The Essential List of Mandatory HAS Criteria for Healthcare Facility Certification 2025 The Quality Requirement in French Healthcare Facilities The quality and safety of care are central to the concerns of modern healthcare systems. In France, the High Authority for Health (HAS) plays a key role in this process, as it is the body mandated by the 1996 ordinances for the certification of healthcare facilities. This evaluation procedure, independent of the facility and its supervisory bodies, focuses specifically on the level of quality and safety of care provided to patients. It is carried out by professionals, called expert assessors, mandated by the HAS, who evaluate facilities based on objectives defined collectively at the national level by professionals and users.
Healthcare facility certification goes far beyond simple administrative compliance. It is based on the patients' perspective regarding their experience within the facility, evaluates outcomes not only in terms of health but also in terms of the overall care pathway (reception, information provided, team coordination, discharge), and engages teams in a pragmatic approach where they take the initiative to organize their practices to achieve results using the most appropriate methods. It also offers the possibility of relying on the HAS (French National Authority for Health) for self-assessment and constitutes recognition of the teams' commitment to a process of continuous improvement in the quality and safety of care. Certification is neither an inspection nor a ranking between facilities, and does not interfere with other regulatory assessments. It is the only national system in France that offers a comprehensive framework for the analysis and external evaluation of the quality of care and services, acting as a motivating factor for healthcare professionals and patient representatives. Within this rigorous system, certain criteria are mandatory. These criteria correspond to fundamental requirements which, if not met, can potentially prevent certification. Understanding these mandatory criteria is therefore essential for any healthcare facility wishing to achieve and maintain a high level of quality and safety of care.
The French National Authority for Health (HAS) and the evolution of certification The healthcare facility certification process , initiated 25 years ago, is part of a broader effort to secure production processes in the healthcare sector and beyond. It responds to a legitimate expectation of transparency regarding the quality of service provided to patients, public authorities, and healthcare professionals, thereby stimulating a collective approach to continuous improvement. Since its first version in June 1999, which fostered a culture of quality and safety of care, the procedure has constantly evolved. The second iteration in 2005 introduced the evaluation of professional practices in care units, while the 2010 version (V2010) emphasized increased requirements in terms of patient care and risk management, particularly through priority required practices. The 2014 version strengthened the ability of healthcare facilities to continuously identify and manage their risks by introducing patient-centered assessment methods, such as the patient tracer method, and by engaging facility management on quality and safety issues. More recently, starting in 2021, the certification process has undergone a profound transformation, with three major objectives set by the HAS (French National Authority for Health) College: Medicalizing certification and better taking into account the outcome of patient care: The goal is for certification to be meaningful for healthcare teams by focusing on their practices and the outcome for patients in terms of effectiveness, safety, and satisfaction. The objectives and criteria are defined by consensus, are easy to share, and correspond to the requirements of good professional practices.
Simplify the certification process in all its aspects : To facilitate adoption, certification strengthens the autonomy of institutions, prioritizes results rather than adherence to processes, and offers pragmatic and field-based evaluation methods.Promote the territorial integration of healthcare facilities and the development of care pathways : Certification must recognize the efforts of institutions to improve the quality and safety of the patient's healthcare pathway within their territory, in coordination with all stakeholders in prevention, healthcare, social care, and social services.These developments address current quality challenges, including the development of patient engagement as partners in their individual and collective care, the shift from a resource-based approach to a results-based approach (appropriateness of care), and the development of multi-professional teamwork, and adaptation to structural changes in the health system. The HAS itself is evaluated according to international standards, having been accredited by the International Society for Quality in Health Care (ISQua) since February 2023 for its entire certification procedure.
The structure of the 2025 certification framework The certification framework is the foundation of the
The framework is structured in three main chapters, broken down into objectives and criteria:
Chapter 1: The Patient : This chapter focuses on the direct outcome for the patient, ensuring respect for their rights, consideration of their needs and preferences, and their engagement as a partner in their care. It covers objectives such as respect for patient rights (1.1), patient information (1.2), patient engagement in their care plan (1.3), and the involvement of patients and their representatives in the life of the institution (1.4).Chapter 2: Care Teams : This chapter assesses the teams' ability to seek appropriate, effective, and safe care, to consult and coordinate throughout the patient's journey, and to manage risks associated with care. The objectives include team coordination (2.1), risk management related to practices (2.2), safety in high-risk areas (2.3), and a culture of relevance and evaluation (2.4).Chapter 3: The Institution : This chapter concerns the institution and its governance, assessing its capacity to drive continuous improvement in the quality and safety of care, to manage its professional resources, to enhance its territorial positioning, and to adapt to digital innovations and eco-responsible care. The objectives are overall management through quality and safety of care (3.1), control of professional resources and skills (3.2), territorial positioning (3.3), and adaptation to eco-responsible care and digital innovations (3.4).This framework is modular, integrating 86 generic criteria applicable to all establishments and 32 specific criteria adapted to populations (children, the elderly), modes of care (home hospitalization), or sectors of activity (emergency, surgery, maternity, mental health, radiotherapy, etc.).
HAS certification relies on varied and complementary evaluation methods, designed to be close to the field and reflect the reality of practices. These methods are used both by HAS expert visitors during external visits and, if the facility so wishes, by its own internal evaluators as part of self-assessment. The Tracer Patient: This method consists of evaluating the quality and safety of care provided to a given patient within the facility. It involves collecting, with the consent of the patient and/or their family, their experience. The evaluator meets with the patient and then speaks with the team providing their care. For external evaluations, only physician expert visitors are involved in this method. The Tracer Pathway: This method allows for the evaluation of the continuity and coordination of patient care, as well as teamwork and the culture of quality and safety of care. The evaluator meets with the teams involved in the patient's care pathway and, accompanied by a professional, retraces the patient's physical journey within the facility, meeting with the teams involved at the different stages. The Target Tracer: This involves evaluating the actual implementation of a specific process on-site. The evaluation starts from the field and, in case of malfunctions, works its way back to the process organization. To do this, the evaluator meets with the teams, consults relevant documents, and makes direct observations. Targeted tracers are carried out, for example, on the medication circuit, infection prevention, adverse event management, etc. The System Audit: This method aims to evaluate a process more comprehensively to ensure its control and its ability to achieve the defined objectives. The evaluation begins with a review of the process components, followed by meetings with management, the chair of the medical board, the nursing management, heads of specific departments, and user representatives. Finally, it verifies how the process is implemented in practice with professionals and their supervisors.
Observations : Observations are made continuously during each tracer (patient, pathway, target group). They are based on a list of points directly observable in the field, such as respect for patient dignity and privacy, accessibility of premises, and control of infection risk.Each method is broken down into evaluation grids that incorporate the evaluation elements of the applicable generic and specific criteria. The responses to the grids ("Yes", "No", "N/A", "RI") are aggregated to calculate a score for each evaluation element, then for each criterion, objective, and chapter, resulting in an overall score for the institution. Advanced criteria are not included in this rating. The assessment also relies on the Quality and Safety of Care Indicators (QSCI) to measure the improvement momentum of healthcare facilities. The crucial importance of the HAS mandatory criteria: Among the 86 generic and 32 specific criteria of the HAS framework, 21 are classified as "mandatory." These criteria represent fundamental requirements for the quality and safety of care. Their distinctive feature lies in their potential impact on the certification decision: "If an assessment of one of these criteria is negative, the HAS reserves the right not to grant certification to the facility; this may have an impact on the level of the decision." This underscores their critical role in assessing a facility's compliance with essential care standards. The mandatory criteria cover diverse and fundamental areas, ranging from respecting patient rights to managing risks associated with professional practices, including emergency management and the facility's overall quality and safety of care policy. They reflect the inalienable pillars upon which any quality healthcare service must be based. Let's examine each of these mandatory criteria in detail, their assessment elements, and the HAS's expectations. Criterion 1.1-01: Respect for the patient's privacy and dignity. This fundamental mandatory criterion ensures that the facility implements measures to guarantee respect for the patient's privacy and dignity in all circumstances. This includes the cleanliness and maintenance of the premises, the vigilance of professionals to avoid inappropriate remarks or attitudes (particularly the infantilization of vulnerable individuals such as the elderly or those living with disabilities), and the effective accessibility of equipment and services. The evaluation elements for this criterion focus on the patient's experience and direct observations. From the patient's perspective, it is verified that the reception and care provided respected their dignity, privacy, and integrity. Furthermore, access, circulation, premises, and signage must allow for easy movement. The observations of the expert visitors focus on the practices of professionals guaranteeing the patient's dignity, privacy, and integrity, as well as on the conformity of the premises and equipment to these principles and to safety standards. Particular attention is paid to accessibility for people with disabilities. This criterion is reinforced by the e-Satis Quality and Safety of Care Indicators (QSCI), which measure patient satisfaction and experience.
The care of children and adolescents requires a setting specifically adapted to their needs. This imperative criterion requires that minors be hospitalized in adult wards, and if this exceptionally occurs, appropriate measures must be implemented (reserved space, trained professionals, secure environment). The presence of parents, essential for supporting the child, must be organized taking into account the care plan.
The evaluation elements verify that best practices related to the specific needs of minors are applied in the services that admit them. It is imperative that parental presence be organized 24/7, unless otherwise advised by a doctor. Furthermore, hospitalized minors must benefit from age-appropriate recreational and educational activities. Observations are also carried out to ensure that the environment and premises are suitable for respecting the privacy, dignity, and safety of minors, including when they are cared for in an adult ward.
This mandatory criterion emphasizes the obligation for all healthcare professionals to regularly and appropriately assess the patient's pain, whether acute or chronic. Anticipation and effective pain management are crucial for preserving the patient's dignity, improving their quality of life, and promoting their recovery. Professionals must adapt treatments and use the most appropriate techniques to provide rapid and lasting relief from suffering, taking into account the assessment scale adapted to the patient's situation (vulnerability, disability, involvement of family and friends). Assessment elements include encouraging the patient to express their pain and guaranteeing its relief. For professionals, it is verified that anticipation and pain relief measures are documented in the patient's file, that pain reassessments are recorded to adapt treatment, and that non-pharmacological approaches are offered. This criterion is also linked to the IQSS (Quality, Safety, and Environment) assessment of pain management. Criterion 1.1-06: Compassionate Care for All Patients. Compassionate care is a fundamental principle that encompasses respect, dignity, and well-being for each individual, involving all stakeholders in the institution. This essential criterion requires not only high-quality medical care, but also particular attention to communication, personalized support, and respect for patient autonomy (hydration, nutrition, hygiene, etc.). It includes active listening, the absence of any form of mistreatment, and the creation of a safe environment. Promoting respectful care is inseparable from the well-being of healthcare professionals. The evaluation criteria focus on the team's ability to assess the patient's autonomy in meeting their basic needs, even during periods of high activity. From the patient's perspective, it is verified that they have received the necessary assistance for their basic needs, that professional practices are respectful, and that all staff members introduce themselves. The team must also identify risks to patient well-being, implement improvement measures, and know how to report potential situations of internal mistreatment.
Patient involvement in their care is a guarantee of effectiveness and risk reduction. This mandatory criterion aims to ensure that the patient expresses their free and informed consent, adheres to and follows their care plan, which requires their participation in defining objectives, implementation, and follow-up. The care plan, established after a comprehensive assessment and taking into account the patient's needs and preferences, must be a guiding principle, readjusted in collaboration with the patient, taking into account any potential deterioration in their mental health.
The assessment elements focus on presenting the patient with the different therapeutic options, their benefits and risks, so that they can express their preferences and needs and give their consent. From the professionals' perspective, an initial comprehensive assessment (medical, psychological, social, autonomy, rehabilitation) is expected to be conducted by professionals involving the relevant disciplines and support services. The team must develop a suitable care plan, adapt it according to the patient's evolving situation, and document it in the patient's file. This criterion is supported by the IQSS (Quality, Safety, and Quality of Care) indicators linked to e-Satis.
This mandatory criterion is essential for the continuous improvement of the quality of care. The institution must consider the results of patient satisfaction and experience measurements to define the guidelines for its policy on improving the quality and safety of care. The detailed analysis of the results must be shared with healthcare professionals, and regular follow-up must be conducted to ensure that improvement objectives are met. Evaluation elements for governance include encouraging patients to participate in satisfaction surveys (particularly e-Satis), monitoring this participation, and integrating improvement actions resulting from the analysis of patient satisfaction and experience results into the quality improvement program. For healthcare professionals, it is expected that the results of patient satisfaction and experience assessments will be shared with care teams every six months. Teams must analyze their own results and implement improvement actions, and the recommendations of the Users' Committee (CDU) must be taken into account.
This mandatory criterion recognizes the importance of integrating physical examination into psychiatric care. This examination, performed for all patients hospitalized in psychiatry, allows for differential diagnosis and the identification of somatic comorbidities that may interfere with psychiatric care. It must be carried out within a short timeframe, particularly for involuntary hospitalizations.
The evaluation criteria specify that a physical examination must be carried out within 24 hours for involuntary full hospitalizations in psychiatry. For patients hospitalized for voluntary care without going through the emergency department, the physical examination must be carried out within an appropriate timeframe (maximum 3 working days). If the patient was seen in the emergency department, the report must be included in the medical record and the follow-up instructions implemented. Regular somatic monitoring must be documented in the discharge summary. This criterion is linked to the IQSS (Quality, Safety, and Quality of Care) criteria for coordination and somatic care during inpatient hospitalization.
Medication prescribing is a critical step in the care pathway. This mandatory criterion requires that medical teams adhere to good practices to ensure the safety and efficacy of treatments. This implies a clear prescription, tailored to the patient's specific characteristics (health status, medical history, allergies, interactions), and compliant with recommendations. The legibility of the prescription is essential to avoid any confusion.
The assessment elements verify that the admission prescription takes into account the patient's usual treatment. The prescription must clearly state the prescriber's identification and signature, the date, the time, the INN (International Nonproprietary Name) of the molecules, the dosage, the solvent and its volume (for injectables), and the route of administration. The patient's self-management capacity (outside of the PAAM program) must be assessed and documented. Any conditional prescription must be justified, and prescriptions must be filled in a timely manner by authorized professionals, without transcription by non-medical personnel.
Administration is the final step in the medication circuit, where any undetected error can cause harm to the patient. This mandatory criterion requires healthcare teams to rigorously follow medical prescriptions, applying the "5 Rights" (right patient, right medication, right dose, right route, right time). Medication preparation must comply with recommendations (extemporaneous preparation, crushing if necessary, identification until administration). The evaluation criteria require that authorized professionals adhere to good preparation practices (avoiding interruptions in tasks) and administration practices. High-risk situations (injectables, chemotherapy, etc.) must be identified and managed with particular precautions. The concordance between the product, the patient, and the prescription must be systematically verified before administration, and the administration (or the reason for non-administration) must be documented in the patient's record at the time of administration. The patient's self-administered medication intake must also be documented. Criterion 2.2-06: Prevention of Medication Errors This mandatory criterion emphasizes the proactive prevention of medication errors. It relies on rigorous practices, the vigilance of healthcare teams, and ongoing professional development. High-risk medications, which carry a greater risk of harm in the event of an error, must be specifically managed at every stage of the process, and their evolving list must take into account feedback and "never events." Preparations in controlled atmospheres (chemotherapy, etc.) are crucial to prevent contamination and ensure dose accuracy. The evaluation criteria require that professionals be trained in medication risk prevention and know how to control the highest-risk medications. A collaborative and appropriate list of high-risk medications must be available to professionals. The controlled atmosphere preparation process must be fully controlled (prescription, pharmaceutical analysis, preparation, dispensing, transport, storage, administration). Finally, medication errors must be systematically analyzed as a team and followed up with an action plan.
Standard hygiene precautions are the foundation of healthcare-associated infection prevention and apply to all patients. This mandatory criterion covers hand hygiene, the wearing of personal protective equipment (gloves, masks, gowns), the management of excreta and waste, as well as the maintenance of equipment and surfaces. The use of alcohol-based hand rubs at key moments is essential, as is the absence of jewelry on the hands and wrists.
The assessment elements verify that the team complies with hand hygiene guidelines (before/after patient contact, before aseptic procedures, etc.) and prioritizes the use of alcohol-based hand rub. The team must apply best practices for excreta management (personal protective equipment, appropriate equipment) and know the procedures to follow in case of a bloodborne pathogen exposure incident. Improvement of practices must be based on the regular analysis of indicators in conjunction with the operational hygiene team (OHT). Observations focus on hand hygiene prerequisites (no jewelry, short sleeves, short nails). This criterion is linked to the IQSS (Individual Quality and Safety Assessment) on the consumption of hydroalcoholic solutions (ICSHA).
Managing life-threatening emergencies requires immediate responsiveness and optimal coordination to preserve the patient's life. This imperative criterion requires that healthcare professionals receive ongoing training in emergency protocols, and that a clear organizational structure ensures rapid identification of the situation, fluid communication between teams, and the immediate availability of equipment and medications. Emergency simulation exercises are essential for evaluating and improving procedures. The elements for evaluating professionals include the existence of a single, dedicated phone number to contact an authorized physician in case of a life-threatening emergency, training for all healthcare professionals in first aid procedures, and the availability and regular monitoring of emergency carts or bags. The completion of simulated scenarios is also verified. Governance must assess the effectiveness of the life-threatening emergency response system. Criterion 2.3-06: Risk Management in Interventional Areas In interventional areas, risks, particularly infectious risks, are high and require exemplary rigor. This mandatory criterion emphasizes the mastery of hygiene practices, the sterilization of equipment, and the maintenance of premises. Equipment must be disinfected regularly and checked before each intervention. Les professionnels doivent suivre des protocoles stricts pour limiter les contaminations, incluant les gestes aseptiques et le port d'une tenue appropriée. Une vigilance particulière est portée aux flux de circulation.
Les éléments d'évaluation vérifient que l'équipe réalise toutes les étapes de préparation du patient selon le protocole en vigueur (douche, traitement des pilosités, antisepsie cutanée). Les professionnels doivent tracer la conformité des équipements opératoires à l'ouverture de la salle. Les observations concernent le port d'une tenue et d'équipements adaptés et strictement dédiés au secteur interventionnel. Ce critère est lié aux IQSS sur les infections du site opératoire.
La check-list « Sécurité du patient » est un outil crucial pour renforcer la sécurité des interventions chirurgicales. Ce critère impératif met en avant son utilisation systématique et exhaustive à chaque étape de la prise en charge (identification du patient, vérification du site opératoire, contrôle des équipements, validation de la procédure). La HAS encourage l'adaptation de cette check-list par les professionnels pour une meilleure appropriation. L'analyse régulière de sa réalisation permet d'identifier les écarts et d'améliorer la communication et la coordination.
Les éléments d'évaluation exigent qu'une check-list, éventuellement adaptée aux recommandations de la HAS, soit systématiquement et exhaustivement réalisée par les équipes des blocs opératoires et secteurs interventionnels à chaque étape, en présence des professionnels concernés. Des évaluations de sa mise en œuvre, notamment le suivi des Go/No Go (éléments à vérifier avant de passer à l'étape suivante), doivent être suivies par les équipes, et des actions d'amélioration mises en œuvre sur la base de l'analyse des résultats des indicateurs de suivi.
La prise en charge des femmes enceintes exige une attention particulière à la prévention des risques obstétricaux majeurs. Ce critère impératif vise à s'assurer que les équipes sont formées à détecter rapidement les complications potentielles (hémorragie du post-partum, prééclampsie, accouchements dystociques) et à appliquer des protocoles stricts pour les anticiper. La surveillance prénatale renforcée et la gestion efficace des urgences obstétricales sont primordiales. Les simulations d'urgence et la fluidité de la communication contribuent à une réactivité optimale.
Les éléments d'évaluation des professionnels incluent la disponibilité de tous les éléments du dossier patient à l'admission, même en urgence. L'équipe doit maîtriser l'interprétation du rythme cardiaque fœtal et les manœuvres obstétricales grâce à des formations. Le matériel d'urgence vitale en cas d'hémorragie du post-partum doit être vérifié et conforme, et la procédure d'urgence vitale doit être accessible et connue des professionnels.
La naissance est un moment clé où la sécurisation de la prise en charge du nouveau-né est primordiale pour sa santé et son bien-être. Ce critère impératif exige que les équipes soignantes suivent des protocoles pour l'identification immédiate du nourrisson, la prévention des infections et l'évaluation de ses fonctions vitales (score d'Apgar). Une surveillance continue permet de détecter rapidement toute anomalie. Les soins essentiels (maintien de la température, alimentation) doivent être systématiquement réalisés, et une communication claire avec les parents est nécessaire.
Les éléments d'évaluation des professionnels vérifient que l'ensemble des professionnels prenant en charge les nouveau-nés sont formés par simulation. Ils doivent connaître les procédures de prise en charge (réanimation néonatale, infection néonatale). Le clampage retardé du cordon ombilical et la mise en peau à peau doivent être tracés, et leur raison argumentée si non effectués. La température du nouveau-né doit être recueillie et tracée. L'accompagnement de l'allaitement doit s'inscrire dans une démarche qualité formalisée, et les professionnels doivent analyser leurs résultats pour définir des mesures d'amélioration.
Ce critère impératif encadre strictement les pratiques d'isolement et, le cas échéant, de contention des patients hospitalisés sans consentement, afin de garantir le respect de leurs droits et leur dignité. Ces mesures ne doivent être utilisées qu'en dernier recours pour prévenir un danger imminent. Les équipes soignantes doivent s'assurer que chaque décision est médicalement justifiée, proportionnée et régulièrement réévaluée.
Les éléments d'évaluation exigent que la décision d'isolement, prise par un psychiatre et éventuellement assortie d'une prescription de contention, soit tracée dans le dossier du patient, précisant les modalités de surveillance. Un examen psychiatrique et somatique doit être réalisé au moment de la mise en isolement. L'isolement doit se faire dans un espace dédié respectant l'intimité, la dignité et la sécurité, avec un moyen d'appel pour le patient s'il est contenu. L'infirmier doit surveiller l'état somatique et psychique du patient et le tracer. Une analyse clinique doit être proposée au patient à la sortie d'isolement pour prévenir la récidive, et l'équipe doit analyser les indicateurs de pratiques cliniques liés à l'isolement et la contention.
La lutte contre l'antibiorésistance est une priorité de santé publique, et ce critère impératif y contribue directement. Le respect des bonnes pratiques d'antibiothérapie est indispensable pour limiter les complications graves et prolongations d'hospitalisation. La justification et la réévaluation systématique des prescriptions d'antibiotiques sont au cœur de cette démarche.
Les éléments d'évaluation vérifient que l'établissement met en place les éléments-clés d'un programme de bon usage des antibiotiques (politique, plan de formation, stratégie d'évaluation). Les praticiens doivent être formés au bon usage des antibiotiques. Toute prescription d'antibiotique et sa prolongation doivent être justifiées dans le dossier. Les praticiens doivent se référer à un référentiel et pouvoir faire appel à un référent en antibiothérapie. Les prescriptions doivent être systématiquement réévaluées entre la 24e et la 72e heure. L'EOH, les équipes, le référent en antibiothérapie, la PUI (Pharmacie à Usage Intérieur) et le laboratoire de microbiologie doivent surveiller la consommation d'antibiotiques et les résistances.
Ce critère impératif place la gouvernance de l'établissement au centre de la démarche d'amélioration de la qualité et de la sécurité des soins. La politique doit fixer des objectifs personnalisés basés sur une analyse de toutes les données disponibles (point de vue du patient, indicateurs, risques). Son élaboration, mise en œuvre et évaluation doivent être participatives, associant la direction, la CME (Commission Médicale d'Établissement), l'encadrement, les professionnels, la commission des soins infirmiers, et les représentants des usagers. Elle doit se décliner en un programme d'actions unique, structuré, pertinent et personnalisé.
Les éléments d'évaluation exigent que la CME élabore et suive la politique qualité/sécurité avec les parties prenantes mentionnées. Les orientations prioritaires doivent être fondées sur une analyse de l'ensemble des indicateurs (IQSS, expérience patients) et des risques spécifiques. Le programme d'amélioration de la qualité et de la sécurité des soins (PAQSS) doit prendre en compte les préconisations des autres autorités d'évaluation externes (ARS, ASN, CGLPL, ABM). Ce PAQSS doit être structuré, pertinent, actualisé, unique et évalué annuellement. L'encadrement et les professionnels doivent connaître les principales actions du PAQSS les concernant.
Pour une culture de sécurité bienveillante qui analyse l'erreur plutôt que de la condamner, ce critère impératif demande à la gouvernance de promouvoir activement la déclaration des événements indésirables et des presqu'accidents. La gestion des vigilances et l'analyse des EIAS (Événements Indésirables Associés aux Soins) sont vues comme des opportunités d'amélioration collective de la sécurité du patient.
Les éléments d'évaluation requièrent que les événements indésirables graves associés aux soins soient systématiquement analysés avec les équipes concernées, selon les méthodes de la HAS. Une synthèse des facteurs contributifs et des plans d'actions doit être diffusée aux professionnels et aux représentants des usagers. Les EIG doivent être systématiquement déclarés sur le portail national de signalement, avec un volet 2 dans les trois mois. Les EIAS analysés dans le cadre de l'accréditation doivent être transmis en interne et leurs actions d'amélioration contribuer au PAQSS. Les professionnels doivent être formés à l'annonce d'un dommage lié aux soins.
Ce critère impératif vise à s'assurer que l'établissement est préparé à faire face aux situations sanitaires exceptionnelles, c'est-à-dire les événements susceptibles de provoquer des tensions hospitalières importantes. Cela implique l'identification des menaces et la mise en place d'un plan de gestion gradué (niveau 1 pour impact limité, niveau 2 ou plan blanc pour impact majeur). Le plan blanc doit prévoir l'activation d'une cellule de crise, la mobilisation des ressources et la communication.
Les éléments d'évaluation vérifient que les catégories de risques (y compris numériques) sont identifiées. Le(s) plan(s) de gestion des tensions et situations exceptionnelles doivent être collectivement élaborés. La cellule de crise doit être opérationnelle dans les 45 minutes suivant l'alerte, avec les outils et procédures nécessaires. Les exercices de gestion de crise et les activations réelles doivent être suivis d'un retour d'expérience (RETEX) menant à des actions d'amélioration. Les moyens matériels et humains nécessaires doivent être connus et rapidement mobilisables, et leur opérationnalité vérifiée. Les professionnels concernés doivent connaître la gouvernance, les modalités d'alerte et de mise en œuvre des plans de crise.
La continuité des soins est fondamentale pour que les patients reçoivent des soins rapides et appropriés en tout temps. Ce critère impératif exige une disponibilité continue des professionnels médicaux et paramédicaux, contribuant à une meilleure gestion des urgences et une surveillance constante des patients. Elle repose sur des règles de présence ainsi qu'un système de gardes et astreintes assurant la permanence des soins 24h/24.
Les éléments d'évaluation se concentrent sur la conformité de l'organisation médicale et paramédicale aux recommandations et à la réglementation, garantissant une prise en charge adéquate. Il est vérifié que les soignants peuvent joindre un médecin à tout moment. De plus, des solutions doivent être mobilisées en cas d'absentéisme imprévisible.
Ce critère impératif vise à réduire les passages évitables aux urgences générales pour les personnes âgées de plus de 75 ans. L'établissement, en collaboration avec ses partenaires de ville (médecins traitants, EHPAD, HAD), doit formaliser des circuits courts et/ou mettre en œuvre des réseaux de télémédecine. L'objectif est d'assurer une prise en charge adaptée et coordonnée en amont, évitant ainsi des déplacements inutiles et potentiellement préjudiciables pour cette population vulnérable.
Les éléments d'évaluation exigent que les services de spécialité (cardiologie, pneumologie, psychiatrie, etc.) et les services de gériatrie et d'urgences participent à la prise en charge des patients âgés non programmés, avec une organisation d'acteurs en place. Les établissements doivent identifier les établissements de recours à contacter pour avis, et disposer d'outils de télémédecine (consultation et/ou avis). Chaque service de spécialité doit proposer des solutions de télémédecine aux correspondants du territoire pour éviter les transferts. Des indicateurs spécifiques (nombre de passages aux urgences des patients âgés de 75 ans et plus suivis ou non d'hospitalisation, durée de séjour PMSI MCO) doivent être mesurés, et l'établissement doit établir un programme d'amélioration basé sur ces résultats.
Les critères impératifs du référentiel de certification des établissements de santé par la HAS ne sont pas de simples exigences à cocher ; ils incarnent les fondements inébranlables d'une culture de la qualité et de la sécurité des soins en France. En se concentrant sur des aspects aussi cruciaux que le respect de la dignité et de l'intimité du patient, la prévention des erreurs médicamenteuses, la gestion des urgences vitales, l'adaptation de l'environnement pour les mineurs, ou encore la prévention des transferts évitables pour les personnes âgées, ces critères poussent les établissements à une excellence opérationnelle et éthique.
Le fait qu'une évaluation négative sur l'un de ces critères puisse potentiellement conduire à une non-certification met en lumière leur rôle de garde-fou essentiel. Ils représentent les lignes rouges à ne pas franchir, les engagements minimaux que tout établissement se doit de respecter pour assurer la sécurité et le bien-être de ses patients.
Au-delà de la conformité, la mise en œuvre rigoureuse de ces critères impératifs favorise une dynamique d'amélioration continue, stimulant la réflexion collective, la formation des professionnels, et l'adaptation des pratiques aux meilleures recommandations. Ils encouragent une approche centrée sur le patient, où l'expérience et la satisfaction de ce dernier sont non seulement mesurées mais activement prises en compte. Enfin, ils renforcent la coordination des équipes et la gouvernance, créant un environnement propice à l'innovation et à une prise en charge globale et intégrée.
