Toward quality improvement in a French hospital: structures and culture.

This paper describes the evolution of quality improvement efforts over the past decade in a 600-bed French teaching hospital, after reviewing some characteristics of the French hospital system. The sequential attempts to improve drug dispensation illustrate the evolution of quality improvement efforts. Initial studies conducted in voluntary medical wards led to the modification of traditional prescription forms. Resulting improvements were presented in Evaluation Committee meetings, inducing other wards, to undertake similar changes on their own. A more systemic program currently is underway. The success of initial efforts can be credited to the willingness of physicians and nurses to engage in changes when the need for change was evident in their daily work experience, in spite of the questionable validity of some of the original findings. Focusing on systemic processes rather than on individual faults allowed this involvement. Reassessing the validity of so-called medication errors also highlighted the importance of careful process analysis, which should be stressed during the development of quality assurance procedures. The variability inherent in clinical conditions calls for a flexible, outcome-oriented approach, as used in quality improvement methods. Quality improvement efforts are spreading throughout the hospital. However, diffusion of change from motivated work groups to the larger community remains a challenge. To obtain a consistent performance level across all parts of the organization, and to avoid losing impetus due to uncoordinated efforts, innovation must become a consistent feature of the hospital structure.