospital, etc.

However, these gains were made primarily by

people lower down the hierarchy or working in less

prestigious structures. These same people were the

ones who expected the most from self-assessment

as a potential tool for organizational change.

At the level of the UHC, both a CQI program

and a risk management program were adopted.

New values took root, particularly the need to

place the patient and his or her family at the heart

of all processes. Although such a principle should

have been present prior to self-assessment, the

accreditation manual made it possible to better

understand how to actually put it into practice:

What motivates me to want to be part of thisprocess is that I consider it possible for everyperson to evolve and this warrants doing things toimprove, bearing in mind the latest data andputting our heads together to seek solutions . . .plus, I find that we manage to provide patients withbetter treatment [nurse manager].

The hospital also learned the importance of a

writing culture and the place it should hold. Until

then, the organization’s memory was transmitted

essentially by word of mouth. Few things were

committed to paper, including information

regarding the patient. In this respect, there was no

single file for the hospital and no centralized

archives, and medical examination forms were

rarely signed. Accreditation also provided an

opportunity for people to become more familiar

with the notion of self-assessment – as opposed to

that of supervision – and to understand the

importance of gaining a better understanding of

the hospital’s activities in order to continue to

progress. However, such changes in attitude did

not come about after just a few months, and a

climate of trust had to take root in order to

maintain this capacity for reflection. Finally,

expertise in how to conduct self-assessment was

acquired (Beaumont, 2002).

Shift in the hospital’s relationship with its

environment

Self-assessment provided an opportunity to

rethink the mechanism for collecting data on client

satisfaction. A new collection system (completion

of a new questionnaire, implementation of a new

distribution circuit for questionnaires, centralized

processing of questionnaires and regular feedback

of standardized information to departments) was

set up in order to foster a higher response rate, as

the rate at the start of the preparations for

accreditation stood at only 6 percent. During self-

assessment, the ten member hospitals of the UHC

community expressed a keen interest in sharing

their know-how and information with the UHC

community. Moreover, a committee was created to

enable these hospitals to benefit from the UHC’s

tools, expertise, information and training.

Gradually, the valorization of the unique features

of the hospitals caused the UHCs’ position to shift

towards greater complementarity and

collaboration. These hospitals went above and

beyond the framework of accreditation in order to

foster better integration and continuity of care

across the various structures:

In other words, what’s changed is the possibility offoreseeing together eventual problems related toquality and of better integrating our practices[manager, member of the community of hospitals].

Self-assessment also had an impact on relations

between the hospital and other health

professionals working in the same urban

community. A survey was conducted with a view to

discerning the needs that these physicians might

have with respect to the hospital. Finally, self-

assessment had little effect on relations with health

authorities. These authorities were interested more

in the results of the eventual accreditation visit

than in the modalities of preparation.

Discussion

This is the first study to document the impact of

accreditation preparations on healthcare

organizations in France. The congruence between

our model of analysis and the observations

collected previously (Campbell, 1975;

McClintock et al., 1979; Contandriopoulos et al.,

1990) and across the various sources of data

(Pourtois and Desmet, 1989) allows us to assert

that the validity of this study is good. Furthermore,

presentation of these results to people who had

participated in the self-assessment of other public

hospitals in France (Pomey, 2003) allowed them to

gain an awareness of and to formalize what had

been observed in their own hospitals.

Putting the results of this study in perspective

with those obtained elsewhere allows us to draw

certain conclusions regarding the impact of

accreditation on healthcare organization.

Above all, self-assessment is, along with the

tabling of the accreditation report, one of the two

most propitious moments for implementing

change (Duckett, 1983; Shaw, 2003), albeit with a

variable impact on the different sections of the

organization and the different professionals

involved.

The clinical and medico-technical departments

are those most solicited by self-assessment.

Moreover, in these departments, nurse managers




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are the most motivated to take part in the process

on account of their sensibility to management-

related matters (Duckett, 1983; Lozeau, 1996,

2002; Francois, 2001). It is nurse managers who

assume the leadership role in this regard. For their

part, physicians are involved in the process to

varying degrees: public health physicians are often

found in a position of operational leadership and,

at the department level, department heads are

most easily mobilized. Administrative departments

are less inclined to conduct their own self-

assessment. They participate in the exercise

essentially through the cross-sectional self-

assessment that is performed when the ANAES

accreditation manual is filled out. However, they

claim the legitimacy to conduct accreditation. In

addition, self-assessment is an opportunity to

introduce a writing culture, all the more so in

France where such a culture was practically non-

existent prior to the implementation of

accreditation. Self-assessment also provides an

opportunity to set up a more standardized and

better integrated quality control and risk

management program (Baker et al., 1995;

Daucourt and Michel, 2003).

However, self-assessment is less conducive to

change with respect to organizational trajectory

and to relations with health authorities, as

previously evidenced by Duckett (1983). It does

not contribute to help hospitals better define their

activities and fields of action. At present, the

trajectory of hospitals in France is reviewed

primarily within the framework of the objectives

and means contracts between regional

administrative authorities and hospitals, which

essentially cover spheres of activity and funding

(Zurcher and Pomey, 2000).

Our study has also brought to light points never

previoulsy discussed in the literature. First and

foremost, it has revealed a certain polarity in the

perception that professionals have of accreditation

preparations. On the one hand, the process is

viewed as bureaucratic, owing to the obligation –

essentially imposed by the administration – to

hold meetings and to complete the standards

manual. On the other hand, it was seen as

participatory and consensual because of the

opportunity to speak freely and voice opinions

regarding the functioning of the hospital. Indeed,

self-assessment provides people lower down the

hierarchy or working in less prestigious structures

within the hospital the opportunity to be heard.

Thanks to the creation of non-hierarchical loci of

exchanges where the hospital’s dysfunctions can be

discussed, it is possible for all professionals to

speak their mind. This fosters communication and

the forging of new ties, thereby creating social

capital. However, it is imperative to find a way to

ensure that all voices continue to be heard over

time. Indeed, the hierarchical system that

currently exists in hospitals may not be conducive

to maintaining such loci where all categories of

professionals can present their views and

participate in decision making. This

notwithstanding, studies have shown that

accreditation does make it possible to level out

communication channels within organizations,

and fosters both formal and informal

communications (Duckett, 1983; Beaumont,

2002; Francois, 2001).

A second point concerns the impact of

preparations for accreditation on relations with

nearby hospitals. In this first phase of

accreditation, the preparations served to foster the

sharing of information and greater service

integration.

Finally, our study indicates that the impact of

self-assessment on the hospital’s performance

(Sicotte et al., 1998) translated primarily into the

development of values shared by the professionals

of the hospital and the creation an organizational

environment which is more conducive to fostering

better treatment of patients. Self-assessment

makes it possible to refocus on the person treated

and his or her family, through, for example, a more

systematic evaluation of client satisfaction and the

implementation of a more appropriate complaints

management system.

The latest studies in the field have shown a

growing interest in the development and impact of

performance indicators on organizations (Baker

et al., 1995; Ente, 1999; Lemieux-Charles et al.,

2000; Grachek, 2002). In France, the absence of

such indicators at the hospital level does not make

it possible to measure the real impact of self-

assessment on the treatment of patients (Daucourt

and Michel, 2003). However, preparation for

accreditation did foster the introduction of

performance indicators. These should in future

enable better monitoring of the impact of

preparation for accreditation in each hospital, and

eventually to compare one hospital against

another. Further studies are necessary in this field

in order to evaluate the impact of the accreditation

report and of future accreditation visits

(Beaumont, 2002).

Self-assessment is an exercise that is very time-

intensive for staff. In this study, we did not

evaluate its cost to the hospital, but it certainly

represents a considerable sum that can be justified

only by a significant return on investment.

However, very few studies have documented the

cost of these procedures (Bohigas et al., 1998).

Research needs be pursued specifically to get a fix

on the cost-effectiveness (Drummond, 1980) of

this exercise.




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