[Implementation of quality management in French hospitals: staff interplay and induced changes]

French hospitals have been encouraged to develop quality processes, in particular through the implementation of a mandatory accreditation. Our objectives were to study the models of quality management used in hospitals and to identify the induced changes in organisation and practices.

This multiple case study related to 9 acute care hospitals selected among the hospitals whose quality process were relatively old. The study was based on interviews related to 78 people including 26 administrative staff members, 33 physicians and 19 chief nurses. Implementation analysis and strategic analysis were applied.

Accreditation played a major part in the institutionalisation of quality processes. Implementation appeared more complete in the small size and private statute hospitals compared to the large public statute hospitals. But the main factors accounting for implementation variability were the level of involvement of the executive directors and participation of doctors in the quality process' leadership. The most important changes were establishment of specific structures, appearance of new professions and elaboration of quality documentation. In the hospitals where the quality process was strongly implemented, there was a trend to the de-compartmentalization between the professions and between the structures and phenomena of employees'development and empowerment.

Institutionalisation of quality management is recent and the level of implementation varies greatly among hospitals. Involving doctors remains a major challenge for the development of quality management so that the quality can lead changes in hospital.