Accreditation and Designation User Manual - OECI

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Intermediate self-assessment (optional) Executor: Cancer institute The A&D Programme fee includes four years access to the self-assessment e-tool. The institute has the option to perform an intermediate self-assessment to measure the improvements according to the OECI Quality Standards two years after the peer review visit. Note: This intermediate self-assessment will not be analysed by the OECI. It will be a voluntary exercise of the institute to check the improvements. Start new round A&D Programme Executor: Cancer institute Four years from the date of issue of the previous OECI A&D Certificate, the A&D Certificate will expire. If the cancer institute wants to keep the accreditation and designation it will be necessary to apply for a new round of the A&D Programme, six months before the certificate expires. 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 28 of 28 Version 16 February 2011
6 Where to find the documents needed in the programme? The appendix of this manual contains the documents that are useful to start the Accreditation and Designation programme. However, most documents are available when an institute or an auditor logs in the e-tool. The following table shows the needed and useful documents, and how to access them. Documents available for the auditors, institutes and the public Nr. Name Auditor Applicant institutes Public Doc 1 Application form and designation screening Website Website (electronically) Doc 5 Template project plan for cancer institute Appendix IV + E-tool Appendix IV + E-tool Doc 6 Accreditation and Designation Agreement Send by OECI Doc 7 Template agenda explanatory visit Send by OECI Doc 8 Template payment order stage 1 Send by OECI Doc 9 List required documents E-tool E-tool Website Doc 10 E-tool user manual (institute) Appendix V Appendix V + E-tool Doc 14 Confidentiality agreement E-tool E-tool Doc 15 Conflict of interest form E-tool E-tool Doc 16 Template peer review agenda E-tool Doc 19 Template final peer review report E-tool E-tool Doc 21 Reimbursement form E-tool E-tool Doc 22 Template Feedback and comments form institute E-tool Doc 23 Template improvement plan E-tool Doc 26 Evaluation form cancer institute E-tool Doc 27 Evaluation form audit team E-tool Doc 31 Application form auditors/ chairs Website E-tool Website Doc 32 Travel policy rules E-tool E-tool Doc 37 Auditors e-tool user manual E-tool Doc 42 Glossary E-tool E-tool Documents for internal use of the OECI A&D Group Doc 2 Doc 3 Doc 11 Doc 13 Doc 18 Doc 20 Doc 24 Doc 25 Doc 28 Doc 29 Doc 30 Doc 33 Doc 35 Doc 36 Doc 38 Doc 39 Doc 40 Doc 41 Doc 43 Template letter approval application Template letter disapproval application (not existing yet) Template letter invitation auditors Engagement employer auditor Template auditors meeting agenda Planning institutes Template letter approval accreditation Accreditation Certificate (valid for four years) Template letter of thanks (to institute) (not existing yet) List ID-nr institutes Accountability fact sheet for A&D fee Complaints form cancer institute (not yet existing) PPT Explanatory visit Template letter notification GO PPT auditors meeting PPT peer review introduction and preliminary results Letter presenting draft report Planning auditors Financial procedure (included in this user manual) 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 6 Where to find the document needed in the programme? Page 1 of 2 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
Page 8 and 9: Owner: OECI Organisation of Europea
Page 10 and 11: The keyword in the designation of E
Page 12 and 13: 2.1.1 General explanation of the te
Page 14 and 15: OECI General Assembly Member Instit
Page 16 and 17: − Organizing the auditors’ meet
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Page 20 and 21: 3.3 Cancer institute Obviously all
Page 24 and 25: 5.1.1 Step 1: activities and respon
Page 26 and 27: Designation questionnaire Executor:
Page 28 and 29: Send signed accreditation and desig
Page 30 and 31: 5.3 Step 3: Explanatory visit and p
Page 34 and 35: Finishing self-assesment Executor:
Page 36 and 37: 5.6 Step 6: Payment stage 2 fee If
Page 38 and 39: Preparation of the auditors’ team
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Page 42 and 43: 5.8.1 Week 1-6: Reporting by the au
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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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1.4.6. Roles and tasks of the membe
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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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4.3. Resources and materials 4.3.1.
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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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1.4.7. at national level at regiona
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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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