Accreditation and Designation User Manual - OECI

1.4.12. Registration and evaluation of the recommendations of the multidisciplinary team meeting
Have agreements been reached concerning the registration and evaluation of recommendations that emerge from the
multidisciplinary team meeting?
1.4.12.1.
1.4.12.1.1. Conclusions and advice resulting from the
multidisciplinary team meeting are documented
in the patient’s medical record
1.4.12.1.2. Deviations from conclusions and advice are
documented and motivated in the patient’s medical
record
1.4.12.1.3. There is a procedure described on how the
conclusions and advice from the multidisciplinary
meeting will be evaluated and by whom.
Yes Mostly Partially No not applicable
1.5. Safeguarding the quality system
1.5.1. Quality and risk management and safety requirements
Does the cancer centre have a global policy for quality and risk management and safety requirements?
1.5.1.1.
1.5.1.1.1. There is an identified Quality and Risk
Management Direction
1.5.1.1.2. The quality Director participates in the executive
direction of the cancer centre
1.5.1.1.3. There is a written global programme describing
the policy for: Quality management, including
continuous quality improvement (CQI) certification
processes and individual accreditation of physicians
1.5.1.1.4. There is a written global programme describing
the policy for: Risk management, including a
programme for the centralised reporting of
undesirable events by health care workers
1.5.1.1.5. There is a written global programme describing
the policy for: Safety management of the cancer
centre and its users
1.5.1.1.6. There is a written global programme describing
the policy for: Patient safety management, including
a systematic centralised reporting of side effects
of drugs (current practice)
1.5.1.1.7. There is a programme for the systemic analysis
of major adverse or undesirable events
(e.g.: morbidity and mortality reviews), in each
clinical and technical department
1.5.1.1.8. Patients or patients’ relatives should be part of
these organisations
Yes Mostly Partially No not applicable
10 / OECI Accreditation and Designation / Appendix II