Accreditation and Designation User Manual - OECI

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3.2 Audit team and auditors 3.2.1 OECI audit team This part gives explanations about the OECI audit team. More details about the tasks and responsibilities of individual auditors can be find in the part ‘OECI auditor’. Composition of the audit team The audit team typically consists of four members: − Chair, who is also one of the auditors, − Three auditors, − In case of a preliminary Cancer Unit the audit team possibly includes less than four auditors and the peer review possible takes one day, − In case of a preliminary CCC one person of the audit team possibly starts half a day earlier to check the designation criteria/checklist in advance. In an ideal situation the team consists of: − A chair who is a director of a cancer institute, − Auditors with different positions/ functions in different fields of oncology, like: medical oncology, care, research, pathology, quality assurance, − At least one auditor who understands the language of the country where the cancer institute is situated but who is not a resident of that country, − A mix of experienced and less experienced auditors. Besides the audit team the OECI Accreditation Coordinator will also be present during the peer review visit to coordinate the peer review activities. Selecting an audit team The Executive Manager and A&D Coordinator are responsible for selecting the chair and auditors of an audit team. Before the audit team members will get access to the self-assesment information of the cancer institute: − The particular cancer institute has expressed that there is no conflict of interest with any of the audit team members (4.1), − Each auditor has signed a Confidentiality Agreement (doc 14) and a Conflict of Interest Form (doc 15). 3.2.2 OECI Audit team chair The chair of the audit team has the same profile, tasks and obligations as the OECI Auditor (3.2.3). However, the chair has some specific additional obligations and tasks. Profile − The chair is a Director of a cancer institute (or a position with comparable authority to be decided by the OECI A&D Board), − The chair has attended the auditors’ training, − The chair has experienced at least one peer review as auditor before chairing a peer review. Tasks − The chair opens the peer review visit with a presentation, − The chair has a leading role in the representation of the team, − The chair has a leading role in a balanced division of tasks in the team, − The chair has a leading role in meetings and interviews, − The chair presents the preliminary results at the end of the peer review visit, − The chair presents the preliminary designation type at the end of the peer review visit, − The chair has a leading role in the content of the report and editorial changes. 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 3 People and parties involved in the A&D programme Page 6 of 8 Version 16 February 2011
3.2.3 OECI Auditor Profile An OECI auditor: − Is employed by a cancer institute or hospital and is working in the specific field of oncology, for example: − Is a (quality) manager, an oncology nurse, a cancer researcher or microbiologist, − A (quality) manager, an oncology nurse, a cancer researcher or microbiologist, − Is approved by his/her management to apply as an OECI auditor (engagement letter), − Has attended the OECI audit training, − Has the following skills and qualities: • speaks and writes fluently in English, • has a good overview of the field of oncology in a cancer institute, • is a team player, • has an objective and analytic way of thinking, • has a quality improvement attitude. • Is willing to commit time and efforts for peer review, designation screening and report: - preparation meeting of the audit team: one day - peer review: three days for clinical cancer centres and CCC’s, for cancer units possibly one day - reporting: two days Tasks The auditor: − Prepares the peer review visit according to the preliminary designation type, − Prepares the peer review visit by analysing the self-assesment results and documents of a cancer institute, − Attends the preparation meeting of the audit team one month in advance of the peer review visit, − Attends the preparation meeting on the evening before the start of the peer review, − Performs the peer review according to the agenda and designation checklist, − Writes notes during interviews, presentations and tours, − Scores the standards as a team during the peer review visit, − Draws peer review findings as a team for the preliminary results presentation at the end of day two of the peer review: strengths and opportunities, − Processes notes in e-tool in the first week after the visit and scores the standards that are reviewed, − Provides a list of strengths and opportunities chapter of the standard, − Provides a description of the checklist items for confirmation of the designation type, − Gives written response on the comments and feedbacks on the draft report of the cancer institute, and formulates the final strengths, opportunities and conclusions of the peer review. 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 3 People and parties involved in the A&D programme Page 7 of 8 Version 16 February 2011
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