Patrice François

Accreditation: a tool for organizational change in hospitals?

Examines the dynamics of change that operated following preparations for accreditation. The study was conducted from May 1995 to October 2001 in a university hospital center in France after the introduction in 1996 of mandatory accreditation. An embedded explanatory case study sought to explore the organizational changes: a theoretical framework for analyzing change was developed; semi-structured interviews, focus groups, and questionnaires addressed to the hospitals professionals were used and documents were collected; and qualitative and quantitative analyses were carried out. Professionals from clinical and medico-technical departments participated most. Preparations for accreditation provided an opportunity to reflect non-hierarchically on the treatment of patients and on the hospitals operational modalities by creating a locus for exchanges and collegial decision making. These preparations also led to giving greater consideration to results of exit surveys and to committing procedures to paper, and were a key opportunity for introducing a continuous quality program.

Paradoxes of French accreditation

The accreditation system introduced into the French healthcare system in 1996 has five particular characteristics: (1) it is mandatory for all healthcare establishments; (2) it is performed by an independent government agency; (3) surveyors have to report all instances of non-compliance with safety regulations; (4) the accreditation report is delivered to regional administrative authorities and a summary is made available to the public; and (5) regional administrative authorities can use the information contained in the accreditation report to revise hospital budgets. These give rise to a number of paradoxes: (1) the fact that accreditation is mandatory lends itself to ambiguity and likens the process to an inspection; (2) the fact that decision makers can use the information contained in the accreditation report for resource allocation can incite establishments to adopt strategic behaviours aimed merely at complying with the accreditation manual; and (3) there is a tendency for establishments to reduce quality processes to nothing more than the completion of accreditation and to focus efforts on standardizing practices and resolving safety issues to the detriment of organizational development. All accreditation systems must be aware of these paradoxes and decide on the level of government involvement and the relationship between accreditation and resource allocation. With time, accreditation in France could benefit from both a professionally driven system and from the increased amount of freedom to focus on quality improvement which is necessary for organizational development.

Assessment of an intervention to train teaching hospital care providers in quality management

Background: Successful implementation of continuous quality improvement (CQI) programs in hospitals remains rare in all countries, making it necessary to experiment with implementation methods while considering the cultural factors of resistance to change. Objective: To assess the impact of an educational intervention on involvement of clinical department staff in the quality process. Setting: Twelve voluntary clinical departments (six experimental and six controls) in a French 2000-bed university hospital comprising 40 clinical departments. Intervention: Three day training seminar to a group of 12–20 staff members from each department. Design: Quasi-experimental post-test only design study with control group conducted 12 months after the intervention with a questionnaire completed in a face-to-face interview. Subjects: 98 trained staff and 100 untrained staff from the six experimental departments and 100 staff from the six control departments. Principal measurements: Declared knowledge of the CQI methods and participation in quality management activities. Results: 286 people (96%) were involved in the study. More of the trained staff knew the CQI methods (62.4%) than staff in the control departments (16.5%) (adjusted odds ratio (ORa) u200a=u200a 10.6 (95% CI 4.97 to 22.62)). More trained staff also participated in quality improvement work groups than control department staff (76.3% v 14.0%; ORa u200a=u200a 27.4 (95% CI 11.6 to 64.4)). In the experimental departments the untrained staff’s knowledge of CQI methods and their participation in work groups did not differ from that of control department staff. Conclusions: A continuing education intervention can involve care providers in CQI. Dissemination of knowledge from trained personnel to other staff members remains limited.

Patient compliance with medical advice given by telephone

Data on compliance with medical advice given by telephone consultation services are currently lacking. The aim of this study was to assess patient compliance with medical advice given by a call center. A cross-sectional telephone survey was carried out on a random sample of 463 callers 72 hours after contacting the Grenoble Dial 15 center in France. Four hundred nine subjects (88.3%) participated in the study. Of these, 286 callers (69.9%) complied with the medical advice given. Compliance was 61.4% among patients who were advised to treat themselves, 83.9% among patients who were advised to consult a general practitioner during business hours, and 64.0% among patients who were advised to go to an accident and ED (P <.01). The survey pointed out adverse events resulting from the service. Assessing patient compliance can be an important source of information for improving aspects of patient management provided by telephone consultation services.

Prospective assessment of fluoroquinolone use in a teaching hospital.

The aim of this study was to review the use of fluoroquinolone (FQ) drugs in a teaching hospital and to bring to light the factors associated with FQ misuse. A prospective observational study of FQ prescriptions was conducted in a 2,200-bed teaching hospital. Every hospitalized patient receiving a FQ drug during the 3-week survey period was included. A questionnaire was filled out using medical records and face-to-face interviews with FQ prescribers. An infectious diseases specialist reviewed the questionnaires and analyzed FQ therapy according to local guidelines for FQ prescription. Among the group of 174 patients included, FQ therapy was inappropriate in 88 cases (50.6%; 95% CI 43–58) for the following reasons: inappropriate clinical setting, 43; non-first-line recommendation, 24; inappropriate choice of FQ agent, 9; and inappropriate combination of FQs, 12. FQ prescriptions did not comply with prescription rules in 45 cases (25.9%; 95% CI 20–33). Appropriateness and compliance overlapped for 17 of these 45 patients who received an inappropriate FQ course that did not comply with prescription rules. Finally, FQ therapy was misused for 116 of the 174 patients (66.6%; 95% CI 59–74). Characteristics linked with FQ misuse were hospitalization in surgical wards (pu2009=u20090.03), intravenous therapy (pu2009<u20090.01), and presumptive therapy (pu2009=u20090.05). The FQ misuse rate progressively decreased during the survey period (pu2009=u20090.04). FQ misuse was a common phenomenon in the teaching hospital studied. The significant improvement in FQ prescribing practices observed during the study period demonstrates that frequent review of antibiotic use with prescribers is warranted.

Implementation of a documentation management system for quality assurance in a university hospital.

Development and implementation of guidelines constitutes the basis of quality management systems for any organization. The authors have studied the internal documentation produced by professionals on 88 functional units of a university hospital. Reveals the existence of many documents concerning quality of care with an average of 102 available procedures or protocols per unit. However, this documentation is badly organized, making it difficult to consult and to put into practice. The results of this study were provided to other professionals at our hospital in order to make them aware of the necessity of rigorous document management. We have also written and sent recommendations for drawing up procedures and implementing an efficient documentary management system. This effort complements development of the hospital quality assurance plan.

Compliance with instructions for writing structured care management tools.

The aim of this study was to assess whether clinical guidelines complied with the instructions for writing structured care management tools in a French university hospital. A cross-sectional study of guidelines for appropriate antimicrobial agent use in the authors institution was carried out. A total of 221 guidelines were retrieved in 62 hospital units. The number of guidelines by unit ranged from one to 22 and 198 guidelines (90 per cent) had been developed at the local level. None of the guidelines fully complied with the ten criteria of the instructions. Each guideline met, on average, 4.2 criteria (3.9-4.5). The partial compliance rate was 75 per cent (68-80). In two-level multivariate analysis, factors associated with partial compliance were: dissemination of guidelines after implementation of the instructions (odds ratio = 6.25 (2.41-16.21)), existence of more than one storage site for guidelines in each unit (OR = 3.26 (1.03-10.32)), and hospital unit (variance of the intercept = 1.54).

Implantation de la gestion de la qualité dans les hôpitaux français, jeux d’acteurs et transformations induites

Position du probleme Les etablissements de sante francais ont ete incites a developper des demarches qualite, en particulier par la mise en place d’une accreditation obligatoire. Notre objectif etait d’etudier les modalites de l’implantation de la gestion de la qualite dans les hopitaux et d’identifier les changements induits dans l’organisation et les pratiques. Methodes Cette etude de cas multiples portait sur neuf hopitaux de court sejour selectionnes par choix raisonne parmi les etablissements dont les demarches qualite etaient relativement anciennes. L’etude etait fondee sur des entretiens qui ont concerne 78 personnes dont 26 directeurs et personnels administratifs, 33 medecins et 19 cadres de sante. L’analyse a fait appel aux methodes d’analyse de l’implantation et d’analyse strategique. Resultats L’accreditation jouait un role majeur dans l’institutionnalisation de la demarche. L’implantation de la gestion de la qualite paraissait plus complete dans les etablissements de petite taille et de statut prive par rapport aux grands etablissements de statut public. Mais les facteurs les plus determinants etaient l’engagement de la direction et la participation de medecins dans le leadership de la demarche. Les changements les plus importants portaient sur la mise en place de structures specifiques, l’apparition de nouveaux metiers et l’elaboration de documents qualite. Dans les etablissements ou la demarche qualite etait tres implantee, on notait une tendance au decloisonnement entre les metiers et entre les structures des phenomenes de valorisation et de responsabilisation des personnels. Conclusion L’institutionnalisation des demarches qualite est recente et le niveau d’implantation varie beaucoup selon les etablissements. L’adhesion des medecins reste un des enjeux importants pour que la demarche puisse induire des changements a l’hopital.

Intérêt des revues de mortalité et de morbidité en psychiatrie

A mortality and morbidity (M&M) review consists in analysing, collectively and retrospectively, the cases of patients whose evolution has been marked by a complication or death. This analysis must question whether such an outcome could have been avoided, making it possible to identify the causes and correct the factors having contributed to its occurrence. After a presentation of the methodological and organisational principles, as well as the M&M reviews carried out in France, attention is turned to those performed in psychiatry and identifying the main perspectives for the discipline.

La conduite de projets organisationnels portée par les cadres de santé : étude qualitative à partir d’un dispositif pédagogique

Le travail de coordination operationnelle par les cadres de sante (CdS) est mieux connu que leurs capacites de transformation de l’organisation du travail et des pratiques de soin. Dans cet article, nous etudions des projets organisationnels conduits par des CdS qui peuvent, selon les cas, concerner leur equipe, impliquer la hierarchie hospitaliere ou d’autres equipes. Nous nous appuyons sur une recherche-intervention qui a permis de suivre 17 projets organisationnels portes par des CdS sur une annee. Les resultats de cette recherche mettent en valeur les efforts d’intercomprehension de la part des CdS vis-a-vis des autres acteurs comme la principale condition de reussite. Les CdS qui sollicitent la participation de leur equipe a l’elaboration des solutions obtiennent des ameliorations durables. Quand les problemes identifies impliquent la hierarchie, les CdS cherchent a developper des relations interpersonnelles. Quand ils impliquent d’autres services dont ils sont dependants, les CdS engagent des negociations integratives. Ces resultats suggerent de developper la discussion sur l’organisation du travail et de contractualiser les projets organisationnels. Cette recherche-intervention permet aussi de valider la pertinence d’une formation-action des CdS au diagnostic organisationnel.