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Accreditation and Designation User Manual - OECI

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5.8.2 Step 8: activities <strong>and</strong> responsibilities of all parties (figure 6)<br />

Check draft peer review report<br />

Executor: Cancer institute<br />

− The Director <strong>and</strong> the accreditation contact person of the institute will receive the draft peer review report,<br />

− The institute will have 4 weeks to distribute the draft report within the cancer institute to whomever is<br />

concerned <strong>and</strong> to collect comments <strong>and</strong> feedbacks,<br />

− After four weeks, the contact person that will have collected the comments within the institute, will have to<br />

send the form to the <strong>OECI</strong> Coordinator.<br />

Note: All feedbacks <strong>and</strong> comments will be discussed by the audit team but the report will only be revised with<br />

reliable arguments <strong>and</strong>/or new evidence<br />

Forward comments<br />

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

− The comments <strong>and</strong> feedbacks of the institute on the draft report will be forwarded to the audit team<br />

members,<br />

− They are requested to give their comments via e-mail,<br />

− The institutes comments <strong>and</strong> response of the audit team members will be discussed with the chair of the<br />

audit team.<br />

Discuss comments by teleconference<br />

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

Discuss the feedbacks <strong>and</strong> comments of the cancer institute:<br />

− The comments <strong>and</strong> response of the auditors will be discussed in a teleconference with the chair of the<br />

audit team <strong>and</strong> the <strong>OECI</strong> A&D Coordinator,<br />

− Conclusions concerning the comments will be inserted in doc 22: Feedback <strong>and</strong> Comments form.<br />

Formulate proposal for conclusions, strengths <strong>and</strong> opportunities of the cancer institute for the final report.<br />

Process conclusions teleconference<br />

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

The A&D Coordinator will process the conclusions of the teleconference, which will include:<br />

− Corrections to make, with regard to the comments <strong>and</strong> feedbacks of the cancer institute,<br />

− The formulated general remarks, strengths <strong>and</strong> opportunities, conclusions.<br />

The A&D Coordinator will send the third draft to the chair of the audit team for a final check.<br />

Analyse draft final report<br />

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

The A&D Committee will receive the draft final report with a proposal for the conclusions, strengths <strong>and</strong><br />

opportunities from the audit team.<br />

The A&D Committee will analyse the conclusions, strengths <strong>and</strong> opportunities that are drafted by the audit<br />

team, <strong>and</strong> give final advice to the <strong>Accreditation</strong> Board about the complete final report.<br />

If the A&D Committee makes major changes in the report, the coordinator of the A&D Committee (the<br />

Executive Manager) will send the report for a final check to the chair of the audit team. If there are only minor<br />

changes the report will be sent directly to the A&D Board for the final approval.<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 22 of 28<br />

Version 16 February 2011

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