Accreditation and Designation User Manual - OECI

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THE OECI Accreditation and Designation Programme and Manual WHAT IS ACCREDITATION? Accreditation is a process in which an independent organisation evaluates a health care provider and certifies that the provider meets certain quality standards. The oldest accrediting organisation is the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), but there are several others, in specific areas and various countries. An accrediting organisation’s survey includes an evaluation of the Centre’s clinical services, as well as other aspects of the Centre’s operations such as administration, personnel management and information management, research and education. OECI has specialised its A&D programme on multidisciplinary, global and integrated cancer care and research with a major focus on comprehensiveness. WHO SHOULD BECOME OECI ACCREDITED AND DESIGNATED? Any OECI cancer centre that provides research, education, care services to cancer patients and that is willing to become a recognised member of our OECI cancer community. WHY SHOULD A CANCER CENTRE BECOME OECI ACCREDITED AND DESIGNATED? More than 10 OECI cancer Centres have started the OECI A&D process. Within the EurocanPlatform Programme 7FP Programme, all participating Centres will be requested to take part in the OECI A&D programme. The OECI offers Cancer Centres who seek quality improvement and recognition within the cancer community (patients, funders, regulatory bodies, governments, cancer health policy planners, research partners) a tool to achieve it and a label of high quality care integrated to research and education. WHEN MUST A CANCER CENTRE BE ACCREDITED AND DESIGNATED The accreditation process is likely to take an average of 9 to 12 months, and longer in some cases. The increased need for accreditation will place a heavy demand on the OECI. However the cancer centre should reach a minimum level of quality and organisation in order to fulfil the process and be accepted on board the accreditation programme. The self-assesment system provides a tool for estimating the readiness of the centre. The OECI A&D team establishes a precise timeline agreed with each cancer centre applying for the programme in order to allow the necessary time for the preparation and completion of the self-evaluation, peer-review, report and final designation. HOW DOES THE ACCREDITATION PROCESS WORK? The cancer Centre that wishes to become OECI accredited should contact the OECI A&D team. The Cancer centre must be a member of the OECI (or apply to become a member). The Cancer centre must then review its existing services, practices, and policies and procedures to determine what changes will be required to meet the accreditation standards (self-evaluation). The centre may apply for accreditation after the changes are in place or during implementation. The cancer centre submits an application to the OECI A&D with supporting documentation. The OECI A&D reviews the application and documentation and conducts an on-site survey (peer-review visit). Based on the submitted data and the results of the survey, the organisation will determine whether to accredit the cancer centre and the type of designation awarded. The Cancer centre should then develop a plan, including a detailed timeline, for implementing the necessary changes, developing appropriate policies and procedures and training employees (improvement plan). The core of our A&D Programme self-assesment, external peer review, designation and follow-up are the OECI Quality Standards and Quantitative Questionnaires that have been established and agreed by the OECI. These can be found in the appendix of the manual and are accessible only to our OECI members. The full process contains 10 steps (plus the follow-up) which are described in Chapter 5: • Step 1: Application of a cancer institute in the programme • Step 2: Payment stage 1 fee • Step 3: Explanatory visit and preliminary designation result • Step 4: Self-assesment • Step 5: Go / no go decision • Step 6: Payment stage 2 fee • Step 7: Peer review visit and designation check • Step 8: Reporting • Step 9: Formulate improvement plan • Step 10: OECI A&D Certificate • Follow-up An overview of the necessary supporting documents for the institute, auditors and OECI A&D Group are listed in Chapter 6, followed by a summary of the essential obligations and tasks of the Cancer Institute in chapter 7.
Table of contents 1 Introduction of the OECI A&D Programme 1 of 2 2 Timeline of the OECI A&D Process 1 of 2 2.1 In ten steps to A&D Certification 1 of 2 3 People and parties involved in the A&D Programme 1 of 8 3.1 The OECI 1 of 8 3.2 Audit team and auditors 6 of 8 3.3 Cancer Institute 8 of 8 4 Confidentiality and conflict of interest 1 of 2 4.1 Confidentiality 1 of 2 4.2 Conflict of interest 1 of 2 5 Ten steps A&D Process in detail 1 of 28 5.1 Step 1: Application of a cancer institute in the programme 1 of 28 5.2 Step 2: Payment stage 1 fee 7 of 28 5.3 Step 3: Explanatory visit and preliminary designation result 8 of 28 5.4 Step 4: Self-assessment 9 of 28 5.5 Step 5: Go/no go decision 13 of 28 5.6 Step 6: Payment stage 2 fee 14 of 28 5.7 Step 7: Peer review visit and designation check 15 of 28 5.8 Step 8: Reporting 19 of 28 5.9 Step 9: Formulate improvement plan 24 of 28 5.10 Step 10: OECI A&D Certificate 25 of 28 5.11 Follow-up 27 of 28 6 Where to find the documents needed in the programme? 1 of 2 7 Overview of obligations and tasks of a Cancer Institute 1 of 2 8 Register 1 of 2 Appendix I. Designation Decision Schedule 1 Appendix II. OECI Quality standards 3 Appendix III. OECI Quantitative questionnaire 27 Appendix IV. Project plan 41 Appendix V. Self-assesment user manual for institutes 43 Appendix VI. User manual e-tool for auditors 53
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5. Teaching and continuing educatio
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5. Education 5.1. Education 5.1.1.
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