| The objective was to examine the dynamics of change that operated following accreditation preparations. Through implementation analysis, the present embedded explanatory case study sought to explore the organizational changes brought about in a university hospital centre after the introduction in 1996 of compulsory accreditation in France. To this end: (1) a theoretical framework for analyzing change was developed; (2) semi-structured interviews, focus groups, and questionnaires addressed to the establishment's professionals were used, and documents were collected and (3) qualitative and quantitative analyses were carried out. Analyses were run on four axes: nature (extent/rhythm/trajectory), action strategies (accompaniment/resistance), design (deductive/inductive) and issues/challenges (strategic, organizational and environmental). Although preparation involved all areas of the establishment, professionals from clinical and medico-technical services (CMTS) were the ones who most participated, particularly nurses and commission members. The preparation's design, essentially deductive, called for, on the one hand, lectures and an information letter addressed to the professionals, and, on the other, the creation of an internal self-assessment reference system distributed to the CMTS, derived from the accreditation manual, and self-assessment groups to complete the manual. The action strategies did not include any inducements. The main motives for participating were defence of the establishment's interests and the desire to learn. However, the procedure was perceived as bureaucratic. Physician absenteeism at meetings attested to a certain resistance on their part. From an organizational viewpoint, some functions and structures were created. Leadership was exercised by management. The self-assessment groups provided an opportunity to reflect in a non-hierarchical manner on the treatment of patients and on the establishment's operational modalities, by creating a locus for exchanges and collegial decision-making. Persons lower down in the hierarchy (e.g., women, assistant caregiver, surface agents) or working in less prestigious structures (medium- and long-stay) were the ones for whom the preparation was most a source of change, having to acquire new activities, new intellectual models and new social ties. Otherwise, the greatest changes involved giving greater consideration to results of exit surveys, committing procedures to paper (in all services) and adopting a continuous quality improvement (CQI) program. Finally, the establishment set up with its community of establishments a support partnership to deal with quality processes. Accreditation preparation was a key moment for introducing a quality program and change dynamics. The major changes involved the creation of "social capital" and consideration given to the patients' point of view. |
