title: Accreditation at a crossroads: are we on the right track?
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  Comparison of the two cases shows that current trends in the evolution of accreditation threaten the very purpose of the accreditation process.
authors.affiliation: Ecole nationale d'administration publique, 4750 ave Henri-Julien, 5e étage Montréal, Québec, Canada H2T 3E5. Nassera_Touati@enap.ca
authors.forename: Nassera
authors.initials: N
authors.lastname: Touati
authors.forename: Marie-Pascale
authors.initials: MP
authors.lastname: Pomey
mesh_terms: D000068:Accreditation / Q000592:standards; D001291:Attitude of Health Personnel; D002170:Canada; D003695:Delivery of Health Care / Q000458:organization & administration / Q000592:standards*; D005602:France; D006291:Health Policy; D006801:Humans; D015279:Organizational Culture