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