Certified Subject to Conditions: What the Four HAS Decision Levels Mean

At the end of the visit, the Haute Autorité de santé (HAS) issues a decision. It reads on four levels, unchanged when the 6th certification cycle opened. Those four words carry weight: the certification report is public, and the decision can be consulted by patients, supervisory authorities and the establishment’s partners.

Here is what each means, and what each implies in practice.

The four levels

Decision	What it says	Duration
Establishment certified with distinction	The bar is exceeded across the framework	Four years
Establishment certified	Requirements are met	Four years
Establishment certified subject to conditions	Requirements are unmet	Fresh full visit at short notice
Establishment not certified	Gaps are major	Fresh full visit at short notice

The dividing line is sharp. The two upper levels open a full four-year cycle. The two lower ones trigger a fresh full visit within six to twenty-four months — not a partial follow-up on the weak points alone, a full visit.

That is a major practical difference: the establishment does not merely replay the points where it failed, it replays everything.

“Subject to conditions” is not a closure

This needs saying plainly, because the anxiety in teams is real: certification subject to conditions does not close an establishment. Activity continues, patients keep being admitted, operating authorisations are not called into question by this decision.

What the decision records is that one or more requirements are unmet — most often imperative requirements, the ones that do not offset against good results elsewhere. It opens a documented remediation phase and brings the next appointment forward.

Reading it as a punishment is humanly understandable and operationally unproductive. It reads better as a constrained deadline: the establishment has less time than planned to demonstrate real change, and it will have to demonstrate it across the whole framework.

The right of reply: prepare it before the visit

Between the report and the decision, the establishment has a right of reply: it may submit observations under the conditions and deadlines set by the procedure.

This stage is often poorly used, for a simple reason: it arrives at the worst moment. Teams are coming out of the visit, they are tired, and the window is short.

Hence a piece of advice that seems premature and is not: decide before the visit who will draft the observations and on what evidence. Who centralises, who arbitrates, who signs. An establishment that discovers this question on receiving the report loses half the window to internal organisation.

A useful observation is not a plea: it is a verifiable fact, a document, a date. What did not exist on the day of the visit did not exist — the right of reply serves to correct a reading, not to fill a gap after the fact.

What the decision triggers, beyond the report

Certification results do not stay confined to the quality remit. They are among the elements taken into account by France’s quality-based financial incentive scheme, which adjusts an allocation according to an establishment’s quality results compared with those of similar establishments. That scheme has applied to acute care since 2016 and was extended to rehabilitation care and then to psychiatry.

Quality therefore has a budget translation, and a downgraded decision has a cost that goes beyond image.

It also has an internal cost that is rarely anticipated: a fresh full visit within under two years mobilises the same teams again, on the same working time, at the very moment they must be running the improvement plan. It is that accumulation, more than the decision itself, that wears organisations down.

Should you aim for the distinction?

The question comes up in every management committee. The honest answer is: not at the price of distorting your steering.

Aiming for the distinction can make sense for an establishment that is already solid, whose imperative criteria have been under control for several cycles. It makes far less sense for one that has not secured its base: a robust “certified” beats an attempt at distinction that scatters resources.

The literature invites moderation about what such rankings produce. The observational study by Lam, Figueroa, Jha and colleagues, published in 2018 in the BMJ from a large sample of US hospitals, finds no association between accreditation by a private body and lower mortality, fewer thirty-day readmissions or better patient experience, compared with hospitals reviewed by a state survey (see the study). The US context does not transpose directly to the French scheme, but the methodological lesson holds: the decision level is not, on its own, an indicator of quality of care.

What matters more is what the establishment does with its framework between two visits — and on that, the base of imperative criteria weighs more than the race for distinction. We set out that reasoning in our article on the imperative criteria of HAS certification.

The three weeks after the decision

Whatever the decision, the same reflex applies: turn the report into a dated plan before it goes cold.

1. Circulate the report to the teams concerned, not only to the quality department. A public report that clinicians discover through the local press is a failure of internal communication.
2. Translate each gap into an action, with an owner and a date. A gap without an owner does not exist.
3. Pick up the indicators that served the visit and check they will keep being produced outside preparation periods. That is where the difference between one cycle and the next is made.

The context of the 6th cycle — framework structure, what changes and what does not — is set out in our article on the HAS 2025 framework.

Take action

Do not discover the right of reply on receiving the report: name now who will run it and on what evidence. And if your establishment is coming out of certification subject to conditions, treat the next visit as a full cycle, not as a catch-up on a few criteria — it is the whole framework that will be reassessed. For the whole scheme — legal obligation, framework, visit methods, cycle — see our guide to HAS certification of health-care establishments.