Accreditation: a tool for organizational change in hospitals?

Marie-Pascale Pomey -Pierre Contandriopoulos Andre Patrice Franc ois and Dominique Bertrand
The authors
Marie-Pascale Pomey is Assistant Professor, Faculty of Management, University of Ottawa, Ottawa, Canada. -Pierre Contandriopoulos is Professor, Department of Andre Health Administration, Faculty of Medicine, University of Montreal, Montreal, Canada. Patrice Franc ois is Professor, Evaluation Unit, University Hospital Centre, Grenoble, France. Dominique Bertrand is Professor, Department of Public Health, pitaux de Paris, Fernand-Vidal Hospital, Assistance Publique Ho Paris, France.

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 ve years following the reforms a mandatory accreditation review conducted by an agency created specically 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) dened accreditation as:
. . . an evaluation process carried out by independent professionals external to the health care organization and its governing bodies, focusing on its functioning and practices as a whole. It aims to ensure that conditions regarding the safety, quality of care and treatment of patients are taken into account by the health care organization [translation].

Keywords
Quality management, Organizational change, Social change, France

Abstract
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 reect 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.

Electronic access
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The accreditation process, which comprises a selfassessment, a eld 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, gouin, 1998), French-style 1995a, 1995b; Se accreditation has a number of interesting characteristics (Code of Public Health, 1996; Bertrand, 2001): . it is mandatory every ve 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 gouin, 1998; Scrivens, 1998, internationally (Se Shaw, 2003) since seeing the light of day in the United States in 1919 (Roberts et al., 1987).
This study was made possible with the nancial 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.

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

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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 benets in the six areas examined (i.e. administration and management, medical organization, critical review of cases, organization of nursing care, safety, and hospitals denition 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 nding 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; Franc ois, 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 organizations weaknesses, and to implement corrective measures as a function of the users 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 specically 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 ve geographical sites (two short-stay, two mediumand 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 hospitals sites; . a cross-sectional professional standards gouin, 1998) specic to the manual (Se 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 hospitals 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 hospitals 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 identied: (1) Departments (vertical level). (2) Thematic self-assessment groups (TSAGs), created specically to complete the accreditation manuals standards (crosssectional 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.

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(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.

nurses or nursing assistants (44 percent) in departments targeted by the standards manual (81.6 percent) and in the UHCs 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 hospitals policies. Physical surveys of the departments were conducted to ascertain the resources allocated to self-assessment.

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 selfassessment (Table I). The questionnaires were sent out to all of the hospitals 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 was made up mostly of women (80 percent) who worked as
Table I Characteristics of data sources according to level of case analysis Nature of Level data Categories of people Departments Interviews Questionnaires

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

Number expected 40

Number interviewed or responded 35

Documents TSAGs Interviews Questionnaires Documents Interviews Documents

Heads of clinical departments People working full-time in departments targeted by hospital standards manual and in departments not targeted by the manual Documents issued for departments and drafted by departments in connection with self-assessment Presidents TSAG members excluding presidents Documents issued for TSAGs and drafted by TSAGs Quality directors and members of quality bureau Documents issued for quality directors and the quality bureau and drafted by them Hospital head, director of nursing care services, CME president, quality committee president, union representative, users representative, communications director Documents issued for the strategic level and drafted by this level Quality directors Documents issued within the context of the community of hospitals in connection with self-assessment Hospital directors Objectives and means contract

3,248 All 10 114 All 8

1,693 All 9 62 All 7

Operational

All

All

Strategic

Interviews

7 All 8 All

Documents Community of hospitals Interviews Documents

All 3 All

All 2 None

Local and regional administrative authorities

Interviews Documents

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Table II Characteristics of the population surveyed by questionnaire according to occupation Occupation Number Percentage Caregivers: assistants and operatives, paramedics, nurses and midwives Medics Non-caregivers: secretaries, engineer technicians and workers Administrative Total 2,083 185 999 95 3,362 62 5.5 29.6 2.9 100

Notes: In order to facilitate data processing, we grouped the various professionals into 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, radiology technicians, radiology technician managers, speech therapists, sight therapists, psychologists, psychomotor therapists, pedicure-podologists and trainers in training institutions), and nurses and midwives (general nurses, psychiatric nurses, psychiatric nurse managers, nurses, nurse managers, midwives, midwife managers); (2) medics (physicians and pharmacists); (3) non-caregivers: secretaries (medical secretaries and non-medical secretaries), engineer technicians and workers (technicians, including those working in EEG, radiology and laboratories, technician managers, computer technicians, 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 respondents relative to population surveyed Questionnaire addressed to full-time professionals x2 df p 0.00 4.125 7.763 1 2 4 , 0.05 , 0.05 , 0.05

Questionnaires Sex Hospital Occupation

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 hospitals 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 hospitals 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 qualied 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 hospitals elds of activity. Moreover, 67 percent also considered that the process touched all of the hospitals 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 qualied as being rigid (55.3 percent), participatory (52.5 percent), consensual (46.4 percent) and nally concrete (45.4 percent) (Table IV). Knowledge gained over the course of selfassessment 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 denition 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 populations 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

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Figure 1 The dimensions of change

administrative staff ( p , 0:05), except for (1) the development 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 hospitals 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

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Table IV Manner in which accreditation preparations were experienced in the departments Questions Completion of this process constituted a key moment for the hospital Strategy to mobilize professionals was adapted The process affected all of the hospitals elds of activity The process affected all of the hospitals professionals The process was participatory The process was rigid The process was concrete The process was bureaucratic The process was consensual Caregivers 77.4 35.6 74.8 70.5 51.3 56.2 47.4 80.9 46.8 Medics 65 35.5 69.8 62.9 60 51.5 40 65.2 43.2 Yes (percent) Non-caregivers 82.7 38.8 65.1 61.0 50.3 54.5 41.1 76.1 46.2 Administrative 71.9 42.9 75 59.3 58.6 60 55 77.3 56.3 Total 76.6 36.4 71.8 67 52.5 55.3 45.4 77.8 46.4

x2
0.004 0.764 0.115 0.072 0.283 0.811 0.274 0.003 0.788

p
S NS NS NS NS NS NS S NS

Table V Knowledge acquired during self-assessment About Yourself Other professionals Your department Other departments The hospital Quality processes Accreditation process Caregivers 21.2 26.8 30.6 12.8 23.7 44.3 45.6 Medics 13.2 26.3 28.8 14.4 19 53.8 57.5 Yes (percent) Non-caregivers 15.9 19 26.4 12.1 21.2 40.9 39 Administrative 4 22.2 28.6 18.5 25.9 42.9 44.8 Total 18.2 25.0 29.5 13.0 22.6 44.8 45.8

x2
0.024 0.185 0.721 0.781 0.638 0.127 0.013

p
S NS NS NS NS NS S

Table VI Changes enacted thanks to self-assessment Questions This process brought about irreversible changes at the level of the hospital This process brought about irreversible changes at the level of your department Organizational changes were implemented in the department Changes occurred in professional practice New functions were integrated by certain professionals Professional practice evaluation studies were put in place New topics were discussed in the departmental board in connection with the accreditation preparation process Quality indicators were dened Results of exit questionnaires were taken into account systematically Caregivers 72.6 54.6 34.0 30.9 11.7 30.8 42.6 32.2 58.0 Medics 57.5 44.8 35.5 25.2 12.1 25.4 45 27.1 13.7 Yes (percent) Non-caregivers 71.2 51.6 34.3 32.3 17.6 26.2 54 38.4 20.2 Administrative 53.8 41.7 26.7 25.8 32 25 6 28.6 26.7 Total 69.6 52.4 34 30.4 13.6 29.6 39 32.8 21.5

x2
0.011 0.226 0.837 0.497 0.008 0.624 0.007 0.273 0.298

p
S NS NS NS S NS S NS NS

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 noncentral geographic location), despite its university status, and therefore called for the implementation of a specic strategy for survival. The general directors 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 hospitals medical committee tablissement, or CME) dicale dE (Commission Me

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, ve positions were assigned specically 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

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Table VII Spin-offs expected from accreditation Questions Accreditation makes it possible to improve treatment of patients Accreditation makes it possible to develop values shared by all of the hospitals professionals Accreditation makes it possible to better utilize inpatient resources in the hospital Accreditation allows the hospital to better meet the populations expectations Accreditation allows the hospital to better meet the expectations of other health professionals Accreditation contributes to develop networking with the other partners of the health care system Accreditation allows the hospital to better meet the expectations of health authorities Accreditation can allow the hospital to acquire more resources Medics 73.1 69.9 68.7 72 62 69 77.9 77.8 Caregivers 59.7 56.0 48.3 53.8 45.1 54.1 62.9 52.6 Yes (percent) Non-caregivers 81.5 72.6 72.6 77.8 69.6 73.4 78.8 73.9 Administrative 81.8 80 78.1 81.8 78.6 70 79.2 60.0 Total 73.3 68.9 67.0 71.3 61.8 67.8 75.8 73.1

x2
0.000 0.005 0.000 0.000 0.000 0.000 0.015 0.000

p
S S S S S S S S

of debate among the hospitals 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 selfassessment in association with the people working specically to this end, namely two representatives from the CME and one from the hospitals 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 medicotechnical 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 difcult context of accreditation in France and the repercussions of the accreditation visit placed enormous pressure on the hospitals 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 noncompliance 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 conict, 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 directors 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 hospitals 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

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taken over by the administration. At rst, the hospitals 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 and enthusiastic, but it is also practical and somewhat cynical in that I quickly realized that this is for department heads an excellent means of winning back the authority that they are in the process of losing [physician and department head].

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 the personnel as a whole in a new way [comments drawn from the questionnaires].

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 accreditation boils down to eliminating a good measure of risk, or at least trying to eliminate it. All of this has to do with the relationship between the health care system and the justice system, with complaints . . . Certain doctors gure that its in their interest to buy into this system, to improve quality precisely in order to diminish these risks [physician and department 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.

Working on the ANAES manual or on the hospitals 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 ow of information and co-ordination). In short, self-assessment provided an excellent opportunity to forge social relationships and thus create social capital. Bourdieu (1980) dened social capital as:
. . . the durable possession of a network of social relations or membership in a stable group that the individual can mobilize as part of his action strategies. This capital varies in volume and potentiality 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 the management philosophy, and that the hospitals hierarchical structures evolve. In the case of the hospital studied here, no changes in the hierarchical structures occurred following selfassessment, 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

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 rst 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, we found a high degree of cohesion within the multidisciplinary team: all of the departments operatives spoke their mind, no one monopolized the oor and everyone paid attention to what the

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level (both department-specic and interdepartmental), the implementation of indicators for treatment follow-up, the adoption of a standard patient le 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 this process is that I consider it possible for every person to evolve and this warrants doing things to improve, bearing in mind the latest data and putting our heads together to seek solutions . . . plus, I nd that we manage to provide patients with better treatment [nurse manager].

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 benet from the UHCs 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, whats changed is the possibility of foreseeing together eventual problems related to quality and of better integrating our practices [manager, member of the community of hospitals].

The hospital also learned the importance of a writing culture and the place it should hold. Until then, the organizations 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 le 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 hospitals 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 reection. Finally, expertise in how to conduct self-assessment was acquired (Beaumont, 2002).

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, selfassessment 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 rst 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

Shift in the hospitals 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 selfassessment, the ten member hospitals of the UHC

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are the most motivated to take part in the process on account of their sensibility to managementrelated matters (Duckett, 1983; Lozeau, 1996, 2002; Franc ois, 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 selfassessment. They participate in the exercise essentially through the cross-sectional selfassessment that is performed when the ANAES accreditation manual is lled 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 nonexistent 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 dene their activities and elds 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 (Zu rcher 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 hospitals 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 nd 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; Franc ois, 2001). A second point concerns the impact of preparations for accreditation on relations with nearby hospitals. In this rst 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 hospitals 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 eld 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 selfassessment 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 eld 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 timeintensive for staff. In this study, we did not evaluate its cost to the hospital, but it certainly represents a considerable sum that can be justied only by a signicant return on investment. However, very few studies have documented the cost of these procedures (Bohigas et al., 1998). Research needs be pursued specically to get a x on the cost-effectiveness (Drummond, 1980) of this exercise.

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