Accreditation and Designation User Manual - OECI

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3.3 Cancer institute Obviously all employees of a cancer institute are directly or indirectly involved in the accreditation and designation programme, for example during the self-assesment period delivering data and documents for filling out the questionnaires or during the peer review in the interviews, tours and presentations. It is also advised to involve the employees as much as possible to build commitment to the A&D programme and encourage them to work according to the OECI standards. Some staff members have a central role in the organisation of the programme which is outlined in this paragraph. The specific tasks and obligations of the cancer institute are explained step-by-step in the following chapters. 3.3.1 Director cancer institute/Board of Directors The Director/ Board of Directors of the cancer institute are very important in the accreditation programme for the commitment of the cancer institute with the programme. Although the A&D Coordinator will mainly keep contact with the contact person of the cancer institute, the Director/Board of Directors shall be involved in: − Signing the application form with designation screening including the own judgement on designation type, − Discussing the preliminary designation type during the explanatory visit, − Signing the OECI A&D Programme agreement depending on the preliminary designation type (doc 6), − Approving the peer review agenda (doc 16), − Express a potential conflict of interests with the audit team members if necessary (4.2). During the accreditation process of a cancer institute the Director of the institute will receive the following notifications and documents: − Approval/disapproval of application and preliminary designation type, − ‘Go’/ ‘no go’ decision for peer review visit, − Draft peer review report, − Final peer review report including final designation type, − OECI Accreditation and Designation Certificate, with agreed final designation type. 3.3.2 Contact person cancer institute During the A&D Programme the contact person of the institute communicates with people from the A&D Group concerning several issues. With the A&D Secretary with regard to: − A&D Agreement, − Planning of the explanatory visit, − Information about accommodation for peer review visit. With the A&D Coordinator with regard to: − The application and designation screening − Information about the programme, − The content of the explanatory visit, − Designation screening result and accreditation starting point, − Periodical contact during the self-assesment period, − Questions concerning the self-assesment activities or questionnaires, − Organisation of the peer review, − Peer review agenda, − Providing feedback on the draft peer review report, − Follow-up of the A&D Programme. With the Executive Manager with regard to: − Concerning payment of the A&D Programme fee in two stages. 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 8 of 8 Version 16 February 2011
4 Confidentiality and conflict of interest The OECI A&D Programme and the persons and parties involved, are subject to confidentiality of data, information and knowledge, and potential conflict of interests. There is a policy with regard to this confidentiality which is explained in this chapter. 4.1 Confidentiality During the A&D programme of a cancer institute different persons will have access to the information and data of the cancer institute. The OECI A&D Programme has developed a policy to guarantee that all persons having access to the information and data will only use it for the purpose it shall be used for: the accreditation of the cancer institute. In accordance with OECI A&D Group policy, all information related to the accreditation of a cancer institute is strictly confidential. This includes, but is not limited to: reports of evaluation, letters, self-assesment and accreditation materials, interim/annual/biennial reports, correspondence, and the content of any discussion related to the cancer institute and/or its accreditation. All requests for information related to a specific cancer institute and/or programme must be referred to OECI A&D Group, or to the respective cancer institute. The persons who have to sign the confidentiality agreement (doc 14) are: • Members of the OECI A&D Board, • Members of the OECI A&D Management unit • Members of the OECI A&D Committee, • All auditors including the chairs. Freedom of Information Acts which may be applicable in a given state, province, or country do not apply to the OECI A&D Group confidential information related to the accreditation of cancer institutes. 4.2 Conflict of interest All auditors have to sign the Conflict of Interest form (doc 15) for each peer review they are going to perform. To ensure that all matters dealing with the accreditation programme of cancer institutes are conducted in an unbiased manner, the OECI A&D Group has adopted a Conflict of Interest Policy. Criteria that may pose a conflict of interest for a candidate auditor include, but are not limited to: 1. Past or present employment at the cancer institutes being reviewed, 2. Service as a consultant for the cancer institutes being reviewed, 3. Graduation from the cancer institutes being reviewed, 4. Membership on the advisory committee of the cancer institute being reviewed, 5. Other potential conflicts of interest, such as employment of private consultants or subcontracts with private companies etc. It is expected that the candidate auditor will communicate with the A&D Group staff for clarification on any concern. If conflicts of interest are revealed to the entire team, and if it is agreed that the audit team member will be unbiased in evaluating the programme, it will be acceptable to allow the individual to remain on the audit team. Expressing conflict of interest by the institute The composition of the audit team will be sent to the institute to provide the opportunity to express any potential conflict of interest. In case the cancer institute has expressed a potential conflict of interest with one of the auditors in the team, the OECI A&D Board will decide whether the auditor shall be replaced by another auditor. 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 4 Confidentiality and conflict of interest Page 1 of 2 Version 16 February 2011
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