Quality of care: the Court of Auditors very critical!

In a report, the Court of Auditors draws a harsh observation on the policy of improving the quality of care in health establishments. Adverse events are largely under-reported, the indicators do not sufficiently target the results and the relevance of care, the culture of quality needs to be strengthened among caregivers by more fully integrating the role of the patient and finally there is no national policy to improve the quality of care. The Court makes 11 recommendations. Press release.

The quality of care in healthcare establishments constitutes a major public health issue. In France, each year, around 13 million patients are welcomed in 2,965 health establishments distributed between 1,330 public structures, 978 private for-profit structures and 667 private non-profit structures.

The term quality of care is defined by the High Authority for Health (HAS) and brings together several notions such as the safety of medical acts and interventions, as well as their efficiency, accessibility and relevance, as well as the responsiveness of the care system to the patient’s expectations.

The non-quality of care represents a major financial challenge. Based on data from the Organization for Economic Cooperation and Development (OECD), the Court estimates that compensation for avoidable damage in France would amount to more than €11 billion and that for damage relating to unnecessary or low-value care at €22 billion.

In its report, the Court sought to answer three questions: Does the policy implemented make it possible to measure changes in the quality of care in health establishments? Does the policy implemented make it possible to improve the quality of care in establishments? Does the policy implemented reinforce the “culture of quality of care” among hospital professionals while integrating the role of the patient?

A measurement of the quality of care in health establishments that is still incomplete

Adverse events occurring in healthcare establishments and having serious consequences for patients (death, life-threatening, probable occurrence of a permanent functional deficit) are largely under-reported by healthcare professionals despite the existence of a legal obligation in this area since 2004. In fact, between 160,000 and 375,000 events of this nature occur each year during hospital stays, but only 7,100 have been declared in 2024. The monitoring of infections contracted in establishments, which are the cause of around 4,000 direct deaths per year, i.e. more than road mortality, is also not exhaustive. Moreover, the certification of health establishments is not sufficiently based on a risk-based approach and the quality of care indicators are too numerous and excessively focused on hospital processes to the detriment of care results. The Qualiscope plateform, which constitutes the main source of public information on the quality and safety of care in health establishments, remains incomplete and unknown to patients and caregivers alike. Finally, the quality of care criterion is too little taken into account in the financing of health establishments.

A policy that does not sufficiently target results and the relevance of care

The indicators intended to measure the results of acts, examinations and medical or surgical interventions provided in health establishments, today represent a very minority share, around 10%, of health care quality and safety indicators. The calculation of these indicators, which is currently based on the bases
national medico-administrative data, such as the systems medicalization program
information, could be developed on a larger scale. Minimum activity thresholdsdefined for
certain medical and surgical specialties, which constitute a lever for the quality of care, are not
as for them not always respected. This is particularly the case for ovarian cancer surgery (twenty procedures
per establishment per year) or for deliveries (300). Moreover, the issue of relevance of care,
which consists of providing the most appropriate and effective procedure to the right patient, is not sufficiently integrated into the
management of the quality of care, even though it is a central dimension. Furthermore, the Court notes
than ambulatory surgery, with numerous advantages in terms of quality of care and patient satisfaction.
patient, must be subject to reinforced monitoring of adverse events and nosocomial infections,
hospital discharge process and proper consideration of the patient’s socio-economic context. The
medical treatment of patients remains risky, in a context of
too limited use of clinical pharmacy and insufficiently supervised monitoring of so-called high-risk medications.

A culture of quality to be strengthened among hospital professionals, by further integrating the role of the patient

The measurement of patient satisfaction during hospitalization has seen a favorable development with the implementation
set up by the HAS of questionnaires for “e – Satis” patients. The response rates obtained
are, however, still too weak to be sufficiently representative. Moreover, it is essential to
measure the results of care perceived by the patientsuch as symptoms experienced, abilities
functional or quality of life after intervention. The advantages brought by this approach are
recognized both by patients and by health professionals who, by having the possibility of comparing their
results, can modify their practices. The Court further calls for the role of the patient partner to be
develops further. Through his experience, the patient, especially the chronically ill, can help others
patients, suffering from the same pathology, to better tolerate their illness, in complementarity with the
health professionals, who remain responsible for care. Furthermore, the culture of quality of care at
health professionals is a major issue. Its appropriation, on a daily basis, by the actors themselves,
is not satisfactory today. The accreditation system for doctors should evolve,
individual functioning towards a multi-professional logic, and be extended to more specialties
medical. The volume of hours devoted to quality within the initial training of doctors is
insufficient. Finally, team working methods, optimization of the workload of professionals
health or even the stability of teams, are insufficiently taken into account to date.

Establish national governance of the national policy to improve the quality of care

The Court notes the absence of a multi-annual strategy for the quality of care, as well as the lack of management
coordinated by the stakeholders in this policy.
The Court therefore recommends establishing, from 2026, national governance of the policy
for improving the quality of care within health establishments, responsible for developing and monitoring the
implementation of a multi-year strategy further integrating the relevance of care and the role of the patient.

Recommendations

From 2026, during certification visits to health establishments, better take into account serious adverse events associated with care in prior risk analyzes (High Health Authority).
From 2027, rationalize the policy of quality of care indicators under the aegis of the High Authority of Health and stabilize the list of indicators the collection of which is imposed each year on health establishments (ministry responsible for health, High Authority for Health).
From 2027, provide a financial sanction system for health establishments in the event of non-compliance with the obligation to legally declare a serious adverse event associated with care based on the control of a sample of representative patient files (ministry of health).
Gradually from 2026, increase the use of results indicatorsby systematizing their production, based in particular on medico-administrative bases (ministry responsible for health, High Authority for Health).
From 2026, for each health establishment offering care activities subject to a threshold, conduct, at regional level, periodic activity reviews taking into account the quality and safety of care and draw the consequences on the appropriateness and conditions of their continuation (ministry responsible for health).
From 2026, strengthen monitoring of the quality of care provided in outpatient surgery (ministry responsible for health, National Health Insurance Fund, High Authority for Health).
From 2026, develop a national list of high-risk medications, listed by type of service or care unit, for health establishments (ministry responsible for health, National Agency for the Safety of Medicines and Health Products).
From 2026, accelerate the deployment in healthcare establishments of measuring care outcomes reported directly by patients (PROMs), linked to the results indicators, and make these data public (ministry responsible for health, High Authority for Health).
From 2027, develop the individual accreditation system for doctors towards multi-professional team accreditation and extend it to more medical specialties (ministry responsible for health, High Authority for Health).
From 2027, provide in the first cycle of medical studies a new compulsory teaching unit focused on the quality and safety of care (ministry responsible for health, High Authority for Health).
From 2026, establish a national governance of the policy for improving the quality of care, responsible for developing and monitoring the implementation of a multi-annual quality strategy further integrating the relevance of care and the place of the patient (ministry responsible for health, High Authority for Health, National Health Insurance Fund).