Accreditation at a crossroads: are we on the right track?

Objectives: By comparing Canada, where accreditation is optional, to France, where it is required, this study evaluates the extent to which the accreditation process acts as a tool for bureaucratic coercion as opposed to a tool for learning.
Methods: Our study consists of a qualitative meta-analysis of studies of French and Canadian accreditation experiences between 1996 and 2006. Using the conceptual framework of Adler and Borys [Adler P, Borys B. Two types of bureaucracy: enabling and coercitive. Administration Science Quarterly 1996;41:61-89], we assess the characteristics of accreditation in the French and the Canadian environments and distinguish between coercive and enabling modi operandi.
Results: Results show that accreditation has positive impacts in the two countries but is more coercion-oriented in France than in Canada. This is because in France: (1) the fact that accreditation is compulsory and certain standards are required by law limits participant's opportunities to influence the process; (2) standards are not adapted to various clinical programs and as a result, participants contest their legitimacy; (3) ambiguity about the use of accreditation visit results has sullied global transparency. Despite differences between the French and Canadian systems, however, both systems are converging towards a mixed model that includes elements of both philosophies, with the Canadian model becoming more coercive and the French model becoming more flexible and learning-oriented.
Conclusion: Comparison of the two cases shows that current trends in the evolution of accreditation threaten the very purpose of the accreditation process.