Accreditation and Designation User Manual - OECI

Performing the peer review
Executor: OECI audit team
Performing the peer review according to the peer review agenda (doc 16).
During the peer review and in the evenings, the auditors will work on scoring the standards (Yes, Mostly,
Partially, No)for the report and drawing the preliminary conclusions, strengths and opportunities.
Designation checklist during the peer review visit:
− Ask the list on scientific publications including an overview of the authors’ papers in the hospital (First,
second and last author should be clarified)
− Overview is enough, when doubt on the correction of the numbers check impact factor and especially in
the impact factor >10
− Ask on site at different wards at least two times the number of beds
• Cross check, yes or no
− Ask on site at the day care the number of beds/chairs (total)
• Cross check, yes or no
− Ask in two different interviews the number of physicians from different specialties
− Ask on site the number of active clinical trials
• Cross check, yes or no
− Check the facilities the availability of the radiotherapy, medical oncology and surgical oncology
• Check availability, 3 times yes or no
In case the preliminary designation is between a Clinical Cancer Centre and a Comprehensive Cancer Centre,
the audit team will have to additionally focus, during the peer review visit, on the following criteria:
− A highly innovative character and multidisciplinary approach using the potential of basic, translational and
clinical research and clinical facilities and activities, organised in a sufficiently identifiable entity [Short
description]
− A direct provision of an extensive variety of cancer care tailored to the individual patient’s needs and
directed towards learning and improving the professional, organisational and relational quality of care
[Short description]
− Broad activities in the area of prevention, education, and external dissemination of knowledge and
innovation. In order to accentuate the differences with other cancer institutes [Short description]
− The level of infrastructure, expertise and innovation in the field of oncology research [Short description]
− Maintenance of an extensive network including all aspects of oncology treatment and research [Short
description]
Writing notes during the auditors’ peer review
The notes of the interviews, tours and presentation will be processed into the e-tool by the auditors during
and after the peer review.
The auditors have one week after the peer review visit to process the notes and to provide the descriptions
to support the designation type.
The auditors have a personal username and password to enter the e-tool and to go to the peer review report
of the institute. Auditors can process their notes in the e-tool at the same time.
The answers need to provide evidence/proof for the scores given to the standard.
The report needs to be:
− Recognisable,
− Concrete,
− Compact,
− Separate minor and major points,
− Strength and weaknesses from appendices in text,
− Objective statements,
− Examples,
− Reasonable arguments for subjective statements,
− Unanimously agreed by the auditors team.
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 18 of 28
Version 16 February 2011