From clinical guidelines to quality assurance: the experience of Assistance Publique-Hôpitaux de Paris

The objectives of this study are: to present the history of the development of clinical guidelines in France. to present the implementation of a program of clinical guidelines in Assistance Publique-Hôpitaux de Paris (AP-HP), the regional public hospital system of the Paris metropolitan area, and to discuss the lessons learned from this program, which provide a basis for a better policy of guidelines at a national level.

The objective of the AP-HP program is to promote the appropriate use of clinical guidelines and to evaluate their impact on quality of care and/or costs. Experiments such as controlled trials are used to test the effectiveness of some implementation strategies, to verify that guidelines do improve the process of care and to improve physician compliance with clinical guidelines. Guidelines are developed in a context of budget constraint, and the general aim of the program is to promote the more efficient use of available health resources.

In a context of health care inflation, the desire of public authorities is to use guidelines as a tool for cost control strategy, either for ambulatory care or for hospitals. AP-HP experience shows that it is very difficult to develop a national program of clinical guidelines and to implement it in every hospital, as was done in France (but not clearly evaluated) in ambulatory care (under the name 'references médicales'). Guidelines need to be locally adapted, and the best implementation strategies depend on local resources, for example the existence of a pertinent information system. The role of financial incentives is present in French policies, and the role of the drug industry needs to be evaluated.