Accreditation and Designation User Manual - OECI
Accreditation and Designation User Manual - OECI Accreditation and Designation User Manual - OECI
Qualitative Questionnaire 1. General Standards, Strategic Plan and General Management 1.1. Policy and organisation 1.1.1. Oncological policy plan and general report 1.1.1.1. 1.1.1.1.1. The board and/or the management of the cancer centre has an official recent plan (not older than five years) 1.1.1.1.2. The vision on care in the field of oncology care is explained in the plan 1.1.1.1.3. The policy and the goals to be achieved are defined in the plan 1.1.1.1.4. The annual plan or multi-year plan contains actions to achieve the goals 1.1.1.1.5. The cancer centre has concrete annual or multi-year plans on the level of the main services or clusters 1.1.1.1.6. The plan is evaluated in later annual reports 1.1.1.1.7. Improvement activities of the cancer centre (logistics, research, education, multidisciplinary teams) are part of the annual report Yes Mostly Partially No not applicable 1.1.2. Cooperation with universities 1.1.2.1. The cancer centre has formal cooperation or agreement with at least one university for: Yes Mostly Partially No not applicable 1.1.2.1.1. care activities 1.1.2.1.2. educational activities 1.1.2.1.3. research activities 1.1.3. Cooperation with external partners Have agreements been reached, about the allocation of tasks, such as a hospital or radio therapeutic institute in the case of referrals? 1.1.3.1. 1.1.3.1.1. Cooperation arrangements with other cancer centres are clearly documented in (written) agreements covering the goals of the cooperation, tasks, responsibilities and competences of the cancer centre and the cooperating partners 1.1.3.1.2. There are (written) agreements with home care organisations 1.1.3.1.3. There are (written) defined and documented cooperation arrangements with general practitioners. 1.1.3.1.4. There are (written) agreements with nursing home, rest house, palliative care institutions, etc. 1.1.3.1.5. There are (written) agreements with special cancer care service providers such as radiotherapy centre, pathology laboratory, specialised surgery unit etc. Yes Mostly Partially No not applicable 4 / OECI Accreditation and Designation / Appendix II
1.1.4. Cancer data registration (institutional level) Are the data on the patients’ types of cancers recorded in an institutional cancer database? 1.1.4.1. 1.1.4.1.1. The number of new oncology patients is known at an institutional level 1.1.4.1.2. The number of new cases for each type of cancer is known at an institutional level 1.1.4.1.3. There are diagnostic, treatment and outcome data on patients with cancer available annually at an institutional level 1.1.4.1.4. The data are reported and analysed by a multidisciplinary group with recommendations for improvement of care Yes Mostly Partially No not applicable 1.1.5. Complications registry Have agreements been reached concerning keeping and discussing a complications registry? 1.1.5.1. 1.1.5.1.1. There are specific protocols for reporting and recording of complications 1.1.5.1.2. The data are analysed at an institutional level 1.1.5.1.3. After analysis, improvement measures are developed and action plans implemented in agreement with the departments concerned Yes Mostly Partially No not applicable 1.3. Resources and materials 1.3.1. Cytostatic drugs, prescription, preparation and distribution Have agreements been reached concerning the prescription, preparation and distribution of cytostatic drugs? 1.3.1.1. 1.3.1.1.1. A written procedure concerning prescription of anti-cancer drugs is available 1.3.1.1.2. A written procedure concerning preparation of anti-cancer drugs is available 1.3.1.1.3. A written procedure concerning distribution of anti-cancer drugs is available 1.3.1.1.4. The anti-cancer drugs are prepared in a centralised unit 1.3.1.1.5. The anti-cancer drugs are prepared under the direct supervision of a pharmacist Yes Mostly Partially No not applicable Appendix II / OECI Accreditation and Designation / 5
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Qualitative Questionnaire<br />
1. General St<strong>and</strong>ards, Strategic Plan <strong>and</strong> General Management<br />
1.1. Policy <strong>and</strong> organisation<br />
1.1.1. Oncological policy plan <strong>and</strong> general report<br />
1.1.1.1.<br />
1.1.1.1.1. The board <strong>and</strong>/or the management<br />
of the cancer centre has an official<br />
recent plan (not older than five years)<br />
1.1.1.1.2. The vision on care in the field of oncology<br />
care is explained in the plan<br />
1.1.1.1.3. The policy <strong>and</strong> the goals to be achieved<br />
are defined in the plan<br />
1.1.1.1.4. The annual plan or multi-year plan contains<br />
actions to achieve the goals<br />
1.1.1.1.5. The cancer centre has concrete annual or<br />
multi-year plans on the level of the main<br />
services or clusters<br />
1.1.1.1.6. The plan is evaluated in later annual reports<br />
1.1.1.1.7. Improvement activities of the cancer centre<br />
(logistics, research, education, multidisciplinary<br />
teams) are part of the annual report<br />
Yes Mostly Partially No not applicable<br />
1.1.2. Cooperation with universities<br />
1.1.2.1.<br />
The cancer centre has formal cooperation or agreement with at least one university for:<br />
Yes Mostly Partially No not applicable<br />
1.1.2.1.1. care activities<br />
1.1.2.1.2. educational activities<br />
1.1.2.1.3. research activities<br />
1.1.3. Cooperation with external partners<br />
Have agreements been reached, about the allocation of tasks, such as a hospital or radio therapeutic institute in the case of<br />
referrals?<br />
1.1.3.1.<br />
1.1.3.1.1. Cooperation arrangements with other cancer<br />
centres are clearly documented in (written)<br />
agreements covering the goals of the cooperation,<br />
tasks, responsibilities <strong>and</strong> competences of the<br />
cancer centre <strong>and</strong> the cooperating partners<br />
1.1.3.1.2. There are (written) agreements with home care<br />
organisations<br />
1.1.3.1.3. There are (written) defined <strong>and</strong> documented<br />
cooperation arrangements with general<br />
practitioners.<br />
1.1.3.1.4. There are (written) agreements with nursing<br />
home, rest house, palliative care institutions, etc.<br />
1.1.3.1.5. There are (written) agreements with special<br />
cancer care service providers such as<br />
radiotherapy centre, pathology laboratory,<br />
specialised surgery unit etc.<br />
Yes Mostly Partially No not applicable<br />
4 / <strong>OECI</strong> <strong>Accreditation</strong> <strong>and</strong> <strong>Designation</strong> / Appendix II
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