Accreditation and Designation User Manual - OECI

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2 / OECI Accreditation and Designation / Appendix I
Appendix II. OECI Quality standards (This appendix contains a paper version of the OECI quality standards (not for public release). In clinical cancer centres and Comprehensive Cancer Centres the full set of standards will be assessed during the self-assessment and by the audit team during the peer review visit. Cancer Unit are excluded for the standards in chapter 4: Research innovation and developments. The sollowint table shows the chapters and domains with the number of standards and questions. The marked standards are not assessed in Cancer Units. Chapters Domains Nr of standards Sub standards/ questions Total 264 Chapter 1 General standards, strategic plan 26 121 and general management 1.1 Policy and organisation 5 22 1.3 Resources and materials 2 8 1.4 Process control 12 54 1.5 Safeguarding the quality system 7 37 Chapter 2 Screening and primary prevention 5 19 and health education 2.4 Process control 5 19 Chapter 3 Care 10 30 3.4 Process control 10 30 Chapter 4 Research innovation and developments 14 45 4.1 Policy and organisation 7 25 4.3 Resources and materials 3 12 4.4 Process control 3 4 4.5 Safeguarding the quality system 1 4 Chapter 5 Education and teaching 4 19 5.1 Policy and organisation 1 7 5.4 Process control 3 12 Chapter 6 Patient related 6 30 6.4 Process control 4 21 6.5 Safeguarding the quality system 2 9 All standards and questions are presented on the following pages. Additionally to giving a score to each question, the e-tool gives the opportunity to add notes, proof documents and improvement points. Appendix II / OECI Accreditation and Designation / 3
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ORGANISATION OF EUROPEAN CANCER INS
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OECI Accreditation and Designation
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THE OECI Accreditation and Designat
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Owner: OECI Organisation of Europea
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The keyword in the designation of E
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2.1.1 General explanation of the te
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OECI General Assembly Member Instit
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− Organizing the auditors’ meet
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3.2 Audit team and auditors 3.2.1 O
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3.3 Cancer institute Obviously all
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5.1.1 Step 1: activities and respon
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Designation questionnaire Executor:
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Send signed accreditation and desig
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5.3 Step 3: Explanatory visit and p
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Finishing self-assesment Executor:
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5.6 Step 6: Payment stage 2 fee If
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Preparation of the auditors’ team
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Performing the peer review Executor
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5.8.1 Week 1-6: Reporting by the au
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5.9 Step 9: Formulate improvement p
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5.10.1 Evaluation of the A&D Progra
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Intermediate self-assessment (optio
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2 / OECI Accreditation and Designat
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Qualitative Questionnaire 1. Genera
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1.3.2. Administration of cytostatic
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1.4.6. Roles and tasks of the membe
Page 66 and 67: 1.4.12. Registration and evaluation
Page 68 and 69: 1.5.5. Quality assurance in all are
Page 70 and 71: 2.4.5. Smoking control in the cance
Page 72 and 73: 3.4.4. Palliative and terminal care
Page 74 and 75: 4. Research, innovation and develop
Page 76 and 77: 4.3. Resources and materials 4.3.1.
Page 78 and 79: 5. Teaching and continuing educatio
Page 80 and 81: 6. Patient related 6.4. Process con
Page 82 and 83: 6.5. Safeguarding the quality syste
Page 84 and 85: 1.4.7. at national level at regiona
Page 86 and 87: 2.3. Infrastructures with a focus o
Page 88 and 89: 2.9. Radiology 2.9.1. Number of CT
Page 90 and 91: 2.15. Facilities 2.15.1. On site Ac
Page 92 and 93: 3.4. Human resources (4) 3.4.1. Pat
Page 94 and 95: 4.3. Structures 4.3.1. Yes No not a
Page 96 and 97: 5. Education 5.1. Education 5.1.1.
Page 98 and 99: Planning of the project Start Expla
Page 100 and 101: Go to the qualitative and quantitat
Page 102 and 103: 3. Before moving to the next item p
Page 104 and 105: The following screen will appear. F
Page 106 and 107: • Close the questionnaire if you
Page 108 and 109: Print only the questions or the ful
Page 110 and 111: Workspace: Go to the questionnaires
Page 112 and 113: 2. Preparing a peer review Open a q
Page 114 and 115: To view the remarks and the score o
Page 118 and 119: Qualitative Questionnaire 1. Genera
Page 120 and 121: 1.3.2. Administration of cytostatic
Page 122 and 123: 1.4.6. Roles and tasks of the membe
Page 124 and 125: 1.4.12. Registration and evaluation
Page 126 and 127: 1.5.5. Quality assurance in all are
Page 128 and 129: 2.4.5. Smoking control in the cance
Page 130 and 131: 3.4.4. Palliative and terminal care
Page 132 and 133: 4. Research, innovation and develop
Page 134 and 135: 4.3. Resources and materials 4.3.1.
Page 136 and 137: 5. Teaching and continuing educatio
Page 138 and 139: 6. Patient related 6.4. Process con
Page 140 and 141: 6.5. Safeguarding the quality syste
Page 142 and 143: 1.4.7. at national level at regiona
Page 144 and 145: 2.3. Infrastructures with a focus o
Page 146 and 147: 2.9. Radiology 2.9.1. Number of CT
Page 148 and 149: 2.15. Facilities 2.15.1. On site Ac
Page 150 and 151: 3.4. Human resources (4) 3.4.1. Pat
Page 152 and 153: 4.3. Structures 4.3.1. Yes No not a
Page 154 and 155: 5. Education 5.1. Education 5.1.1.
Page 156 and 157: Planning of the project Start Expla
Page 158 and 159: Go to the qualitative and quantitat
Page 160 and 161: 3. Before moving to the next item p
Page 162 and 163: The following screen will appear. F
Page 164 and 165: • Close the questionnaire if you
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Print only the questions or the ful
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Workspace: Go to the questionnaires
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2. Preparing a peer review Open a q
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To view the remarks and the score o
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