Accreditation and Designation User Manual - OECI

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Preparation of the auditors’ team meeting Executor: OECI Auditor The individual preparation of the auditors’ team meeting includes: − Analysing the self-assesment reports of the cancer institute: • quantitative report including: scores, notes and improvement points, • quantitative report, − Analysing the documents the cancer institute has attached to the e-tool, − Formulation of main topics for the peer review visit, − Designation checklist (doc 34). Booking the hotel for the auditors’ meeting Executor: OECI Secretary The OECI secretary will book the hotel for the auditors for the auditors’ meeting and for the peer review visit. Complete peer review agenda Executor: Cancer institute While the audit team is getting ready for the auditors’ meeting, the institute will prepare and complete the peer review visit agenda. The concept agenda will be approved by the auditors’ chair during the selfassessment period. The concept agenda has to be completed by the cancer institute. The auditors will have interviews with employees of the cancer institute. The institute has to plan the persons from the requested departments and the location/room where the interviews will take place. Completion deadline: 1 week before the auditors’ preparation meeting. Sending the agenda Executor: OECI A&D Coordinator The agenda of the preparation meeting will be sent one week before the meeting and will include the concept peer review agenda. 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 16 of 28 Version 16 February 2011
Auditors’ team meeting Executor: OECI audit team One month before the peer review, the auditors will meet to prepare the peer review. Input: − Result designation screening, − Concept peer review agenda (completed by the cancer institute with interviewees and locations), − Self-assesment reports (qualitative and quantitative), − Attached documents of the cancer institute, − Designation checklist. Content of the meeting: − A general presentation of the accreditation programme, − An explanation of the roles and responsibilities of the auditors, − Report writing procedures, − Planning of interviews, − Content of interviews, − Follow-up of the accreditation programme for the cancer institute. Every auditor will take notes during the peer review visit. Preparation of the peer review Executor: OECI Auditor Individual preparation of the peer review following the appointments made during the auditors’ team meeting. Meeting day before the peer review Executor: OECI audit team The evening before the peer review the auditors meet in the hotel for: − Final preparation, − Extra focus on the designation type especially when the institute prefers the CCC level − Group dinner. 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 17 of 28 Version 16 February 2011
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 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 34 and 35: Finishing self-assesment Executor:
Page 36 and 37: 5.6 Step 6: Payment stage 2 fee If
Page 40 and 41: Performing the peer review Executor
Page 42 and 43: 5.8.1 Week 1-6: Reporting by the au
Page 46 and 47: 5.9 Step 9: Formulate improvement p
Page 48 and 49: 5.10.1 Evaluation of the A&D Progra
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Page 60 and 61: Qualitative Questionnaire 1. Genera
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2.9. Radiology 2.9.1. Number of CT
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2.15. Facilities 2.15.1. On site Ac
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3.4. Human resources (4) 3.4.1. Pat
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4.3. Structures 4.3.1. Yes No not a
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5. Education 5.1. Education 5.1.1.
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Planning of the project Start Expla
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Go to the qualitative and quantitat
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3. Before moving to the next item p
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The following screen will appear. F
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• Close the questionnaire if you
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Print only the questions or the ful
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Workspace: Go to the questionnaires
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2. Preparing a peer review Open a q
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To view the remarks and the score o
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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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1.4.6. Roles and tasks of the membe
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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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2.4.5. Smoking control in the cance
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3.4.4. Palliative and terminal care
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4. Research, innovation and develop
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4.3. Resources and materials 4.3.1.
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5. Teaching and continuing educatio
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6. Patient related 6.4. Process con
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6.5. Safeguarding the quality syste
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1.4.7. at national level at regiona
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2.3. Infrastructures with a focus o
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2.9. Radiology 2.9.1. Number of CT
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2.15. Facilities 2.15.1. On site Ac
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3.4. Human resources (4) 3.4.1. Pat
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4.3. Structures 4.3.1. Yes No not a
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5. Education 5.1. Education 5.1.1.
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Planning of the project Start Expla
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Go to the qualitative and quantitat
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3. Before moving to the next item p
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The following screen will appear. F
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• Close the questionnaire if you
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Print only the questions or the ful
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Workspace: Go to the questionnaires
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2. Preparing a peer review Open a q
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To view the remarks and the score o
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Accreditation and Designation User Manual - OECI

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