Accreditation and Designation User Manual - OECI

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1.3.2. Administration of cytostatic drugs Are there protocols for the administration of cytostatic drugs? 1.3.2.1. 1.3.2.1.1. The cancer centre has described procedures or guidelines on the administration of anti-cancer drugs 1.3.2.1.2. The anti-cancer drugs are as much as possible administrated in specialised wards (e.g., administration of anti-cancer drugs takes place only in some well-defined wards (medical oncology ward…) 1.3.2.1.3. There is a dedicated day-care unit for the administration of anti-cancer drugs Yes Mostly Partially No not applicable 1.4. Process control 1.4.1. Continuity of care within the cancer centre Have agreements been reached concerning the continuity of care, and replacement of nursing, medical, paramedical, and support staff associated with oncology? Is the care covered 7 days a week by specialised staff? 1.4.1.1. 1.4.1.1.1. Continuity of specialised care is warranted 24 hours a day on the medical, paramedical, nursing and supportive levels. This can, among other things, be achieved by planning continuity of care during nights, week-ends, holidays, illness, attendance at conferences or other reasons for absence, within each discipline 1.4.1.1.2. Patients are informed about all the aspects of the continuity of care and eventually referred to another hospital 1.4.1.1.3. The patient receives information about the contact person for medical and nursing oncological matters Yes Mostly Partially No not applicable 1.4.2. Waiting and throughput times Have norms, standards been defined concerning the maximum waiting and throughput times for oncological patients with regard to first outpatients’ visit, admission, and tests/treatment? 1.4.2.1. There are guidelines (for different types of tumours) for the (maximum) waiting times between: 1.4.2.1.1. referral by the general practitioner or referring specialist and the first visit to the outpatient’s clinic or the admission into the cancer centre 1.4.2.1.2. first visit and the time of definitive diagnosis 1.4.2.1.3. definitive diagnosis and first treatment 1.4.2.1.4. There is a record of those waiting times 1.4.2.1.5. There is continuous measurement and analysis of those waiting times leading to improvements when needed 1.4.2.1.6. There is a clear definition of the roles of each category of staff on those issues Yes Mostly Partially No not applicable 6 / OECI Accreditation and Designation / Appendix II
1.4.3. Compliance with guidelines Have agreements been reached concerning the use of guidelines relating to diagnosis, treatment, follow up and research? 1.4.3.1. 1.4.3.1.1. The medical specialists and the employees of the cancer centre apply the (local/regional/national/ international) guidelines on diagnostics, treatment, follow up and research 1.4.3.1.2. The guidelines are easily accessible 1.4.3.1.3. The guidelines are updated on a regular basis depending on medical developments 1.4.3.1.4. Each decision that differs from the guidelines is recorded in the file of the patient Yes Mostly Partially No not applicable 1.4.4. Compliance with guidelines Do you report the compliance with multidisciplinary guidelines? 1.4.4.1. 1.4.4.1.1. Compliance with guidelines is measured through the registration of the patients’ cancer data 1.4.4.1.2. Deviations from guidelines are analysed 1.4.4.1.3. Deviations from guidelines are discussed 1.4.4.1.4. Deviations from guidelines are reported annually Yes Mostly Partially No not applicable 1.4.5. Tasks and responsibilities of the (oncology) nurses Have agreements been reached concerning the tasks and responsibilities of nurses working at the oncology department? 1.4.5.1. 1.4.5.1.1. For each technical, clinical or outpatient’s department where patients with cancer are treated, there are nurses trained in oncology 1.4.5.1.2. Anti-cancer drugs are administered by specially educated (oncology) nurses 1.4.5.1.3. The cancer centre has nurses with expertise with regard to the tumours treated (e.g.: breast, colo-rectal, head and neck, gynaecological cancer) 1.4.5.1.4. There are procedures describing the tasks and responsibilities of (oncology) nurses 1.4.5.1.5. Roles and responsibilities of nurses with different expertises (oncology, palliative care,…) are described regarding special involvement in oncology care 1.4.5.1.6. The nursing discipline has one staff member as contact person for oncology care Yes Mostly Partially No not applicable Appendix II / OECI Accreditation and Designation / 7
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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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1.4.12. Registration and evaluation
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1.5.5. Quality assurance in all are
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