Accreditation and Designation User Manual - OECI

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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
5.8 Step 8: Reporting After the peer review visit, it will take about 4 months to finish the final peer review report (figure 5). The reporting period will be split in two phases. In week 1 to 6 the auditors will be working on the draft report. This is outlined and explained in the sub-process: ‘Reporting by audit team’ (figure 6). Figure 6: Step 8 Reporting 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 19 of 28 Version 16 February 2011
Page 1: ORGANISATION OF EUROPEAN CANCER INS
Page 4 and 5: OECI Accreditation and Designation
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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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1.4.12. 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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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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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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