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Accreditation and Designation User Manual - OECI

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Check draft<br />

Executor: <strong>OECI</strong> Auditor<br />

The first draft of the report will be send to the audit team to analyse:<br />

− The scores of the auditors,<br />

− The proposed text per st<strong>and</strong>ard to support the audit team scores,<br />

− The list of st<strong>and</strong>ards with different findings among the auditors in the scores <strong>and</strong> notes (deviations),<br />

− The proposed designation type with the short descriptions for each item,<br />

− The proposed designation conclusion.<br />

The auditors are requested to give feedback <strong>and</strong> comments on the draft report.<br />

Discuss draft by teleconference<br />

Executor: <strong>OECI</strong> Chair audit team<br />

The A&D Coordinator will discuss the draft report <strong>and</strong> feedback of the auditors with the chair of the audit<br />

team by teleconference. The input of the teleconference is a list of deviations sent by the A&D Coordinator.<br />

Make final draft<br />

Executor: <strong>OECI</strong> A&D Coordinator<br />

The A&D Coordinator:<br />

− Processes the conclusions of the teleconference with the chair of the audit team,<br />

− Discusses the final draft with the Executive Manager,<br />

− Sends the final draft to the cancer institute with a feedback <strong>and</strong> comments form.<br />

Check final draft<br />

Executor: <strong>OECI</strong> Chair audit team<br />

The second draft of the report will be sent to the chair to check:<br />

− Final scores as discussed in the teleconference with the audit team,<br />

− Final text per st<strong>and</strong>ard that supports the audit team scores,<br />

− Final designation type with the short description for each item,<br />

− Final designation conclusion,<br />

− Editorial changes.<br />

Proceed final corrections<br />

Executor: <strong>OECI</strong> A&D Coordinator<br />

The A&D Coordinator will proceed the final corrections of the chair <strong>and</strong> send the final draft report latest in<br />

week 6 after the peer review to the Director <strong>and</strong> accreditation contact person of the cancer institute.<br />

The draft is sent together with:<br />

− Doc 41: Letter presenting the draft report,<br />

− Doc 22: Feedback <strong>and</strong> comment form.<br />

The final draft will contain:<br />

− The st<strong>and</strong>ards reviewed during the peer review visit with the scores of the cancer institute from the selfassessment,<br />

the scores of the auditors <strong>and</strong> the findings of the auditors supporting the scores,<br />

− Description of the designation check findings.<br />

The strengths <strong>and</strong> opportunities will be presented in the final report.<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 21 of 28<br />

Version 16 February 2011

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