2.9 Patient empowerment
2.9.1 Patient information
Patients in Belgium have the right to receive all information necessary to gain insight into their state of health from their care provider. This information should be supplied in clear language and, in principle, verbally. Patients have the right to refuse to be informed. Despite the right not to know, health care professionals can still decide to inform the patient if there is a risk of serious detriment to the health of a patient or third parties. The health care professional can also decide not to inform the patient if the communication may cause obvious damage to the patient’s health and if another health care professional has been consulted. If the health care professional decides not to inform the patient, he or she must note the professional reasons for this choice in the patient’s record and notify the potential confidant of the patient.
The right to give informed consent establishes that the prior consent of patients is required for every intervention by health care professionals. The patient should at least be given information on the aim of the intervention (e.g. diagnostic or therapeutic), nature of the intervention (e.g. painful or not), degree of urgency, duration, frequency, contra-indications relevant for the patient, side-effects and risks, after-care, possible alternatives, financial consequences and possible consequences in the case of refusal or withdrawal of consent.
Patients also have the right to a patient file that is carefully maintained and secure. Patients are entitled to inspect their patient file and must be offered the possibility to do so. Information exclusions apply to information on a third party; and to the personal notes of the health care professional (unless the patient is assisted by another health care professional appointed by the patient as a confidant). Maximum amounts are in place that patients can be charged for a copy of his/her medical file: €0.10 per text page, €5 per figure and €10 per CD-ROM, with a maximum total of €25 (FPS Health, Food Chain Safety and Environment 2009b).
A study performed by the Vlaams Patiëntenplatform (VPP) showed that most physicians informed their patients about the aim and nature of the intervention, and the degree of urgency. However, less attention was paid to providing information on potential alternatives and consequences in case of refusal or withdrawal of consent. Moreover, information on the related cost for the patient was not mentioned by a quarter of the interviewed doctors. This study also highlighted information difficulties for specific patient groups, that is, foreign patients, patients with mental disorders, patients with a low qualification levels and patients unable to give informed consent. Patients have the right to obtain information in easily understood language and the VPP highlighted that more attention for this aspect is needed (Schoonacker and Louckx 2006).
An assessment by the Socialist Sickness Fund on patients’ rights also showed that 65% of the hospitalized patients received insufficient information on the expected cost of the stay and one in four patients was not sufficiently informed beforehand about their treatment by the physician. Moreover, the study showed that lower-income people were less informed beforehand about their treatment than higher-income people and that the elderly patients (≥ 71 years old) were less informed than younger patients (≤ 50 years old) (Socialistische Mutualiteiten 2008).
Nurses are also involved in providing information to patients. As defined in the Nursing Minimum datasets (see Section 2.5.2 Information systems), patient education is considered as a nursing activity.
Patients can also obtain relevant information from official organizations. Most sickness funds run a health promotion and patient education service to produce information folders and to organize information meetings, with a focus on primary prevention, health promotion and general health topics. They also provide information to health care providers, mostly by means of periodicals. However, a study performed by the Socialist Sickness Fund highlighted that few patients (63%) were aware of the possibility of receiving information from their sickness funds and that more than three out of four respondents (79%) had not requested information from their sickness fund prior to hospitalization (Socialistische Mutualiteiten 2008).
Information on tariffs, reimbursed acts and consultations as well as reimbursement of pharmaceuticals can also be found on the NIHDI web site. Some federal organizations such as the KCE, the IPH and the Belgian Centre for Evidence-based Medicine (CEBAM) are other potential sources of information but are more focused on health professionals.
Patient associations are also important sources of information. The French federation, Ligue des Usagers des Services de Santé (LUSS), and the Flemish federation VPP have 200 and 82 patient associations, respectively. There is also the federation Patiënten Rat & Treff for the German community and Radiorg for rare diseases. The consumer organization Test-Achats is also a potential source of information and provides advice and evaluations of practices related to health care in a specific magazine called Test-Santé.
Concerning initiatives to increase access to information for disabled people, the labelling of pharmaceutical products in Braille has become mandatory since May 2006. The instructions must also be made available by companies in a format suitable for blind and visually impaired people upon the request of patient organizations.
Since 25 February 2014, physician status (conventioned or not) can be found via the website of the NIHDI (https://www.inami.fgov.be/webprd/appl/psilverpages/fr). From July 2014, hospitals will be obliged to better inform patients, prior to admission, by making information available on the hospitals website and by offering a contact person who can provide the patient more personalized information about the costs associated with their hospitalization. Additional measures will follow. For more details: http://www.presscenter.org/fr/pressrelease/20140221/plus-de-transparence-sur-le-cout-des-soins-pour-les-patients-deuxieme-lecture (in French) / http://www.presscenter.org/fr/pressrelease/20140221/plus-de-transparence-sur-le-cout-des-soins-pour-les-patients-deuxieme-lecture?lang=nl (in Dutch)
Currently, the financial information relating to hospitalization is given to the patient at the moment of the admission or just before. The patient does not always have the time or the spirit to measure all financial implications of their choices. Better prior information is desirable. The 20 September 2013, a bill of law is foreseen to oblige hospitals to:
• make these informative documents available on the hospitals website;
• refer a contact person from who the patient can get more personalized information about the costs associated with their hospitalization.
More information available here: http://www.presscenter.org/fr/pressrelease/20130920/accessibilite-aux-soins-de-sante (in French) / http://www.presscenter.org/fr/pressrelease/20130920/accessibilite-aux-soins-de-sante?lang=nl (in Dutch)
2.9.2 Patient choice
Belgium promotes freedom of patient choice and competition between providers. Patients have free choice of health care professionals and health care institutions (e.g. hospitals). Patients also have free choice of sickness funds and the sickness funds cannot refuse a patient. Conversely, according to the medical code of ethics and except in case of emergency or of failing in his duty of humanity, a physician has the possibility to refuse to treat a patient for professional or personal reasons. In this case, the physician must inform the patient or his/her relatives, continuity of care must be maintained and any useful information must be passed to the successor physician (Ordre des médecins 2009).
The right to free choice of health care professional gives patients the choice to contact several different health care professionals before choosing one. Patients can always choose to consult with another health care professional and may change their choice of health care professional (right to a second opinion) (FPS Health, Food Chain Safety and Environment 2009b).
According to the Itinerat Institute, too little information about the quality of care is available to the patients to help them in their choice (Daue and Crainich 2008). Moreover, in hospitals, the choice is limited by supply and, in some specialties and/or hospitals, the choice can be limited (Schoonacker and Louckx 2006).
2.9.3 Patients’ rights
The rights and obligations of the population have been stated since 1997 in “the Charter of the socially insured”. The main purpose of the charter is to “protect the population through a whole set of rules to be respected by all social security institutions” (FPS Social Security, 2009c). The basic principles of the Charter can be summarized as follows: (1) information and answers to questions on population rights must be provided by the social security institution; (2) the institution must grant any particular benefit if the person seems to be entitled to it; (3) benefits must be granted in a rapidly and without exceeding a four-month delay; (4) if exceeding such a delay the institution must pay interest to the entitled; (5) reasons as well as other resources (appeal procedures, reference number, etc.) relating to any decision must be provided to the socially insured; and (6) the socially insured can appeal any decision of the social security institution within three months.
In August 2002, Belgium introduced legislation on patients’ rights. The purpose of the Patients’ Rights Act is to strengthen the legal status of the patient. Prior to this Act, patients’ rights could be inferred from general legal principles, international treaties and constitutional and criminal stipulations. The Patients’ Rights Act regulates the rights of patients with regard to health care professionals, including physicians, dentists, pharmacists, nurses, midwives, physiotherapists and paramedics. Every health care professional must comply with the patients’ rights legislation. Hospitals are also obligated to comply with the stipulations of the law on patients’ rights with regard to the medical, nursing and other health care professional aspects of the legal relationship with patients. Two national campaigns were organized to raise awareness and make patients’ rights better known to the public.
The following rights are established by law:
- right to quality of service provision
- right to free choice of health care professional
- right to patient health state information
- right to give informed consent
- right to inspect and to have a copy of the patient file
- right to protection of privacy
- right to submit a complaint to the competent ombudsperson
- right to palliative care and pain relief.
Each patient has the right to health care that best corresponds to their needs according to the medical knowledge and technology available, and health care must be provided with respect for human dignity and the patient’s autonomy, without any discrimination.
Moreover, patients are entitled to respect of their privacy for every intervention provided by the health care professional. Other people may be present only if it is required for professional reasons (FPS Health, Food Chain Safety and Environment 2009b). Patients’ rights concerning patient information and patient choice are described above, and those regarding complaints are described in the next sections.
The Socialist Sickness Fund interviewed 7000 members to assess respect of patients’ rights. They found that less than a half were aware of their rights as patients. Also, around half were not aware of the possibility to submit a complaint to an ombudsperson and to have access to their medical file (Socialistische Mutualiteiten 2008).
For the 10 years of the law on patient rights, the FPS Public Health launched a campaign in December 2012 focusing on the benefits of a good relationship between the patient and the caregiver. More information can be found via the following link: www.droitsdupatient.be or www.patientenrechten.be
2.9.4 Patients and cross-border care
In Belgium, cross-border care and care for foreigners are mainly funded on the basis of the European Council Regulation on the coordination of social security schemes (883/2004 and 987/2009)12 and of the rulings of the Court of Justice of the European Communities (ECJ). However, regulations 1408/71 and 574/72 will for the time being remain in force for relations between the EU27 and Iceland, Liechtenstein, Norway and Switzerland if Regulation 858/2003 (third-country nationals) is not replaced by a new regulation.
If a Belgian travels in a country of the EEA or in Switzerland and if he or she must receive unforeseen medical treatment which becomes medically necessary during his or her stay, taking into account the nature of the benefits in kind and the expected length of stay, his or her medical expenses will be covered according to the legislation in the host country upon presentation of his or her European Health Insurance Card (EHIC). Depending on the country, medical care will be totally or partially reimbursed on the spot or soon after returning home. The EHIC is not valid for private hospitals or treatments, is individual (each family member must have his or her own EHIC), is limited to temporary stays and is reserved for unplanned care (Belgium Federal Portal 2009).
For planned treatment in another country of the EEA or in Switzerland, medical costs can be covered by the Belgian sickness funds using the E112 form or under the rulings of the ECJ. To be covered, this medical care must be among the benefits reimbursed in Belgium.
For hospital care, a prior authorization from the sickness fund is required but not for non-hospital care, unless the treatment requires the use of highly specialized and cost-intensive medical infrastructure or medical equipment, which is normally only to be found in a hospital environment and which does not require an overnight stay. However, the distinction between non-hospital and hospital treatment is not clearly defined and it is highly recommended that patients seek advice from the sickness funds. In Switzerland, reimbursement according to the rulings of the ECJ is possible (applicable since 1 July 2008) (Coheur 2009; Mutualité professionnelle et libre de la région wallonne 2009).
In the case of planned non-hospital care (beyond the exceptions already mentioned), the reimbursement of the costs of cross-border health care is not subject to a prior authorization (E112) under the so-called “Kohll and Decker procedure”. The insured person is entitled to reimbursement of the costs incurred within the limits of and under the conditions of the Belgian reimbursement rates.
The standard procedure for obtaining the E112 form is to apply for a prior authorization to the medical examiner of the sickness fund. The insured must submit a medical report prepared by a Belgian physician containing a description of the treatment and/or intervention; a clarification of why the treatment cannot be provided within a reasonable period, taking into account the state of health and the probable cause of the illness of the insured person and, if necessary, an explanation of why the treatment can take place in better medical conditions abroad;13 and contact details of the place where the treatment can be carried out. If the treatment is not among the benefits provided for by the Belgian legislation, no authorization will be given. If the treatment can be provided in Belgium at the same quality level and within a reasonable period, again, no authorization will be given. With the E112 form, the treatment cost will be covered at the treating country’s coverage rate. If the Belgian reimbursement amount is higher than in the treating country, the patient, upon request, will be entitled to an additional reimbursement by his sickness fund; however, the reimbursed sum may not exceed the costs actually incurred by the patient and the sickness fund does not have to reimburse more than the sum it would have to pay if the same treatment had been provided in Belgium (Coheur 2009; Mutualité professionnelle et libre de la région wallonne 2009).
Most, if not all, private hospitals refuse the E112 form. In this case, instead of the E112 form, it is possible to apply Article 294 (§1, 2) of the Royal Decree of 3 July 1996. This concerns medical treatment for which the patient has received a prior authorization from the medical examiner of his sickness fund in case treatment can be provided under better medical conditions in a hospital abroad. According to this Article, the patient will pay the treatment cost and can then ask for reimbursement from his sickness fund within the limits of and under the conditions of the Belgian reimbursement rates. When an international convention cannot be applied or does not exist, Belgian insured persons must refer to this section of the Royal Decree which concerns hospitalizations only (Coheur 2009; Mutualité professionnelle et libre de la région wallonne 2009).
A proposal for a new directive on patient mobility from the European Commission is in progress. This directive should clarify procedures for citizens seeking health care abroad. The major principles of this directive are to improve legal security for the patient seeking cross-border health care, common principles in European health care systems, and more collaboration between Member States.
Moreover in 2007, a bill regarding patient mobility was passed in Belgium. This law will come into force on a date determined by ministerial decree, which is expected to be in July 2010. The law aims to deal with the bottlenecks in hospital financing caused by patient mobility, and guarantees for Belgian patients are provided. The law also creates an Observatory for Patient Mobility at the NIHDI and the FPS Health, Food Chain Safety and Environment (BS–MB 2007).
Beyond this, more and more cross-border cooperation has been developed. In Belgium, residents of specific border regions have access to medical care in specific areas on the other side of the border through a more flexible procedure of issuing the specific E112 form. This system applies to people living within 15 km of the border and wanting to be treated in a facility up to 25 km on the other side of the border; people living in Eupen, Malmedy, Sint-Vith, Arlon, Messancy, Bouillon, Chimay, Couvin and Gedinne; people living in the administrative districts of Virton and Bastogne; or people living in Mellier, Léglise, Ebly, Juseret, Vitry and Anlier. The E112 “border” form is issued without providing any medical motivation or justification. However, only specific care is concerned (mainly hospitals and dialysis care) (Mutualité professionnelle et libre de la région wallonne 2009).
Moreover, residents of the Euregio Meuse-Rhine can use the form EMR E112+ to simplify the authorization process further. The geographical area of the Euregio Meuse-Rhine includes the provinces of Liège and Limburg in Belgium; the province of North Brabant and Limburg in the Netherlands; Aix-la-Chapelle and the districts of Bitburg, Prüm and Daun in Germany. The form EMR E112+ provides access to outpatient specialist medical care (and subsequent hospital treatment as well as the prescription of pharmaceuticals and medical devices) and is issued without medical report or agreement of the medical examiner of the sickness fund. However the use of prior authorization can be maintained for specific services (Mutualité professionnelle et libre de la région wallonne 2009).
Several cooperation agreements between French and Belgian hospitals have also been set up to improve access and quality of care, and allow patients to overcome the requirement of a prior authorization for medical care across the border. Each convention has its own specificities regarding the hospitals’ partners, the medical fields covered and the people involved (Belgian patient in France or vice versa). Four Organized Cross-border Areas for Access to Care (ZOAST) have also been created between France and Belgium. These ZOAST ensure continuity of care through the free movement of patients between France and Belgium. In these areas, Belgian patients can receive hospital and/or ambulatory care in specific French hospitals on the basis of a specific E112 form (e.g. E112 MRTW or E112 ARLWY), which is issued by their sickness fund without providing any medical motivation or justification. Cooperation agreements on cross-border urgent medical transport have also been developed in border area between France and Belgium.
Moreover, in 2005, a framework agreement has been set up to offer a global legislative framework to all the inter-hospital conventions and agreements between France and Belgium. This agreement has already been ratified by the parliament of France and was in the process of being ratified by the Belgian and competent regional parliaments at the time of writing (De Cock 2009).
Other initiatives with Germany, Luxembourg and the Netherlands are under way. A Benelux decision on cross-border urgent medical transport was approved in 2008 (Secrétariat Général Benelux, Van Haver and Boon 2008).
To reduce waiting lists, Dutch and English health care purchasers have concluded direct contracts with Belgian hospitals. For example, people living in the Dutch region Zeeuws-Vlaanderen and in Noord Brabant have the possibility of receiving specialized treatment in specific Belgian hospitals. The OZ and CZ Dutch sickness funds estimated that the number of affiliates treated in Belgian contracted hospitals was 2203 in 2000 and 7267 in 2004.
In 2003, the English National Health Service (NHS) also concluded contracts with seven Belgian hospitals, and five of them were extended until 31 March 2007. All these five contracts concerned knee and hip replacements. Between May 2003 and November 2004, a total of 432 NHS patients with hip and knee problems have been treated in one of these five hospitals. However, since September 2004, the flow of English patients to Belgium has been reduced because of an increase of capacity in England and the end of the “London Patient Choices” project and its budget for overseas treatment (Glinos, Baeten and Boffin 2006).
The aim of cross-border cooperation is to improve access and quality of care. Nevertheless, if the increase of cross-border care is not embedded in properly balanced regulations, it may carry the risk of eroding Belgian public health care funding and thus diminishing current overall health standards for a given public budget. The financial and non-financial (waiting lists, distributional equity across hospitals, quality of care) consequences linked to these flows need to be studied. The KCE will study these issues in a future report (programmed in 2010–2011). This report will also try to give a general overview of foreign patients undergoing elective surgery in Belgium (ambulatory and inpatient). Even if data on E112 procedures are available, private interventions or data regarding contracts between different parties such as hospitals or health insurers are lacking. The number of E112 forms for the treatment of foreign patients in Belgium (including both ambulatory and inpatient care) was estimated to be 10 773 in 1998 and 19 378 in 2008. Patients coming from the Netherlands represent around 66% of non-Belgian patients (Glinos, Baeten and Boffin 2006).
In November 2013, the website of the Belgian National Contact Point for Cross-Border Healthcare went online. It serves to inform EU citizen about the Belgian health care system, and to inform Belgian patients on how to apply for reimbursement from treatment received in another EU member state. A list of National Contact Points in other countries is also provided.
For more details: http://health.belgium.be/eportal/Aboutus/crossborder_healthcare/19082424_EN?ie2Term=contact&ie2section=83&&fodnlang=en
2.9.5 Complaints procedures (mediation, claims)
The law on patients’ rights also grants the right to a complaints procedure. Patients can submit their complaint to an ombudsperson. The ombudsperson should in the first instance, support communication between the patient and the health care professional. If the patient and health care professional do not reach a solution, the ombudsperson has to proceed to mediation. If the ombudsperson’s mediation does not lead to a solution, the ombudsperson has to inform patients about other alternatives for taking the complaint forward. On the basis of the information obtained as a mediator, the ombudsperson makes recommendations to prevent similar complaints in future. Under the hospital legislation, and following the set standards, every hospital must appoint an ombudsperson.
In ambulatory care, any conflict between a patient and a health care professional is managed by a federal ombuds service. The federal ombuds service has been established in the FPS Public Health, Food Chain Safety and Environment. Complaints are treated by the federal ombuds service if there is no competent local ombudsperson. These may be about, for example, GPs, dentists, pharmacists, independent nurses and physiotherapists. The federal ombuds service also has to deal with complaints concerning the way in which conciliation by the local ombudsperson has been carried out. However, the federal ombuds service is not a substantive profession agency for complaints, which should be treated in the first instance by the local ombudsperson where available.
In the mental care sector, mediation is exercised either by an external ombuds service (external mediation) or by the hospital ombudsman (Cobbaut et al. 2009).
In 2008, the federal ombuds service received 482 complaints and 290 requests for information (Gryson, Verhaegen and Debreyne 2008). Moreover, an assessment by the Socialist Sickness Fund of patients’ rights showed that 49% of the 7000 interviewed patients were unaware of the existence of a mediation service in the hospital where they were treated (Socialistische Mutualiteiten 2008).
2.9.6 Patient safety and compensation
The professional liability of a physician, except for disciplinary liability, is not governed by special laws. This means that both the civil liability and the criminal liability of the physician for damage or injury caused by improper performance of the duties entailed in the discharge of his or her professional functions are governed by the general rules of civil and criminal law (Nys 1997).
Obtaining professional liability insurance for health care professionals was advised but was not mandatory. A bill to oblige every individual or institutional health care provider to have liability insurance is still in progress (Act of 15 May 2007).
A patient is entitled to recover damages in respect of negligent medical treatment only if he or she has actually suffered damage. In principle, all the damage, moral damage included, has to be compensated.
Fault is the main basis of a claim for malpractice. Deviation from the professional standard is to be considered as a fault in the practice of medicine. Patients who have been the victim of a medical fault are faced with many obstacles in recovering damages. Long legal procedures are often necessary while results are uncertain. Patients who experience damage after a medical intervention or treatment can only receive compensation if they themselves can prove that damage has been caused by a fault. The plaintiff must prove not only that the defendant physician was negligent, but also that the defendant’s negligence was the cause of the damage sustained. Damage that is not caused by a fault is therefore not compensated.
Therefore, a bill based on the French system has been developed in Belgium to compensate, under certain conditions, damage resulting from health care that does not involve the responsibility of the caregiver. Under this new system, damage resulting from an act of care, prevention or diagnosis that does not involve the responsibility of the caregiver, that shows a certain degree of seriousness and that is abnormal in relation to the patient’s health and to the state of science will be compensated for without the patient having to prove the medical fault. In these cases, the condition for indemnity will therefore no longer be the existence of fault and the causal link between damage and fault. The payment for these damages will be entrusted to a fund to be established with this aim.
For several years now a patient safety policy within the hospitals has been developed through pilot projects on issues including incident reporting in the case of medication mistakes and the development of patient safety indicators based upon the MCD. In 2007, committees for quality and patient safety were created in the hospitals involving a coordinator who sets up and follows the incident reporting in order to create a “no shame, no blame” culture within the institution.
2.9.7 Patient participation/involvement and patient satisfaction
In Belgium, the question of patient participation in the health care system is linked to the role of sickness funds. Sickness funds in Belgium are more than simple insurers; their role is also to represent the patients and to make their voices heard in the health care policy-making process. However, because of their multiple tasks, their positioning is complex and they are more focused on the representation of the whole insured population’s interests rather than the representation of specific interests of individuals (Tegenbos et al. 2008; Leys et al. 2007).
Patients’ associations also represent patients’ interests. With the increase of patients’ associations, French, Flemish and German federations have been created: the LUSS, the VPP, the Patiënten Rat & Treff and Radiorg. These federations receive public subsidies from federal and federated authorities and have representatives in the Federal Commission of Patients’ Rights. The aim of the Federal Commission of Patients’ Rights is to collect and treat information, to formulate notices to the Minister of Social Affairs and Public Health, to assess the application of patients’ rights, to assess mediations processes and to treat claims related to mediations processes (Tegenbos et al. 2008; Leys et al. 2007).
In order to increase patients’ participation in the health care system, different initiatives have been undertaken and some organizations have included representatives of patients’ associations in their management processes. For example, the Walloon Institute for Mental Health (IWSM) has included representatives of patients’ associations in their administrative board and the Flemish Association for Mental Health (VVGG) involves representatives of patients’ associations in their management. Representatives of patients’ associations for disabled people and their relatives are also involved in the management of the AWIPH and the VAPH. Subsidized homes for the elderly must also have a resident council included in their management (Tegenbos et al. 2008, Leys et al. 2007).
According to the Eurobarometer report of 2002 on the public’s satisfaction with the health care system, a clear majority (65.1%) of the Belgian population is satisfied with the present organization of health care. The system runs well according to 23.8% of Belgians (compared to 13.2% in the EU15). However, 41.3% of Belgians said that minor changes are needed (30.7% in the EU15), 22.7% felt that fundamental changes are needed (38.2% in the EU15) and 5.2% want to rebuild the health care system completely (13.5% in the EU15) (OECD 2009a). According to the Eurobarometer report of 2007 on health and long-term care in the EU, the quality of care and the availability and accessibility of health care were positively perceived by the Belgian population compared to European perceptions (see Table2.4) (Eurobarometer, 2007).
2.9.8 Physical access
According to the United Nations Convention on the Rights of Persons with Disabilities of 13 December 2006, disabled people have the right to live independently and participate fully in all aspects of life. States must take appropriate measures to ensure, on an equal basis with others, access to the physical environment, to transports, to information and communication, and to other facilities and services open or provided to the public, both in urban and rural areas. These measures, which include the identification and elimination of obstacles and barriers to accessibility, apply to buildings, roads, transportation and other indoor and outdoor facilities, including schools, housing, medical facilities and workplaces; and to information services, communications services and other services, including electronic services and emergency services (Conseil d’État 2009). This Convention was transposed into Belgian legislation by the Act of 13 May 2009.
Moreover, according to the Act of 23 October 1964 on the setting of standards for hospitals, specific services, such as geriatric and rehabilitation services, must allow easy access adapted to the disabilities of patients. Any barriers to access, such as steps, stairs and other obstacles, should be avoided and any risk of slipping must be prevented. The environment for patients must be facilitated by the installation of railings and handrails. Sanitary facilities must also be adapted, and wheelchairs in sufficient numbers must be provided in the corridors. Numerous regional regulations to improve the access and integrity of disabled people have also been developed.