La qualité des soins, nouveau paradigme de l’action collective ?

Abstract

La démarche de qualité des soins transforme l’art médical en exercice scientifiquement fondé, l’autonomie professionnelle en situation d’interdépendance systémique, la définition de la technique médicale en construction pluridisciplinaire et politique. Modèle d’organisation et d’évaluation de l’action collective de soins dans une perspective d’efficacité curative et de maîtrise de la dépense, elle repose sur l’élaboration de nouvelles méthodes et techniques normatives qui, visant à encadrer les comportements professionnels, affectent les intérêts, les modes d’organisation, les valeurs des divers acteurs liés par le système, et apparaissent ainsi comme des enjeux majeurs de négociations et de conflits.Quality of care (QC), understood as a set of norms defining “how to treat the patient right” in the public interest, is a new programme for organizing health systems that is being developed in all advanced pluralist democracies. QC aims to be a systemic means for regulating health-care supply in a social and political context that pays ever more attention to “dangers” in the health sector and to the rising cost of health. It entails drawing up new operational specifications based on methods and techniques for assessing actual practices in health care in terms of expenditures and overall effectiveness. QC’s characteristics are analysed: feedback between the definition of a strategy for care and its assessment through experiments, the use of systems of information, the tracking of errors, auditing, etc. QC aims at providing, on a technical basis, an efficient social and political response to the growing “complexification” of health care. It thus tries to integrate into the notion of “quality” the products, structures, procedures, information and co-ordination that takes place in the process of providing care. Though not yet widely implemented in France, QC, as it gradually spreads, significantly redistributes power among health-care providers. It creates major changes in cognitive, normative and organisational arrangements, that, in turn, modify interests, organisations, values and norms among health professionals. Moreover, it brings new actors into the game. QC thus turns out to be a major social and occupational issue for reforming health systems