Accreditation and Designation User Manual - OECI

More documents

Recommendations

Info

1.4.6. Roles and tasks of the members of the supportive care staff Have agreements been reached concerning the roles and tasks of the supportive care staff? 1.4.6.1. 1.4.6.1.1. Roles and responsibilities for each of the paramedical disciplines are described regarding the involvement in oncology care 1.4.6.1.2. Roles and responsibilities for each of the supportive disciplines are described regarding the involvement in oncology care 1.4.6.1.3. Each of the paramedical discipline has one staff-member as contact person (referent) for oncology care 1.4.6.1.4. Each of the supportive disciplines has one staff-member as contact person (referent) for oncology care Yes Mostly Partially No not applicable 1.4.7. Communication between the members of the supportive care staff What is the focus of the communication between nursing, paramedic and supportive disciplines? 1.4.7.1. Communication amongst members of the supportive care staff (nursing, paramedical and supportive disciplines) occurs through: Yes Mostly Partially No not applicable 1.4.7.1.1. Consultation 1.4.7.1.2. Data transmission 1.4.7.1.3. Transfer of knowledge 1.4.7.1.4. Information and implementation of guidelines Have agreements been reached within the cancer centre concerning who is authorised to refer patients to paramedical and/ or support disciplines, and under what circumstances? 1.4.8.1. 1.4.8.1.1. It is made clear for which problems related to cancer and at which moment paramedical disciplines should be consulted 1.4.8.1.2. It is made clear for which problems related to cancer and at which moment supportive disciplines should be consulted 1.4.8.1.3. There are written procedures on the circumstances for calling on and referral to paramedical disciplines 1.4.8.1.4. There are written procedures on the circumstances for calling on and referral to supportive disciplines Yes Mostly Partially No not applicable 8 / OECI Accreditation and Designation / Appendix II
1.4.9. Multidisciplinary harmonisation / integrated care Have agreements been reached on the harmonisation of integrated care, between the various disciplines involved in the diagnosis, treatment and counselling of oncology patients? 1.4.9.1. 1.4.9.1.1. The responsibilities of the different disciplines involved in the diagnosis of the patient in the cancer centre are described 1.4.9.1.2. The responsibilities of the different disciplines involved in the treatment of the patient in the cancer centre are described 1.4.9.1.3. The responsibilities of the different disciplines involved in the follow-up of the patient in the cancer centre are described 1.4.9.1.4. The multidisciplinary team advises on the inclusion of patients in clinical trials 1.4.9.1.5. The name of the physician responsible for the coordination of the care of the patient is defined and communicated to the patient Yes Mostly Partially No not applicable 1.4.10. Selection criteria for the oncology team meeting Are the selection criteria concerning which patient should be discussed in the multidisciplinary setting clear and documented? 1.4.10.1. 1.4.10.1.1. Criteria are defined for the selection of patients to be discussed in the multidisciplinary team meetings 1.4.10.1.2. These selection criteria are clear, documented and based on a consensus between the different disciplines Yes Mostly Partially No not applicable 1.4.11. Procedure for the oncological multidisciplinary team meetings Is there a procedure for the oncological multidisciplinary team meetings? 1.4.11.1. There are procedures describing how the regular multidisciplinary team meetings apply following criteria: 1.4.11.1.1. One of the specialist in charge of the care of the patient is present during the discussion of the patient 1.4.11.1.2. During the presentation of patients, diagnostic results and examination results are available 1.4.11.1.3. The necessary facilities to show diagnostic and examination results are available 1.4.11.1.4. Conclusions and advice resulting from the multidisciplinary team meeting are documented in the patient’s medical record 1.4.11.1.5. There is a clear description of the way to inform all the members of the multidisciplinary team about which patients will be discussed 1.4.11.1.6. There is a clear description of the communication of the advice resulting from the discussion to all the physicians and other disciplines involved in the care of the given patients 1.4.11.1.7. There is a clear description of the communication of the advice resulting from the discussion to the concerned patients 1.4.11.1.8. Each final decision about care of the patient that differs from the advice and conclusions of the multidisciplinary team is documented and recorded in the patient’s medical record 1.4.11.1.9. There is a procedure describing how the conclusions and advice from the multidisciplinary meeting will be evaluated and by whom Yes Mostly Partially No not applicable Appendix II / OECI Accreditation and Designation / 9
Page 1:
ORGANISATION OF EUROPEAN CANCER INS
Page 4 and 5:
OECI Accreditation and Designation
Page 6 and 7:
THE OECI Accreditation and Designat
Page 8 and 9:
Owner: OECI Organisation of Europea
Page 10 and 11:
The keyword in the designation of E
Page 12 and 13:
2.1.1 General explanation of the te
Page 14 and 15:
OECI General Assembly Member Instit
Page 16 and 17:
− Organizing the auditors’ meet
Page 18 and 19:
3.2 Audit team and auditors 3.2.1 O
Page 20 and 21:
3.3 Cancer institute Obviously all
Page 22 and 23:
Page 24 and 25:
5.1.1 Step 1: activities and respon
Page 26 and 27:
Designation questionnaire Executor:
Page 28 and 29:
Send signed accreditation and desig
Page 30 and 31:
5.3 Step 3: Explanatory visit and p
Page 32 and 33:
Page 34 and 35:
Finishing self-assesment Executor:
Page 36 and 37:
5.6 Step 6: Payment stage 2 fee If
Page 38 and 39:
Preparation of the auditors’ team
Page 40 and 41:
Performing the peer review Executor
Page 42 and 43:
5.8.1 Week 1-6: Reporting by the au
Page 44 and 45:
Page 46 and 47:
5.9 Step 9: Formulate improvement p
Page 48 and 49:
5.10.1 Evaluation of the A&D Progra
Page 50 and 51:
Intermediate self-assessment (optio
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
2 / OECI Accreditation and Designat
Page 60 and 61:
Qualitative Questionnaire 1. Genera
Page 62 and 63:
1.3.2. Administration of cytostatic
Page 64 and 65:
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 116 and 117: 2 / OECI Accreditation and Designat
Page 118 and 119: Qualitative Questionnaire 1. Genera
Page 120 and 121: 1.3.2. Administration of cytostatic
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
Page 166 and 167: Print only the questions or the ful
Page 168 and 169: Workspace: Go to the questionnaires
Page 170 and 171: 2. Preparing a peer review Open a q
Page 172:
To view the remarks and the score o
show all

Accreditation and Designation User Manual - OECI

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?