Accreditation and Designation User Manual - OECI

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Finishing self-assesment Executor: Cancer institute Six months after the beginning of the self-assessment period, the institute has completed the questionnaires and closed the self-assessment in the e-tool: − Quantitative questionnaire, − Qualitative questionnaire, − Notes to support scores, − Requested proof documents and other proof documents attached to questions, − Described non-compliance points/improvement points. Analyse self-assesment results Executor: OECI A&D Committee − To analyze and examine the self-assesment reports before peer review, − To analyze the proof documents for peer review, − To analyse the results of the self-assesment, − To advise the Accreditation Board concerning a ‘go’/ ‘no go’ decision. Owner: OECI Organisation of European Cancer Institutes Status: Revised - 24 th January 2011 - A&D Working Group Approved by: OECI Accreditation and Designation Board Chapter 5 Ten steps A&D process in detail Page 12 of 28 Version 16 February 2011
5.5 Step 5: Go/no go decision The final ‘go’ or ‘no go’ decision will be taken by the OECI A&D Board. Before the Board takes the decision the A&D Committee will analyse the self-assesment results according to the criteria for self-assesment. The Committee proposes to the A&D Board a ‘go’ or ‘no go’ decision. The ‘go’ decision is made at least two months in advance of the planned peer review visit. Meaning of ‘go’ A ‘go’ means that the OECI A&D Board has approved the institute for a ‘go’ after the OECI A&D Committee has given its independent examination for this approval concerning the criteria: The institute has provided convenient input of evidence and information to make it possible for an audit team to do a reliable peer review visit on site. The input includes: 1. All items are scored, 2. The questionnaires should be useful for the auditors to prepare the audit, which means that the institute provides transparency in the available evidence (written documents) and explanations (notes): • Scores are justified with a note or a document with evidence, unless the score does not need explanation, • The relevant documents/procedures/guidelines/cooperation agreements etc, that are requested in the standards are attached, • The list of documents requested by the OECI are attached to the e-tool. If the documents are not available in English, an English summary of the documents should be provided, • For questions scored as ‘partially’ or ‘no’ are described in a non-compliance/ improvement point. The e-tool manual for institutes explains how to put the evidence in the e-tool (Appendix and doc 10). Task: Chair of the A&D Group The Board of Directors of the institute will receive a notification letter of the ‘go’ decision (doc 36) signed by the chair of the A&D Group. Task: A&D Coordinator The contact person of the institute will receive information about the continuation of the programme: − Concept empty peer review agenda including the audit team (doc 16), − Explanation on how to fill and complete the agenda, − Deadline of sending the completed agenda, − Obligations of the cancer institute for a successful peer review visit: • Availability of the staff involved in the peer review visit at the time and location they are expected to be present at according to the agenda, • Facilitation of the maintenance of the audit team as agreed in the A&D Programme Agreement, • Providing permission to observe activities or procedures in the cancer institute during the peer review visit, • On request of the OECI audit team, the institute shall provide access to all relevant locations, files and documents needed for assessment during the on-site peer review, • The executed language during the peer review is English. The cancer institute staff involved in interviews need to understand and to speak in English. If not, the OECI requires the presence of an independent person who is able to translate. Meaning of a ‘no go’ Generally, a ‘no go’ decision means that the peer review visit will be postponed. A possibility for a ‘no go’ decision is an inconvenient input for the audit team to prepare and perform the peer review in a reliable way. It might be possible that additional information (notes) or evidence (documents) are needed. Owner: OECI Organisation of European Cancer Institutes Status: Revised - 24 th January 2011 - A&D Working Group Approved by: OECI Accreditation and Designation Board Chapter 5 Ten steps A&D process in detail Page 13 of 28 Version 16 February 2011
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