Accreditation and Designation User Manual - OECI

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5.1.1 Step 1: activities and responsibilities of all parties involved (figure 3) Filling out the application form and designation screening list Executor: Cancer institute − The institute can start to fill out the ‘Online application form’ on the website: oeci.selfasessment.nu under the menu ‘How to apply?’ − The page starts with a general introduction of the programme and by clicking ‘Go to the online application form’ the application procedure will be explained, − The institute can access the application form by making a username and password as explained on the page. The application contains the judgement of the institute and the designation type. On the last page of the application form the institute can send the application to the OECI A&D Coordinator. The approval/signature of the Director/ Board of Directors is requested for the full commitment to the programme. Registration of application form Executor: OECI A&D Coordinator − The OECI A&D Coordinator receives the application form through the e-tool, − OECI A&D Coordinator sends a delivery note to the applicant’s institute. Examination of the application Executor: OECI A&D Board − New applications are discussed in the next teleconference of the OECI A&D Board (every month), − The application is analysed according to the criteria for application as set in the application form, − The institutes’ judgement of the designation type should be discussed, − The A&D Board will make the final decision of approving or disapproving the application. Note: The OECI A&D Programme for Cancer Research Centres is not yet developed, this is one of the goals of the OECI A&D Group. Criteria for application Applying to the A&D Programme is a voluntary decision of the cancer institute. However, to provide the institute with a qualitative accreditation programme and to meet with the goals for accreditation and designation, there are obligations that each institute involved shall meet to apply to the A&D Programme: − Membership of the OECI, − Strong commitment to quality improvement (signature of Director/ Board of Directors), − Dedicated staff (contact person, project group, all involved employees), − Stable management structure (no interim management on level of board of directors), − No major changes/problems (expected management change, merger, housing movements, financial crisis), − Following the steps of the A&D Programme with care and within the required timeline, − Involvement in oncology research and education programmes (for Cancer Units the involvement in research programmes is not requested), − Cancer care is performed on an identifiable unit with an identifiable budget, management and organisational structure. 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 2 of 28 Version 16 February 2011
Defining concept planning for institute Executor: OECI A&D Coordinator If the OECI A&D Board approves the institute, the A&D Coordinator will draw the planning: − Designation screening, − Explanatory visit: planned in cooperation with the institute, − Self-assesment period, − Peer review: the final peer review dates are planned in alignment with the availabilities of the cancer institute and the audit team chair. This will be archived in the accreditation planning (doc 41). Notification of approval Executor: OECI A&D Secretary If an institute is approved to apply to the A&D Programme: − The A&D Secretary sends the approval letter attached by e-mail (doc 2) to the Board of Directors of the institute and the contact person signed by the A&D Chair, − The concept planning (designation screening, explanatory visit, self-assesment, peer review) is mentioned in the e-mail, − The A&D Secretary will plan the explanatory visit date in cooperation with the contact person of the cancer institute and delegates of the A&D Group, − Attached to the e-mail and letter of approval: • A&D Agreement to be signed (doc 6), • Accreditation and Designation Manual with timeline (doc 0). 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 3 of 28 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 26 and 27: Designation questionnaire Executor:
Page 28 and 29: Send signed accreditation and desig
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Page 34 and 35: Finishing self-assesment Executor:
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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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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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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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2. Preparing a peer review Open a q
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To view the remarks and the score o
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