ACCREDITATIONS AND OTHER ACTIONS

Hospital accreditation objectives

France Accreditation is a process of external evaluation. It occurs periodically, every three years. Its objectives are

  • A system establishment to improve the healthcare quality and the patient safety
  • A level achievment of quality criteria considered essential and qualified priority practice
  • A quality measurement related to some particular as a challenge for improving quality, it completes the analysis of the quality system by introducing key performance indicators. it measures the consistency between the implementation of improvement and quality control on particular points. It ‘s a user expectation.

Accreditation does not establish a ranking of hospitals. It does not notice health professionals. It is not a substitute for state safety controls.

Accreditation procedure steps

Accreditation scope

The accreditation procedure concerns with all hospital activities

Survey organization

  • Written request and voluntary accreditation by the candidate hospital Volet Identification et de planification
  • Request study by France Accreditation and approval
  • Accreditation contract signature
  • Initial audit An internal audit, prior to accreditation survey, will be conducted by France Accreditation. Following this audit, a support plan prior to accreditation survey may be recommended to the hospital.
  • Self-evaluation The self-evaluation is an essential step in the accreditation process. The hospital professionals conduct their own quality assessment of their organization and their practices according to the accreditation manual (Standards).

This step assesses the initial quality and :

  • Identify improvement actions for improvement
  • measure the future impact,
  • strengthen the professional commitment.

The hospital agrees to feed forward on to France Accreditation the self-evaluation results two months before the scheduled accreditation survey.

  • Surveyor involvement and accreditation survey Following the initial audit, France Accreditation agrees to schedule an initial survey of 3 days with a team of three french surveyors. A schedule date be set with the hospital. The survey aims to objectify the quality level achieved and the existence of a continuous improvement.
  • Accreditation conclusion and accreditation report
    • Accreditation reportA report is prepared by the surveyors at the end of the hospital visit. It allows France Accreditation to base a graduated decision. France Accreditation feed back the pre-accreditation report to the concerned hospital. The hospital will have one month to submit its comments. As a result, the final report will be feed forwarded to the hospital within two months.
    • Communication and publication of the accreditation reportA summary of the final accreditation report is published on France Accreditation website. The hospital undertakes to provide, in full, to public and to professionals who apply the accreditation report as transmitted by France Accreditation.Communication actions of the hospital cover the full report.
    • Follow-up and compliance with France Accréditation decisions and opinionTo follow up the decisions, procedures and deadlines for follow-up are expected. This may include:
      • an action plan,
      • a follow-up report
      • a follow-up survey of one or some topics or units,
      • a targeted survey when the hospital does not provide the follow-up report at time.

      The hospital agrees to comply with all obligations imposed upon it in the follow-up actions mentioned into the accreditation decision and France accreditation report, including the period of targeted survey as well as the follow-up report deadline.

    • Accreditation evidence documents retentionFrance Accreditation maintains all evidence papers to the new accreditation occurrence and the accreditation report will be saved for an unlimited time
    • Accreditation durationThe duration of each accreditation is mentioned in the final report of accreditation. Accreditation is usually granted for a period of three years. France Accreditation may apply at any time at accredited hospital and during the accreditation period any data and any information and make any surveys seeming necessary.
    • Hospital Obligations The hospital shall: – Send to France Accreditation the self-evaluation results two months before the survey – Prepare the survey, including professionals information who should feed forward to the surveyors all evidence documents and information relevant to their mission and their practices; – Comply with the accreditation duration mentioned into the accreditation report.
    • Transparency, data communication and required documents The hospital agrees to notify to France Accreditation information and documents necessary to the accreditation process. The hospital agrees to notify to France Accreditation any development that may affect the accreditation process.
    • ConfidentialityThe surveyors and France Accreditation are required to respect the confidentiality of information during their mission. This duty is also after the surveyors stopped their cooperation with France Accreditation.
    • Reporting duty If, during the survey, the surveyors find evidence or lacks involving personal safety, they are obliged to inform France Accreditation, which shall notify in writing the hospital management.
    • Surveyor evaluation Following the survey, the hospital might conduct the surveyor evaluation on the basis of a questionnaire.
    • Observers during the surveyFrance Accreditation informs the hospital of observer attendance during a survey Observers appointed by France Accreditation will neither trade with the hospital during the survey nor in the accreditation process.

 Accreditation levels (Decision)

Accreditation Without recommendation France Accreditation supports the hospital to continue the improvement. The accreditation expires in three years.
Accreditation with recommendation(s) At least one recommendation The institution might implement the recommended measures. It provides evidence during the current accreditation or at coming accreditation survey in 3 years.
Accreditation with reserve(s) At least one reserve (with possible recommendations) 3 to 12 months are left to the hospital to produce a monitoring report related the issues and demonstrate that it has improved these points.
No accreditation Many major reserves or/ and Decision to suspend the accreditation A non-accreditation decision is taken when the hospital is subject of several major reserves and reserves. It can also be taken following a decision to suspend accreditation for a hospital that has not significantly improved by the deadline, observed dysfunctions.

The accreditation decision may include

  • Recommendations: invite the institution to make progress in some areas
  • reserves: statement (s) of deficiencies in some areas,
  • major reservations: statement (s) of serious shortcomings regarding the requirements of quality and patient safety.

Decisions and summaries of accreditation reports are published on the France Accreditation website. http://www.france-accreditation.fr.

It is up to hospital to ensure the widest advertisement internally and externally.

 Structure of the accreditation manuel

The chosen structure of the manual is:

– a two-chapter structure

– chapter I: Management of the establishment – chapter II: Patient care

– organisation of the items to be evaluated according to stages in a process of improvement.

To improve the readability of the manual and provide a structure for the grading system, each evaluation item is grouped into three columns, E1, E2 and E3.

E1, E2, E3 correspond to the stages usually found in an improvement plan: anticipate, implement, evaluate, improve.

Column E1 E2 E3
Stage Anticipate Implement Evaluate and improve
Type of item to be evaluated Define a policy, organise an activity, define an action plan, etc. Carry out an activity, meet requirements, implement an action plan, train, raise awareness, etc. Evaluate the activity, implement improvement action plans, ensure these plans are effective, etc.

This organisation of the items to be evaluated facilitates the understanding by users (professionals in establishments, surveyors) of the manual and of the requirements of each criterion.

The level reached by the establishment in the various evaluation items enables each criterion to be graded using one of 4 grades: A, B, C and D; these correspond to an assessment of the level of quality attained by the establishment for this criterion.

The subject areas developed in the manual deal with: Management of establishments

  • Strengthening requirements for setting up a safety system management and developing a culture of safety.
  • Development of requirements for evaluating and improving organisational and professional practices; this involves continuing with measures and consolidating these by deploying them at an institutional level, adapting and integrating them in the practice in all areas of activity, widening their scope to include notions of equity, access to care and analysis of the appropriateness of care.
  • Raising awareness of management changes within establishments, through:
    • promotion of decision-making and management procedures by means of scorecards and by monitoring evaluation and improvement activities, giving a high priority to dialogue;
    • integration of requirements pertaining to sustainable development.

Patient rights

  • New positioning of requirements pertaining to ethical issues.
  • Raising awareness of the idea of positive treatment. In continuance with a movement that arose within the medical and social work sector, it has appeared to be necessary, to go beyond requirements for the prevention of abuse, which is limited to criminal and individual behaviour, by encouraging establishments to implement steps to ensure that organisations become more respectful of individuals’ requirements and expectations.
  • Reinforcing the requirements concerning the respect of patients’ rights at the end of life and the right to palliative care.

Patient care

  • Top-priority objectives for improving the safety of care are displayed.
  • Reinforcement of evaluation of how operating suites function.
  • The improvement in the care of chronic illnesses and in therapeutic education for patients educations.
  • Reinforcement of the evaluation of high risk activities.

Required priority practices

In order to provide greater leverage of quality and safety of care, required priority practices have been introduced in the manuel. These required priority practices are criteria for which there are more explicit expectations. The study by the team of surveyors of the establishment’s position with respect to these requirements will be systematic and will have a standardised approach.

Selection of these practices is based on the identification by HAS, by the parties involved and by national and international experts, of those areas that are deemed to be fundamental for the improvement of healthcare quality and safety, as well as the capacity of the accreditation process to generate changes in these areas. Failure to achieve a significant level of compliance with regards to these requirements will automatically lead to an adverse accreditation decision or even to a decision of non accreditation.

9Criterion 14.bPRPPatients’ access to their medical records.

1 Criterion 1.f PRP Continuing professional development (CPD) policy and organisation.
2 Criterion 8.b PRP “Risk management” function.
3 Criterion 8.f PRP Management of adverse events.
4 Criterion 8.g PRP Control of risk of infection.
5 Criterion 9.a PRP System for managing complaints and claims.
6 Criterion 12.a PRP Pain management.
7 Criterion 13.a PRP Care and rights of patients at the end of life.
8 Criterion 14.a PRP Management of the patient record.
10 Criterion 15.a PRP Patient identification at all stages of treatment.
11 Criterion 20.a PRP Patient medication quality system.
12 Criterion 25.a PRP Management of emergencies and unscheduled care.
13 Criterion 26.a PRP Organisation of the operating suite.

France Accréditation indicators

This involves using the indicators collected in France that contribute to the measurement of quality and that correspond to the accreditation criteria.

At this stage the number of indicators is limited. In the long term, indicators developed specifically for the accreditation process will be added to the currently available indicators, thus allowing them to provide a significant contribution to measurement of the quality of establishments. Establishments are expected to include the available measurements in their self-evaluation work. Surveyors will also use the available measurements to evaluate the level of quality attained in relation to specific criteria. Collecting information about this indicator also confirms that the evaluation work has been carried out. The criteria for which indicators are available are indicated by a specific logo.

Criterion 8.gIND

Control of risk of infection.

Criterion 8.hIND Correct use of antibiotics.Criterion 12.aIND Pain management.Criterion 14.aIND Management of the patient record.Criterion 19.bIND Nutritional problems.Criterion 20.aIND Patient medication quality systemCriterion 24.aIND Discharging the patientCriterion 28.cIND CPD procedures linked to indicators of clinical practice.

1 Criterion 2.e IND Indicators, scorecards and management of the establishment.
2 Criterion 8.g IND Control of risk of infection.
3 Criterion 8.h IND Correct use of antibiotics.
4 Criterion 12.a IND Pain management.
5 Criterion 14.a IND Management of the patient record.
6 Criterion 19.b IND Nutritional problems.
7 Criterion 20.a IND Patient medication quality system
8 Criterion 24.a IND Discharging the patient
9 Criterion 28.c IND CPD procedures linked to indicators of clinical practice.

To know the indicator list of the Haute Autorité de Santé :

Click Here

To know the accreditation manual of the Haute Autorité de Santé: Click Here