Accreditation and Designation User Manual - OECI

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5.9 Step 9: Formulate improvement plan The next step for the cancer institute will be the formulation of the improvement plan. The opportunities stated in the final peer review report are an input to write the improvement plan (doc 23: template improvement plan). The plan has to show the willingness to improve the opportunities described in the peer review report as well as a systematic improvement approach. The plan contains: Standard Opportunity Action Goal Actions Who is involved Start Evaluation Dead Priority (SMART) description and responsible (date) (date) line (high/ desired for result (Names (date) medium/ result and department) low) 1.1.1 etc A cancer institute may choose a lay-out for an improvement/action plan, such as: − Lay-out as used in the institute, − E-tool function for describing improvement points/non-compliances, − OECI A&D template (doc 23). The institute will have three months to produce the improvement plan. Based upon the improvement plan the Accreditation and Designation Certificate can be awarded by the OECI A&D Board. 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 24 of 28 Version 16 February 2011
5.10 Step 10: OECI A&D Certificate Within 1 month (month 17) after the OECI received the improvement plan from the institute, the OECI A&D Board will take the final A&D decision. The improvement plan will have to follow some general obligations: − To show the willingness to improve the main opportunities from the peer review report, − To show a systematic approach with: opportunities/ goals, actions, persons responsible, start date, evaluation date, end date and priority, − It is out of the scope of the OECI A&D programme to give advice on how an institute approaches the actions. The institute will receive the Accreditation and Designation Certificate if the improvement plan of the institute is approved by the OECI A&D Board. The Certificate will also include the final designation. It will receive a letter stating that the institute will be awarded with the certificate. The institute may choose the way of receiving the Certificate, either during the OECI General Assembly or by post mail. The A&D Certificate will be valid for four years from the date of issue. To maintain the A&D Certificate after these four years the institute will have to start a new round A&D Programme at least six months before the expiring date of the certificate. ORGANISATION OF EUROPEAN CANCER INSTITUTES EUROPEAN ECONOMIC INTEREST GROUPING Registered number OECI-EEIG B-001 CERTIFICATE OF ACCREDITATION AND DESIGNATION ORGANISATION OF EUROPEAN CANCER INSTITUTES EUROPEAN ECONOMIC INTEREST GROUPING hereby certifies that the YOUR (cancer) INSTITUTE Town - Country meets the quality standards for cancer care and research, and it is therefore designated as: COMPREHENSIVE CANCER CENTRE Issued on: 2010-08-15 Validity date: 2012-08-15 Marco Pierotti OECI President Mahasti Saghatchian Chair OECI Accreditation Designation Programme Figure 8: OECI Accreditation and Designation certificate (Action: add newest version) 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 25 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
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Page 10 and 11: The keyword in the designation of E
Page 12 and 13: 2.1.1 General explanation of the te
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Page 28 and 29: Send signed accreditation and desig
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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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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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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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• Close the questionnaire if you
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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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