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Accreditation and Designation User Manual

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1. 5 1 12 Yes No 5172 1 Do you have formalised exchange programmes 5110122 national 5 1 12 3 international 5 1 12 4 Do you have formalised patient education programmes 5 1 12 5 Do you have formalised education programmes for decision makers 5 1 12 6 Do you have formalised continuous medical education CME programme 5 2 Analysis 5 2 1 Based on the analysis do you have an annual or multi annual training educational programmes for Yes No 5 2 1 1 physicians Beil 2 researchers 5 2 1 3 nurses 5 2 1 4 paramedics 5 2 15 supportive disciplines psychologists etc 526 other disciplines please specify in the note 40 OECI Accreditation and Designation Appendix III Appendix IV Project plan Project plan doc 5 for cancer institute to organise self assessment General Name of the project OECI Accreditation Programme Institute name Name of the cancer institute Place and country Place and country of residence Division department Part of the hospital that is involved or whole hospital Owner of the project Board of Directors of the institute name person in specific Project leader in the institute Name of OECI contact person in the institute and position function in the institute OECI Accreditation Coordinator Femke Boomsma Start date OECI accreditation Date What is
2. Nr of beds and ambulatory day If yes care beds gt 100 R First selection Active clinical trials gt 50 Comprehensive Cancer Centre Nr of scientific papers gt 30 Nr of scientific papers with impact factor gt 17 Clinical cancer centre or Comprehensive Cancer Crnter Appendix I OECI Accreditation and Designation 1 2 OECI Accreditation and Designation Appendix Appendix II OECI Quality standards This appendix contains a paper version of the OECI quality standards not for public release In clinical cancer centres and Comprehensive Cancer Centres the full set of standards will be assessed during the self assessment and by the audit team during the peer review visit Cancer Unit are excluded for the standards in chapter 4 Research innovation and developments The sollowint table shows the chapters and domains with the number of standards and questions The marked standards are not assessed in Cancer Units Chapters Domains Nr of standards Sub standards questions Total 264 Chapter 1 General standards strategic plan 26 121 and general management 1 1 Policy and organisation 5 22 1 3 Resources and materials 2 8 1 4 Process control 12 54 1 5 Safeguarding the quality system 7 37 Chapter 2 Screening and primary prevention 5 19 and health education 2 4 Process control 5 19
3. 3 3 Human resources 3 3 3 1 Please specify the number of FTE gastro enterologists pneumonologists respiratory physicians gynaecologists haematologists paediatricians psychiatrists anaesthesiologists infectious disease specialists geneticians dermatologists pharmacist pharmacologists geriatricians neurologists intensive care specialists medical oncologists X cardiologists endocrinologists urologists plastic surgeons Appendix III OECI Accreditation and Designation 35 3 4 Human resources 4 3 4 1 Pathology Technicians Pathologists Please specify the number of FTE 3 4 2 Nuclear medicine technicians in physicians in physicists engineers nurses in nuclear medicine nuclear medicine nuclear medicine Please specify the number of FTE 3 4 3 Radiology Radiologists technicians in radiology nurses in radiology Please specify the number of FTE 3 4 4 Radiotherapy radiation therapists dosimetrists radiation technicians in radiotherapy Please specify the number of FTE 3 4 5 Supportive care Dieticians psychologists nutricians speech physiotherapists stoma social therapists therapists workers Please specify the number of FTE 36 OECI Accreditation and Designation Appendix III 4 Research Outside scope
4. 6 OECI Accreditation and Designation Appendix II 1 4 3 Compliance with guidelines Have agreements been reached concerning the use of guidelines relating to diagnosis treatment follow up and research 1 4 3 1 Yes Mostly Partially No not applicable 1 4 3 1 1 The medical specialists and the employees of the cancer centre apply the local regional national international guidelines on diagnostics treatment follow up and research 1 4 3 1 2 The guidelines are easily accessible 1 4 3 1 3 The guidelines are updated on a regular basis depending on medical developments 1 4 3 1 4 Each decision that differs from the guidelines is recorded in the file of the patient 1 4 4 Compliance with guidelines Do you report the compliance with multidisciplinary guidelines 1 4 4 1 Yes Mostly Partially No not applicable 1 4 4 1 1 Compliance with guidelines is measured through the registration of the patients cancer data 1 4 4 1 2 Deviations from guidelines are analysed 1 4 4 1 3 Deviations from guidelines are discussed 1 4 4 1 4 Deviations from guidelines are reported annually 1 4 5 Tasks and responsibilities of the oncology nurses Have agreements been reached concerning the tasks and responsibilities of nurses working at the oncology department 1 4 5 1 1 4 5 1 1 For each technical clinical or outpatient s department where pati
5. 5 1 12 Yes No 5172 1 Do you have formalised exchange programmes 5110122 national 5 1 12 3 international 5 1 12 4 Do you have formalised patient education programmes 5 1 12 5 Do you have formalised education programmes for decision makers 5 1 12 6 Do you have formalised continuous medical education CME programme 5 2 Analysis 5 2 1 Based on the analysis do you have an annual or multi annual training educational programmes for Yes No 5 2 1 1 physicians Beil 2 researchers 5 2 1 3 nurses 5 2 1 4 paramedics 5 2 15 supportive disciplines psychologists etc 526 other disciplines please specify in the note 40 OECI Accreditation and Designation Appendix III Appendix IV Project plan Project plan doc 5 for cancer institute to organise self assessment General Name of the project OECI Accreditation Programme Institute name Name of the cancer institute Place and country Place and country of residence Division department Part of the hospital that is involved or whole hospital Owner of the project Board of Directors of the institute name person in specific Project leader in the institute Name of OECI contact person in the institute and position function in the institute OECI Accreditation Coordinator Femke Boomsma Start date OECI accreditation Date What is are the motive s Motives Arguments for s
6. 3 4 8 1 2 Families are proactively informed on the available support 3 4 9 Rehabilitation Is there access to a rehabilitation unit with mono and multidisciplinary interventions 3 4 9 1 3 4 9 1 1 There is access to a functional rehabilitation department focused on cancer patients 3 4 9 1 2 The rehabilitation unit manages the psychosocial and physical rehabilitation of the patient starting at an early stage of the treatment and continuing during the post therapeutic care period 3 4 10 Prosthetic surgery Do patients receive information and advice about the possibilities of prosthetic surgery 3 4 10 1 Yes Mostly Partially No not applicable 3 4 10 1 1 The person s in charge of providing information on prosthetic surgery is are clearly identified 3 4 10 1 2 The patient is informed about how to get information 3 4 10 1 3 This information includes the potential risks 3 4 10 1 4 Prosthetic and reconstructive surgery is available and accessible to all appropriate patients Appendix Il OECI Accreditation and Designation 17 4 Research innovation and development Note Cancer Units are excluded for the questions in this chapter 4 4 1 Policy and organisation 4 1 1 Organisational and hierarchical structure Is there a description of the organisational and hierarchical structure of the RID organisa
7. The peer review visit in a Cancer Unit does not include the full set of standards Standards related to chapter 4 Research innovation and development are not assessed The audit team possibly includes less than four auditors Note There might be reasons for an institute not being able to continue the A amp D programme towards the peer review visit after the self assessment such as delay of the self assessment period no go decision changes in the management of the institutes etc One year after the payment of stage 1 an institute will be reminded of its participation in the programme The application of the institute will expire if the institute will not continue the programme within two years after the payment of stage 1 The OECI A amp D Group will not return the payment of stage 1 Note lf there is a discrepancy between the designation judgement of the institute and the preliminary designation that remains after the explanatory visit the institute shall pay the fee equal to the designation type applied for For example an institute that has classified itself as a clinical cancer centre and is willing to continue the programme as such shall pay in total 30 000 although the preliminary designation is a cancer unit Note If an institute decides to apply for A amp D as clinical cancer centre or CCC the full set of standards will be assessed including the standards related to chapter 4 Research innovation and
8. gt pout us ISQUA 2010 and ESMO 2010 presentations online JECI present on SQue 2010 Pans DECI present on ESMO 7010 Moan a Background Accreditation Background Designation Organizational structure Go to the E tool Octoder 21 2010 by Aamiustratar integration Designate and gt Description ASD process Go to presentations in the menu PEROT 4i oA A C htitpjoeci selassessment nu cms node 7 Applied cancer institutes July 2010 Accreditation anc gt OEG standards Adiminestrator s blo Dangnation Newsletter Vol 4 is 7 How to apply anina Go to http oeci selfassessment nu compass user or through the website http oeci selfassessment nu An Auditor s username has been supplied with a password use this to log in to the application Log on Use your username and password to login Username password When successfully logged in you will find the following screen Appendix VI OECI Accreditation and Designation 53 Home User Questionnaires Show heip Logout femke auditor Instructions Workspace Go to the questionnaires of the institute that has been assigned to you Home LaOECI Orcansanon oF European Cancer Instrrures Enrortan Economie Interest Gaosewe You are an auditor You have the following options Internet connection normal operation No internet connection e Export audits to memory stick e Me
9. 4 3 1 3 Do you have a biostatistic unit 4 3 1 4 Do you have a Unit of health economy 4 3 1 5 Do you have a data management unit trial bureau 4 3 1 6 Do you have a local cancer registry 4 3 2 Number of studies active that is open to patient accrual during year x X 4 3 3 Number of studies activated in year x Phase Phase Il Phase Ill Phase IV 4 3 4 Number of new investigator initiated local trials Percentage of new investigator initiated local trials 4 3 5 Number of new investigator initiated national trials Percentage 4 3 6 Number of new investigator initiated international trials Percentage 4 3 7 Number of new clinical trials with external industrial sponsor Percentage 4 3 8 Number of new patients in clinical trials indicator number of new patients included in clinical trials Number of new patients in the institute 4 3 9 Does your cancer centre have research collaboration with other cancer centres Yes No 4 3 9 1 at national level 4 3 9 2 at international level 38 OECI Accreditation and Designation Appendix Ill 4 4 Research budget including basic clinical translational 4 4 1 Total research budget cancer centre X 4 4 2 Nr of EU grants Nr of EU grants Public funding Charities unrestricted Industrial running in year x coordinated in year x grants partnersh
10. 6 4 1 1 2 written information on relevant aspects of oncology to general practitioners 6 4 1 1 3 The written information includes information about diagnostic examinations and methods of treatment 6 4 1 1 4 The written information includes information about clinical trials 6 4 1 1 5 The written information includes information about supportive care complementary care and palliative care 6 4 2 Inform patients on admission Have procedures been established on informing cancer patients about cancer centre admission procedures 6 4 2 1 Yes Mostly Partially No not applicable 6 4 2 1 1 There is detailed information about the admission procedure 6 4 2 1 2 This information is available and communicated to the patient 6 4 2 1 3 The admission procedure is regularly assessed for efficiency 6 4 2 1 4 The cancer centre can accept patients during day and night in the event of an emergency admit them if necessary or refer them to another institute 24 OECI Accreditation and Designation Appendix Il 6 4 3 Informing patients about results treatment and counselling Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counselling in terms of how it is done and what it means 6 4 3 1 6 4 3 1 1 The cancer centre has procedures
11. ELEL Improvement activities of the cancer centre logistics research education multidisciplinary teams are part of the annual report 1 1 2 Cooperation with universities 1 1 2 1 The cancer centre has formal cooperation or agreement with at least one university for Yes Mostly Partially No not applicable 1 1 2 1 1 care activities WPI 2 educational activities 1 1 2 1 3 research activities 1 1 3 Cooperation with external partners Have agreements been reached about the allocation of tasks such as a hospital or radio therapeutic institute in the case of referrals 1 1 3 1 Yes Mostly Partially No not applicable 1 1 3 1 1 Cooperation arrangements with other cancer centres are clearly documented in written agreements covering the goals of the cooperation tasks responsibilities and competences of the cancer centre and the cooperating partners 1 1 3 1 2 There are written agreements with home care organisations 1 1 3 1 3 There are written defined and documented cooperation arrangements with general practitioners 1 1 3 1 4 There are written agreements with nursing home rest house palliative care institutions etc 1 1 3 1 5 There are written agreements with special cancer care service providers such as radiotherapy centre pathology laboratory specialised surgery unit etc 4 OEC
12. Nr of beds and ambulatory day If yes care beds gt 100 R First selection Active clinical trials gt 50 Comprehensive Cancer Centre Nr of scientific papers gt 30 Nr of scientific papers with impact factor gt 17 Clinical cancer centre or Comprehensive Cancer Crnter Appendix I OECI Accreditation and Designation 1 2 OECI Accreditation and Designation Appendix Appendix II OECI Quality standards This appendix contains a paper version of the OECI quality standards not for public release In clinical cancer centres and Comprehensive Cancer Centres the full set of standards will be assessed during the self assessment and by the audit team during the peer review visit Cancer Unit are excluded for the standards in chapter 4 Research innovation and developments The sollowint table shows the chapters and domains with the number of standards and questions The marked standards are not assessed in Cancer Units Chapters Domains Nr of standards Sub standards questions Total 264 Chapter 1 General standards strategic plan 26 121 and general management 1 1 Policy and organisation 5 22 1 3 Resources and materials 2 8 1 4 Process control 12 54 1 5 Safeguarding the quality system 7 37 Chapter 2 Screening and primary prevention 5 19 and health education 2 4 Process control 5 19 Chapter 3 Care 10 30 3 4 Process control 10
13. COmpARSssS How to start Questionnaires INTRODUCTION The OECI Accreditation Project A Process to Evaluate and improve Quality in European Cancer Centres The OFC helps health care professionals and Cancer Centres to improve the organisation of care To this end the OFC accrediation working group has developed norms centona and ha them in an electronic self evaluation guide By using this guide cancer centres can find out w Questionnaires es CECI Qualitative 08 08 OS t1 M264 r ce gt Questionnaire v3 2009 2010 264 100 pt a L p TE r t D CEC Quantitative 03 08 30 06 Wo 662 R pi um ere onnaire v2 2009 2010 0 amp Click to open the questionnaire 44 OECI Accreditation and Designation Appendix V 2 Three steps to fill out the qualitative questionnaire e Step 1 Give a score to all items in the questionnaire The quality questionnaire consists of Chapter 1 General standards strategic plan and 26 121 47 general management 1 1 Policy and organisation 5 22 1 3 Resources and materials 2 8 1 4 Process control 12 54 1 5 Safeguarding the quality system 7 37 Chapter 2 Screening and primary prevention and 5 19 7 health education 2 4 Process control 5 19 Chapter 3 Care 10 30 11 3 4 Process control 10 30 Chapter 4 Research innova
14. amp 7 Appendix V OECI Accreditation and Designation 47 The following screen will appear Follow step 1 2 and 3 Start Questionnaires Documents Report Progress Documents These are the documents that are of value to you as a user and to the auditors They are only visible to you as user and to th auditors that have been assigned You can add documents to the list by selecting them select a folder and press Upload Large documents may take a while to be uploaded please be patient in that case 1 Click to choose the kind of document you are going to add Map 38 2 Guidetir i These are the options the Document system will arrange the documents Guidelines v Feedback ae Guidelines 2 Search for the document in your system 3 Upload the document Audit reports Action lists Requested documents Risk related documents Quality documents Other documents e Step 3 Add a non compliance improvement point If you have scored a question with partially or no a red sentence appears under the question that a non compliance point has been identified This means that quality improvement can be made regarding this substandard by the institute The institute is required to describe an improvement point by Clicking on the red line 1 1 2 Cooperation with universities he cancer centre has formal cooperation or agreement with at lea
15. 1 1 4 Cancer data registration institutional level Are the data on the patients types of cancers recorded in an institutional cancer database 1 1 4 1 Yes Mostly Partially No not applicable 1 1 4 1 1 The number of new oncology patients is known at an institutional level 1 1 4 1 2 The number of new cases for each type of cancer is known at an institutional level 1 1 4 1 3 There are diagnostic treatment and outcome data on patients with cancer available annually at an institutional level 1 1 4 1 4 The data are reported and analysed by a multidisciplinary group with recommendations for improvement of care 1 1 5 Complications registry Have agreements been reached concerning keeping and discussing a complications registry 1 1 5 1 Yes Mostly Partially No not applicable 1 1 5 1 1 There are specific protocols for reporting and recording of complications 1 1 5 1 2 The data are analysed at an institutional level 1 1 5 1 3 After analysis improvement measures are developed and action plans implemented in agreement with the departments concerned 1 3 Resources and materials 1 3 1 Cytostatic drugs prescription preparation and distribution Have agreements been reached concerning the prescription preparation and distribution of cytostatic drugs 1 3 1 1 Yes Mostly Partially No not applicable 1 3 1 1 1 A written procedure concerning p
16. 1 5 2 1 5 There is a regular internal audit system 1 5 2 1 6 There is a quality and risk dashboard of the cancer centre with an annual evaluation of the results and if necessary revision of its content 1 5 3 Accuracy of the diagnostic services Are the diagnostic services safe efficient and accurate for workers and patients 1 5 3 1 Yes Mostly Partially No not applicable 1 5 3 1 1 Security checking of devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are part of the maintenance contracts 1E5312 Latest security checks have been done on time TESA Calibration of devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are part of the maintenance contracts 1 5 3 1 4 Latest calibrations have been done on time 1 5 3 1 5 Devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are periodically certified by an authorised company Expiration date is still valid 1 5 3 1 6 There is a reporting system for near miss accidents during the use of the devices and equipment 1 5 4 Quality and risk management of research and new techniques Are there monitoring systems for quality and risk management associated with the introduction of new techniques new practice 1 5 4 1 Yes Mostly Partially No
17. AOECI Organisation of European Cancer Institutes E User Manual amp EurocanPlatform gt iaOEC I Organisation of European Cancer Institutes Accreditation and Designation User Manual Femke Boomsma Dominique de Valeriola Wim van Harten Henk Hummel Ren e Otter and Mahasti Saghatchian OECI Accreditation and Designation User Manual Editors Marco A Pierotti Wim van Harten2 and Claudio Lombardo3 Authors Femke Boomsma4 Dominique de ValeriolaS Wim van Harten2 Henk Hummel4 Ren e Otter4 and Mahasti Saghatchian Editorial Office C cile Tableau Margherita Marincola3 Giorgia Pesce and Georgette van Velzen2 Fondazione IRCCS Istituto Nazionale Tumori Milan Italy Netherlands Cancer Institute Amsterdam The Netherlands Istituto Nazionale per la Ricerca sul Cancro Genoa Italy Comprehensive Cancer Centre the Netherlands Groningen Enschede the Netherlands Institut Jules Bordet Brussels Belgium Institut Gustave Roussy Villejuif France Organisation of the European Cancer Institutes Brussels Belgium Alleanza Contro il Cancro Rome Italy NOOB WMH Publisher OECFEEIG Reg Brussels REEIG N 277 D 2011 12 243 1 ISBN 9789080625662 Organisation of European Cancer Institutes European Economic Interest Grouping c o Fondation Universitaire Rue d Egmont 11 B 1000 Brussels Belgium www oeci eu oeci oeci eu Graphic Designer Studio Sichel Piacenza Printed
18. medical oncology and surgical oncology e Check availability 3 times yes or no In case the preliminary designation is between a Clinical Cancer Centre and a Comprehensive Cancer Centre the audit team will have to additionally focus during the peer review visit on the following criteria A highly innovative character and multidisciplinary approach using the potential of basic translational and clinical research and clinical facilities and activities organised in a sufficiently identifiable entity Short description A direct provision of an extensive variety of cancer care tailored to the individual patient s needs and directed towards learning and improving the professional organisational and relational quality of care Short description Broad activities in the area of prevention education and external dissemination of knowledge and innovation In order to accentuate the differences with other cancer institutes Short description The level of infrastructure expertise and innovation in the field of oncology research Short description Maintenance of an extensive network including all aspects of oncology treatment and research Short description Writing notes during the auditors peer review The notes of the interviews tours and presentation will be processed into the e tool by the auditors during and after the peer review The auditors have one week after the peer review visit to process the notes and to provi
19. resources HR management from bottom to top including directors Chief Officers heads of departments and physicians 1 5 6 1 2 The results of evaluation are documented and used for building future strategies of the institution with alignment of the departments 1 5 6 1 3 Relevant training is provided to all staff according to their level of responsibility 1 5 6 1 4 HR policy includes a formal individual evaluation at least once or twice a year 1 5 6 1 5 Training records of all staff are available 1 5 6 1 6 Skills competences and expertises are assessed in case of recruitment at managerial level 1 5 6 1 7 Specific psychological support is available for the cancer centre s employees including physicians 1 5 7 Privacy protection of personal data Are there procedures for privacy protection of personal data 1 5 7 1 Yes Mostly Partially No not applicable 125 711 There is a Patient Charter an official set of principles a document defining the commitments of both the cancer centre AND the patient In this Charter the cancer centre commits itself to respect and to guarantee the patient s privacy TO iE2 There is a secure procedure for the storage preservation consultation and transmission of personal data according to the national European regulations 1 5 7 1 3 Protocols for clinical trials guarantee the protection of the patient s personal data This
20. 1 Present FTE dedicated Phd students Number of researcher Phd MD and fellows technicians carcinogenesis immunology cell biology drug development Bioinformatics Biostatistics Tumour progression Angiogenesis Epidemiology Psycho oncology Nursing Radiobiology Public health Health economy Clincal trials 4 1 2 Present FTE dedicated Phd students Number of researcher Phd MD and fellows technicians Pharmacogenomic pharmacokinetics dynamics gene therapy onco genomics onco proteomics Functional imaging Toxicology Others 4 2 Structures 4 2 1 Research facilities Animal House Transgenic facility Micro array facility Biochemical analysis Radio labelling cyclotron High Throughput screening Bio Statistics Cytogenetics Massaspectrometry Electon microscopy or electron Animal pathology histology Proteomics facility DNA sequence facility Protein analyses facility a a a a a a a T Flowcytometry a a a a a a a Others namely Appendix Ill OECI Accreditation and Designation 37 4 3 Structures 4 3 1 Yes No not applicable 4 3 1 1 Do you have a private partnership with companies related to research and innovation 4 3 1 2 Do you have a Unit of epidemiology
21. 1 Yes Mostly Partially No not applicable 5 1 1 1 1 The cancer centre analyses the training needs regularly 5L Based on the analysis the institution defines an annual or multi annual training educational programme for physicians 5 1 1 1 3 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for researchers 5 1 1 1 4 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for nurses 5 1 1 1 5 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for paramedics Sll Based on the analysis the cancer centre defines an annual or multi annual training educational programme for supportive disciplines psychologists etc 5 TAL Based on the analysis the cancer centre defines an annual or multi annual training educational programme for other disciplines please specify in the note 5 4 Process control 5 4 1 Participation in teaching oncology Do the physicians researchers nurses and psychologists in the cancer centre participate in the teaching of undergraduate theoretical courses in oncology 5 4 1 1 Does the cancer centre provide teaching to Yes Mostly Partially No not applicable 5 4 1 1 1 physicians 5 4 1 1 2 researchers 5 4 1 1 3 nurses 5 4 1 1 4 psychologists 5 4 1 1 5 su
22. 30 Chapter 4 Research innovation and developments 14 45 4 1 Policy and organisation 7 25 4 3 Resources and materials 3 12 4 4 Process control 3 4 4 5 Safeguarding the quality system 1 4 Chapter 5 Education and teaching 4 19 5 1 Policy and organisation 1 7 5 4 Process control 3 12 Chapter 6 Patient related 6 30 6 4 Process control 4 21 6 5 Safeguarding the quality system 2 9 All standards and questions are presented on the following pages Additionally to giving a score to each question the e tool gives the opportunity to add notes proof documents and improvement points Appendix Il OECI Accreditation and Designation 3 Qualitative Questionnaire 1 General Standards Strategic Plan and General Management 1 1 Policy and organisation 1 1 1 Oncological policy plan and general report 1 1 1 1 Yes Mostly Partially No not applicable 1 1 1 1 1 The board and or the management of the cancer centre has an official recent plan not older than five years eles The vision on care in the field of oncology care is explained in the plan ERLE The policy and the goals to be achieved are defined in the plan ETITA The annual plan or multi year plan contains actions to achieve the goals 1 1 1 1 5 The cancer centre has concrete annual or multi year plans on the level of the main services or clusters HERRE The plan is evaluated in later annual reports ELEL Improvement activities of the can
23. 5 1 3 Structured screening methods are used to refer patients to the psycho oncology team 3 4 5 1 4 Procedures about how to refer the patients to the psycho oncology service including patients in psychological distress are clearly defined 3 4 6 Social Counselling Does the cancer centre have a guideline or policy on the psychosocial counselling of oncology patients 3 4 6 1 Mostly Partially No not applicable 3 4 6 1 1 Social counselling including social workers is available and accessible to all patients 16 OECI Accreditation and Designation Appendix II 3 4 7 Family involvement in care Is care organised for the patient s family during treatment the end of life and the immediate bereavement period 3 4 7 1 Yes Mostly Partially No not applicable 3 4 7 1 1 In agreement with the healthcare team the family can participate in some personal activities e g meals washing 3 4 7 1 2 Each ward offering palliative terminal care has a room for meeting the families 3 4 7 1 3 Visiting time restrictions are lifted and arrangements for relatives to stay sleep as well as for visiting by children are facilitated 3 4 8 Family involvement in care children Is there special attention paid to children with a parent who is dying 3 4 8 1 Yes Mostly Partially No not applicable 3 4 8 1 1 Specific support exists for families with children whose
24. 5 1 9 the cancer centre is labialized Smoke Free 14 OECI Accreditation and Designation Appendix II 3 Care 3 4 Process control 3 4 1 Pain service Does the cancer centre have a protocol guideline for pain control 3 4 1 1 Yes Mostly Partially No not applicable 3 4 1 1 1 The cancer centre applies uses guidelines regarding pain treatment for patients with cancer 3 4 1 1 2 There is regular staff education on pain management 3 4 1 1 3 Patients and their families receive oral and written information about any pain management 3 4 1 1 4 There is a pain score card as part of the guidelines 3 4 1 1 5 The use of the pain score card is regularly assessed 3 4 2 Palliative Supportive care team Does the cancer centre have written agreements for composition and tasks of the palliative supportive care team NB palliative AND OR supportive care 3 4 2 1 The palliative supportive care team Yes Mostly Partially No not applicable 3 4 2 1 1 intervenes in a timely way to request from all inpatients departments 3 4 2 1 2 replies to out patient requests with a help line service or consultation 3 4 2 1 3 provides education for different disciplinary specialists patients and families 3 4 3 Palliative Supportive and terminal care guideline Are there guidelines to palliative and terminal care NB pa
25. 5 4 1 1 4 psychologists 5 4 1 1 5 supportive disciplines psychologists etc 5 4 1 1 6 other disciplines please specify in the note 22 OECI Accreditation and Designation Appendix Il 5 4 2 Types of teaching programmes provided Does the cancer centre participate in teaching for PhD BSc MSc degree s in oncology nursing 5 4 2 1 Does the cancer centre provide Yes Mostly Partially No not applicable 5 4 2 1 1 academic teaching in oncology 5 4 2 1 2 continuous medical education CME 5 4 2 1 3 BSc MSc and PhD programmes related to cancer research 5 4 3 Types of teaching programmes organised Does the cancer centre participate in organising for PhD BSc MSc degree s in oncology nursing 5 4 3 1 Does the cancer centre organise coordinate 5 4 3 1 1 academic teaching in oncology 5 4 3 1 2 continuous medical education CME 5 4 3 1 3 BSc MSc and PhD programmes related to cancer research Appendix Il OECI Accreditation and Designation 23 6 Patient related 6 4 Process control 6 4 1 Educational material Has policy been defined concerning the production distribution and administration of educational material relating to oncology 6 4 1 1 The cancer centre delivers Yes Mostly Partially No not applicable 6 4 1 1 1 written information on relevant aspects of oncology to the patients
26. A amp D Committee will be informed about the final decision of the A amp D Board during their meetings Meetings It depend on the workload At least once a month six weeks by teleconference or videoconference 3 1 6 OECI A amp D Advisory Group An advisory group will be developed to advise the OECI A amp D Board on major issues in the programme 3 1 7 Relations and communication between OECI groups The relations and communication between the OECI groups are described 3 1 7 1 Relation communication between the OECI A amp D Group and OECI Board The OECI Board shall take all necessary steps and make all decisions for the achievement of the goals of the OECI A amp D Group The OECI A amp D Board chair represents the group at the OEC Board as co opted member The OECI Board gives mandate for daily management to OECI A amp D Group All standards and procedures have to be approved by the OECI Board and procedures are also signed by the OECI president The A amp D Chair will give regular feedback to the OECI Board concerning all accreditation and designation activities The Executive Manager will provide a quarterly report for the A amp D Chair This report can be used for giving feedback including new applications visited institutes achieved accreditation etc The A amp D Board decides if a cancer institute will receive OECI accreditation and will give notice to the OECI Board The A amp D Certificate will be signed by the OE
27. Access to Not available 2 11 1 1 Do you have a cytology laboratory mlilelees Do you have a histopathology laboratory 2 11 2 If on site Yes No 2 11 2 1 immunofluorescence techniques 2A 2 Histochemistry 2 11 2 3 flow cytomitry 2 11 2 4 Techniques for molecular biology and genetics by cytology by biopsyon large pieces of excision Please specify the number of samples for tumour pathological diagnosis per year at your cancer centre 32 OECI Accreditation and Designation Appendix III 2 12 Haematology unit 2 12 1 On site Access to Not available 2 12 1 1 Do you have a transfusion centre 2 12 1 2 Do you have a bone marrow bank 2 12 2 Number of laminar flow rooms 2 12 3 Allogenic stem cell Autologous bone marrow Autologous stem cell Please specify the number of bone marrow stem cell transplants per year 2 13 Oncology Multidisciplinary team 2 13 1 Members are Yes No 2 13 1 1 Medical oncologist or equivalent 2A E2 Surgical Oncologist 2 13 1 3 Radiotherapist 2 13 1 4 Radiologist 2 13 1 5 Pathologist BM BolhlS Nurses 2 13 1 7 Others 2 14 Palliative care team 2 14 1 Members are Yes No not applicable 2 14 1 1 Anaesthetist Physician specialising in pain treatment 2 14 1 2 Medical specialists including psychiatrist and medical oncologist 2 14 1 3 Nurses 2 14 1 4 Psy
28. Board will take the final A amp D decision The improvement plan will have to follow some general obligations To show the willingness to improve the main opportunities from the peer review report To show a systematic approach with opportunities goals actions persons responsible start date evaluation date end date and priority Itis out of the scope of the OECI A amp D programme to give advice on how an institute approaches the actions The institute will receive the Accreditation and Designation Certificate if the improvement plan of the institute is approved by the OECI A amp D Board The Certificate will also include the final designation It will receive a letter stating that the institute will be awarded with the certificate The institute may choose the way of receiving the Certificate either during the OECI General Assembly or by post mail The A amp D Certificate will be valid for four years from the date of issue To maintain the A amp D Certificate after these four years the institute will have to start a new round A amp D Programme at least six months before the expiring date of the certificate LaOECl Oncanisarion oF European Cancer INstmrutes European Economic Interest Groupie Registered number OECHEEIG B 001 CERTIFICATE OF ACCREDITATION AND DESIGNATION OECI hereby certifies that the YOUR cancer INSTITUTE Town Country meets the quality standards for cancer care and
29. Chapter 3 Care 10 30 3 4 Process control 10 30 Chapter 4 Research innovation and developments 14 45 4 1 Policy and organisation 7 25 4 3 Resources and materials 3 12 4 4 Process control 3 4 4 5 Safeguarding the quality system 1 4 Chapter 5 Education and teaching 4 19 5 1 Policy and organisation 1 7 5 4 Process control 3 12 Chapter 6 Patient related 6 30 6 4 Process control 4 21 6 5 Safeguarding the quality system 2 9 All standards and questions are presented on the following pages Additionally to giving a score to each question the e tool gives the opportunity to add notes proof documents and improvement points Appendix Il OECI Accreditation and Designation 3 Qualitative Questionnaire 1 General Standards Strategic Plan and General Management 1 1 Policy and organisation 1 1 1 Oncological policy plan and general report 1 1 1 1 Yes Mostly Partially No not applicable 1 1 1 1 1 The board and or the management of the cancer centre has an official recent plan not older than five years eles The vision on care in the field of oncology care is explained in the plan ERLE The policy and the goals to be achieved are defined in the plan ETITA The annual plan or multi year plan contains actions to achieve the goals 1 1 1 1 5 The cancer centre has concrete annual or multi year plans on the level of the main services or clusters HERRE The plan is evaluated in later annual reports
30. Question Progress Sy 1 Open qualitative Questionnaires OEC Qualitative Oeci Qualitative amp Questionnaire v3 questionnaire OEC Quantitative Questionnaire v2 ii5 264 44 gt Bis E aw 3 Oeci Quantitative questionnaire 5 Print the report including result graphs of 2 Open quantitative questionnaire the self assessment scares 5 Print the report including auditor scores and findings of the peer review of the institute Options in the e tool Go into qualitative questionnaire of the cancer institute Go into quantitative questionnaire of the cancer institute Go to the requested documents Go to the documents attached to specific questions Print the reports OT oi Appendix VI OECI Accreditation and Designation 55 2 Preparing a peer review Open a questionnaire and use the treeview to navigate through the chapters domains and standards E ex QQOECT Qualitative Questionnaire v3 E E 1 General Standards Strategic Plan and General Management EE 1 Policy and organization 42 Oncological policy plan and general report 42 Cooperation with unfVersities Eg Cooperation with external partners je ids Cancer data registration institutional level 425 Complications registry H O 3 Resources and materials A C 4 Process control C 5 Safegarding the quality system 2 Screening and primary prevention and health education B
31. Questionnaires OEC Qualitative Oeci Qualitative amp Questionnaire v3 questionnaire OEC Quantitative Questionnaire v2 ii5 264 44 gt Bis E aw 3 Oeci Quantitative questionnaire 5 Print the report including result graphs of 2 Open quantitative questionnaire the self assessment scares 5 Print the report including auditor scores and findings of the peer review of the institute Options in the e tool Go into qualitative questionnaire of the cancer institute Go into quantitative questionnaire of the cancer institute Go to the requested documents Go to the documents attached to specific questions Print the reports OT oi Appendix VI OECI Accreditation and Designation 55 2 Preparing a peer review Open a questionnaire and use the treeview to navigate through the chapters domains and standards E ex QQOECT Qualitative Questionnaire v3 E E 1 General Standards Strategic Plan and General Management EE 1 Policy and organization 42 Oncological policy plan and general report 42 Cooperation with unfVersities Eg Cooperation with external partners je ids Cancer data registration institutional level 425 Complications registry H O 3 Resources and materials A C 4 Process control C 5 Safegarding the quality system 2 Screening and primary prevention and health education B 3 Care H 4 Research innovation and develop
32. The chapter is divided in three parts people and groups within the OECI OECI auditors and the audit team and the people involved from the applied cancer institute 3 1 The OECI The ultimate objective of the OECLEEIG Organisation of European Cancer Institutes European Economic Interest Grouping is the development of oncology in Europe for reducing mortality and morbidity due to cancer and increasing survival and quality of life of the patients Therefore the model of oncology must be based on a global vision of the cancer problem emphasising the integration of research and education with diagnosis prevention and care to promote the development of comprehensive and multidisciplinary organisation within the European Cancer Institutes OECI Statutes The structure of the OECI contains the following bodies General Assembly Executive Board The Manager daily management The Coordination Secretariat The Working Groups 3 1 1 OECI Executive Board The Executive Board OECI Board is composed of at least the following members OECI Statutes The President who presides the meetings of the General Assembly and the Executive Board The Vice President who shall chair all meetings in the absence of the President The immediate Former President The Executive Secretary Two Elected Members one of whom serves as Treasurer One Co opted Member with no voting rights designated on the recommendat
33. a day on the medical paramedical nursing and supportive levels This can among other things be achieved by planning continuity of care during nights week ends holidays illness attendance at conferences or other reasons for absence within each discipline 1 4 1 1 2 Patients are informed about all the aspects of the continuity of care and eventually referred to another hospital 1 4 1 1 3 The patient receives information about the contact person for medical and nursing oncological matters 1 4 2 Waiting and throughput times Have norms standards been defined concerning the maximum waiting and throughput times for oncological patients with regard to first outpatients visit admission and tests treatment 1 4 2 1 There are guidelines for different types of tumours for the maximum waiting times between 1 4 2 1 1 referral by the general practitioner or referring specialist and the first visit to the outpatient s Clinic or the admission into the cancer centre 1 4 2 1 2 first visit and the time of definitive diagnosis 1 4 2 1 3 definitive diagnosis and first treatment 1 4 2 1 4 There is a record of those waiting times 1 4 2 1 5 There is continuous measurement and analysis of those waiting times leading to improvements when needed 1 4 2 1 6 There is a clear definition of the roles of each category of staff on those issues
34. a procedure describing how the conclusions and advice from the multidisciplinary meeting will be evaluated and by whom Appendix Il OECI Accreditation and Designation 9 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 Yes Mostly Partially No not applicable 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 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 Yes Mostly Partially No not applicable 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
35. amp D Coordinator Examination of Vf application Defining concept planning for centre CEC Secretary Notification of A approval Delivery noteto gt cancer centre no go Doc3 Letter of gt disapproval ep Concept period J explanatory visit _ Concept period of _ gt a sellassessment Concept period peer E review d Doc2 Letter of Cancer centre Designation A questionnaire ECI A amp D Coordinator Define preliminary A designation type Cancer centre Send signed A amp D A agreement ECI A amp D Coordinator Preparation o A explanatory visit approval documents Doc6 A amp D agreement a Confirmation of explanatory visit visit oo DocS Project plan centre y Figure 3 Step 1 Application and designation screening Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 1 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 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 fo
36. and A amp D Coordinator compose the audit team for the peer review visit of the institute An audit team consists of Chair is also an auditor Three auditors Coordinator Inthe case of a Cancer Unit the audit team includes possibly less than four auditors Inthe case of a CCC one person of the audit team possibly starts half a day earlier to check the designation criteria in advance See criteria for auditors 3 2 Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 10 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Invitations sent to the audit team Executor OECI A amp D Coordinator The auditors will receive an invitation to perform the peer review The letter will include Date for the preparation meeting under reservation of a go decision Dates peer review defined in alignment with the cancer institute and chair Introduction of the team members Engagement form for management Explanation about potential conflict of interest from the institute The institute may express objections against the audit team members The audit team continues if the institute has agreed with the team You can find attached to the letter Confidentiality agreement doc 14 Before the first p
37. and neck cancer oropharynx C10 head and neck cancer nasapharynx C11 head and neck cancer thyreoid C73H head and neck cancer others 30 OECI Accreditation and Designation Appendix Ill 2 6 Infrastructures with a focus on cancer care 6 of 7 2 6 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients haematological malignancies Hodgkin Lymphoma C81 haematological malignancies Non Hodgkin Lymphoma C82 haematological malignancies Myeloma C90 haematological malignancies All leukaemia neuro oncological Central nervous system C71 C72 neuro oncological others 2 7 Infrastructures with a focus on cancer care 7 of 7 2 7 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients paediatric malignancies all cancers age 0 lt 15 bone and soft tissue tumours primary bone C40 bone and soft tissue tumours Soft tissue C49 bone
38. and soft tissue tumours melanoma of the skin C43 skin cancer Others C44 2 8 Radiotherapy 2 8 1 Number of accelerators for radiation therapy 2 8 2 Number of cobolt units 2 8 3 Resources for proton therapy 2 8 3 1 Do you have resources for proton therapy 2 8 4 Number of conventional RT patients per year 2 8 5 Number of bracytherapy patients per year 2 8 6 Number of IMRT patients per year 2 8 7 Number of IORT patients per year 2 8 8 Number of stereo tactic RT single and fractionated patients per year Appendix Ill OECI Accreditation and Designation 31 2 9 Radiology 2 9 1 Number of CT scanners X 2 9 2 Number of facilities for MRI X 2 9 3 Number of MRI spectroscopy X 2 9 4 Number of mammography X 2 9 5 Waiting time for CT scanners 2 9 6 Waiting time for MRI 2 9 7 Waiting time for mammography 2 9 8 Do you have digitalised imaging PACS 2 9 8 1 2 9 9 Do you have resources for interventional techniques On site Access to Not Available 2 9 9 1 2 10 Nuclear medicine unit 2 10 1 Number of cameras 2 10 2 On site Access to Not available not applicable 2 10 2 1 Pet scan facilities 211012127 pet CT facilities 2 10 2 3 Radio nucleotide treatment facilities 2 11 Laboratory 2 11 1 On site
39. apply to the OECI A amp 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 amp 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 amp 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 confl
40. are the motive s Motives Arguments for starting the project Which goal s would you To achieve a like to achieve Try to define according to the SMART method Specific Measurable Achievable Realistic Time related Steering committee Is there a steering committee present Names of participants and functions Composition of the project team One two persons from each sub project group The sub project groups are small teams of people who are together responsible for a part of the questionnaires One two of the group also participate in the project team Name Position function Responsibilities Project leader in the institute Name e mail Position function Secretary Name e mail Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Appendix IV OECI Accreditation and Designation 41 Planning of the project Start Explanatory visit 29 June 2010 Number of planned internal meetings When periodically meetings Self assessment period September 2010 as proposed February 2011 1St evaluation with OECI Coordinator Date and with whom and evaluation with OECI Coordinator Date and with whom 3rd evaluation with OECI Coordinator Date and
41. audit team The second draft of the report will be sent to the chair to check Final scores as discussed in the teleconference with the audit team Final text per standard that supports the audit team scores Final designation type with the short description for each item Final designation conclusion Editorial changes Proceed final corrections Executor OECI A amp D Coordinator The A amp D Coordinator will proceed the final corrections of the chair and send the final draft report latest in week 6 after the peer review to the Director and accreditation contact person of the cancer institute The draft is sent together with Doc 41 Letter presenting the draft report Doc 22 Feedback and comment form The final draft will contain The standards reviewed during the peer review visit with the scores of the cancer institute from the self assessment the scores of the auditors and the findings of the auditors supporting the scores Description of the designation check findings The strengths and opportunities will be presented in the final report Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 21 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 8 2 Step 8 activities and
42. by OECI Accreditation and Designation Board Version 16 February 2011 OECI General Assembly Member Institutes OECI Executive Board i Vacant Accreditation Advisory Group Accreditation OECI Committee A amp D Board Executive Manager Project staff A amp D Secretary A amp D Coordinator Scientific activities Subcontractor Accreditation Designation Management Unit Compusense Accreditation Designation Working Group Accreditation Designation Programme Figure 2 Organisational structure 3 1 3 OECI Accreditation and Designation Board The requirements for the composition of the A amp D Board are The composition of the A amp D Board shall be approved by the OECI Board The A amp D Board consists of four persons of the OECI member institutes including the chairperson The chairperson is a co opted member in the OECI Board A amp D Board members engage a position within the Board of Directors of an OECI member institute or a position with comparable authority to be decided by the OECI Board General and specific tasks Financial Presenting a quarterly overview of income expenditure Assessing quarterly the income expenditure Policy procedures Decision making on accreditation and designation procedures and policy Accreditation and Designation Programme Approve disapprove the application of new cancer institutes in the A amp D Programm
43. cancer institute and the Deming cycle is completed at least once gt in second cycle e Partially means that the indicator is implemented on project bases or on a modest scale in the cancer institute or the Deming cycle has not been completed e No means that the indicator does not get attention or there are plans to start working on the indicator e Not applicable means that the indicator is not applicable in the cancer institute Appendix V OECI Accreditation and Designation 45 6 4 3 Informing patients about results treatment and counseling Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counseling in terms of how it is done and what it means Yes Mostly Partially No Not Delete Markeer The cancer centre has procedures or guidelines bd ad c c c C 8 0 regarding information transfer on diagnostics treatment follow up and supervision of the patient 1 Select a score for each 2 Depending on the selected substandard it will turn black score the bullet appears in green yes partly green or in red no 3 Before moving to the next item provide evidence for your score e Step 2 Provide evidence for the given score through e Attaching a document to a specific question in the e tool that provides the evidence or e Referring to a document that is already attached in an
44. 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 Poneke Patients or patients relatives should be part of these organisations 10 OECI Accreditation and Designation Appendix II 1 5 2 Quality and risk management and safety requirements 1 5 2 1 1 5 2 1 1 There is a patients committee or association for consultative advice about quality of care and risk management 1 2A There is a preventive maintenance programme for equipment and access to accurate and reliable diagnostic tests 1 5 2 1 3 There is a monitoring system for the appropriate use of diagnostic services 1 5 2 1 4 There is a monitoring system for the appro
45. designation type between the OECI A amp D board and the cancer institute Before the explanatory visit e Signing the A amp D agreement e Paying accreditation fee stage one 5000 for all types of institute Before the beginning of the self assessment period e Organising an internal accreditation project planning and project team Before peer review e Completed self assesment questionnaires results of self assesment e Delivering of requested documents e Go decision of OECI A amp D Board e Paying A amp D fee stage two The remaining A amp D fee for Cancer Units is 15 000 total amount 20 000 and the remaining fee for Clinical Cancer Centres or Comprehensive Cancer Centres is 25 000 total amount 30 000 e Completing the peer review agenda During peer review e Facilitating the maintenance of the audit team as agreed in the audit programme e Providing permission to observe activities or procedures in the cancer institute during on site peer review e On request of the OECI auditors team the institute shall provide access to all relevant locations files and documents needed for assessment during the on site peer review e The participants in the peer review from the institute understand and speak English e During tour on departments and wards an independent translator needs to be available to translate the questions of auditors and answers of staff After peer review e Providing feedback on the peer rev
46. earlier item OR e Adding a note to justify the score if there is no document available AND e Adding the requested documents How to attach a document to a specific question Click on the globe 2 icon and the following screen appears The question where you are attaching a document at The cancer centre has procedures or guidelines regarding information transfer on diagnostics treatment follow up and supervision of the patient There are no documents Upload new file Orn een nieuw document toe te voegen gaat u met de knop Zoeken naar de lokatie waar het document staat Kiik vervolgens op Toevoegen 1 Browse for the document in the institute s document 2 Click to add the document 3 Return to the questions Under the a has appeared nr 1 between brackets for one attached document To get an overview of the specific questions that contain a document you can close the questionnaire and click on the icon in the table under evidence Questionnaires ES Questionnaires These are the most recent questionnaires EA CECI Qualitative 08 08 05 11 E 264 Pi am Ley oY gt Questionnaire v3 2009 2010 264 100 E amp L L L D Ye CECI Quantitative 08 08 30 06 o 662 a Questionnaire v2 2009 2010 0 46 OECI Accreditation and Designation Appendix V How to refer to a document that is already attached Click on the
47. for the oncological multidisciplinary team meetings 1 4 11 1 There are procedures describing how the regular multidisciplinary team meetings apply following criteria 1 4 11 1 1 One of the specialist in charge of the care of the patient is present during the discussion of the patient Yes Mostly Partially No not applicable 1 4 11 1 2 During the presentation of patients diagnostic results and examination results are available 1 4 11 1 3 The necessary facilities to show diagnostic and examination results are available 1 4 11 1 4 Conclusions and advice resulting from the multidisciplinary team meeting are documented in the patient s medical record 1 4 11 1 5 There is a clear description of the way to inform all the members of the multidisciplinary team about which patients will be discussed 1 4 11 1 6 There is a clear description of the communication of the advice resulting from the discussion to all the physicians and other disciplines involved in the care of the given patients 1 4 11 1 7 There is a clear description of the communication of the advice resulting from the discussion to the concerned patients 1 4 11 1 8 Each final decision about care of the patient that differs from the advice and conclusions of the multidisciplinary team is documented and recorded in the patient s medical record 1 4 11 1 9 There is a procedure describing how the conclusions
48. in Piacenza Italy May 2011 This publication is co financed by the European Commission through the 7th Framework Programme within the EurocanPlatform NoE L 5 EurocanPlatform Introduction to the Accreditation and Designation User Manual Dear Colleagues In recent years the treatment of cancer has developed into a multidisciplinary approach in which specialties from many disciplines supported by wide array of technical facilities in various services cooperate to provide optimal treatment Moreover in Comprehensive Cancer Centres CCCs a close cooperation with various research groups and disciplines is a condition to perform successful translational research Individual professional expertise both in research and treatment will remain the cornerstone of the work however a strong organisational structure is necessary As the successful organisation of a CCC is an important ingredient for optimal performance there is a critical need for quality assurance of the Centres and the development of systems establishing the performance of Centres qualifying for international platforms and the success of their programmes In this view the 7 Framework Programme EC funded Network of Excellence EurocanPlatform has selected the OECI Accreditation and Designation A amp D Group to perform a quality assessment research project for CCCs in work package 12 WP12 The OECI A amp D Manual contains all the policies and procedures designed specifica
49. institute and the preliminary designation that remains after the explanatory visit the institute shall pay the fee equal to the designation type they applied for For example an institute that has classified itself as clinical cancer centre and is willing to continue the programme as such they shall pay in total 30 000 although the preliminary designation is a cancer unit Note lf an institute decides to apply for A amp D as clinical cancer centre or CCC the full set of standards will be assessed including the standards related to chapter 4 Research innovation and development Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 14 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 7 Step 7 Peer review visit and designation check Figure 5 shows the activities after the go decision The auditors need 2 months for the audit team to prepare the peer review before the peer review visit can take place in month 10 IEC ASD Coordinator Cancer conve Month 8 Send information to E mail login eTool Complete peer review L dAl aucitees be doc 18 21 32 37 agenda CEC Auditor Prepare auditors team meetng ec Secretary Bocking hotel audiiors meeting CEC Secretary CECI ASD case Booking hotel peer Send agenda s review A ECI audit iea
50. not applicable 1 5 4 1 1 Identification of any risk associated with the introduction of a new technology or new practice is performed systematically 1 5 4 1 2 There is a quality assurance programme for clinical research 1 5 4 1 3 There is a procedure for Serious Adverse Events and Sudden Unexpected Serious Adverse Reaction handling and reporting 1 5 4 1 4 The SOP s are regularly updated and are accessible Appendix Il OECI Accreditation and Designation 11 1 5 5 Quality assurance in all areas Does the cancer centre promote and develop the practice of quality assurance in all areas 1 5 5 1 The quality assurance programmes are included in the global policy for quality and risk management Yes Mostly Partially No not applicable 1 5 5 1 1 Thereis one quality assurance programme in each oncology healthcare area chemotherapy surgery radiotherapy and at risk units anaesthesiology critical care etc 1 5 5 1 2 There is at least one quality assurance programme in areas other than the oncology healthcare area 1 5 5 1 3 All activities of cancer centre follow when applicable the guidelines of Good clinical Practice Good laboratory Practice and Good manufacturing Practice 1 5 6 Quality assurance in all areas HR 1 5 6 1 1 5 6 1 1 Evaluation of the employees is a part of the human resources HR management from bottom to to
51. of Cancer Units 4 1 Research domains 4 1 1 Present FTE dedicated Phd students Number of researcher Phd MD and fellows technicians carcinogenesis immunology cell biology drug development Bioinformatics Biostatistics Tumour progression Angiogenesis Epidemiology Psycho oncology Nursing Radiobiology Public health Health economy Clincal trials 4 1 2 Present FTE dedicated Phd students Number of researcher Phd MD and fellows technicians Pharmacogenomic pharmacokinetics dynamics gene therapy onco genomics onco proteomics Functional imaging Toxicology Others 4 2 Structures 4 2 1 Research facilities Animal House Transgenic facility Micro array facility Biochemical analysis Radio labelling cyclotron High Throughput screening Bio Statistics Cytogenetics Massaspectrometry Electon microscopy or electron Animal pathology histology Proteomics facility DNA sequence facility Protein analyses facility a a a a a a a T Flowcytometry a a a a a a a Others namely Appendix Ill OECI Accreditation and Designation 37 4 3 Structures 4 3 1 Yes No not applicable 4 3 1 1 Do you have a private partnership with companies related to research and innovation
52. of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 16 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Auditors team meeting Executor OECI audit team One month before the peer review the auditors will meet to prepare the peer review Input Result designation screening Concept peer review agenda completed by the cancer institute with interviewees and locations Self assesment reports qualitative and quantitative Attached documents of the cancer institute Designation checklist Content of the meeting A general presentation of the accreditation programme An explanation of the roles and responsibilities of the auditors Report writing procedures Planning of interviews Content of interviews Follow up of the accreditation programme for the cancer institute Every auditor will take notes during the peer review visit Preparation of the peer review Executor OECI Auditor Individual preparation of the peer review following the appointments made during the auditors team meeting Meeting day before the peer review Executor OECI audit team The evening before the peer review the auditors meet in the hotel for Final preparation Extra focus on the designation type especia
53. of the glossary is to provide the user with the meaning of unclear or unknown words for understanding and interpretation of the questions Owner OECI Organisation of European Cancer Institutes Chapter 1 Introduction of the OECI A amp D Programme Status Revised 24th January 2011 A amp D Working Group Page lof2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 2 Timeline of the OECI A amp D process 2 1 In ten steps to A amp D certification It takes ten steps in the OECI A amp D Programme towards OECI A amp D certification Figure 1 presents the ten steps preceded by one of the conditions for application OECI membership The ten steps include the essential decision moments for continuation of the institute in the programme And for monitoring continuous and comprehensive quality improvement in the institute there will be a follow up of the institute s improvement plan one year after certification A detailed explanation of all steps is outlined in Chapter 5 Cancer centre Introduction OECI Membership OECI i A amp D Programme www oeci eu Month 0 6 Figure 1 STEP 1 Application amp Designation screening Cancer centre STEP 2 Payment fee stage 1 STEP 3 Explanatory visit amp preliminary D STEP 4 Self assessment oeci A amp D Board Step 5 Approval Go Vf No go f D no go Cancer centre Go S
54. one of the goals of the OECI A amp D Group Criteria for application Applying to the A amp 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 amp 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 amp 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 Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 2 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Defining concept planning for institu
55. or guidelines regarding information transfer on diagnostics treatment follow up and supervision of the patient Yes Mostly Partially No not applicable 6 4 3 1 2 Policies are defined about who is informing the patient relatives and close friends about the result of an examination further treatment or supervision 6 4 3 1 3 Policies are defined about when this information is delivered 6 4 3 1 4 Policies are defined about how the transmission of information to the people involved in treatment and patient care is organised 6 4 3 1 5 Policies are defined about how the relevant information transferred to the patient is described in the patient s file such as information about the further treatment that can be expected the plan of treatment about requesting a consultation of another medical specialist the consequence of potential side effects 6 4 4 Discharge procedure Does the cancer centre have a discharge procedure 6 4 4 1 6 4 4 1 1 There is a written discharge procedure 6 4 4 1 2 This procedure is regularly assessed 6 4 4 1 3 At discharge information is provided to the patients about patients associations 6 4 4 1 4 At discharge information is provided to the patients about self helping groups 6 4 4 1 5 At discharge information is provided to the patients about home care 6 4 4 1 6 At discharge information is p
56. point is checked and validated by an Ethical Committee 12 OECI Accreditation and Designation Appendix II 2 Screening and primary prevention and health education 2 4 Process control 2 4 1 Availability of screening programmes In the setting of private health policy does the cancer centre organise or participate in screening programmes 2 4 1 1 Mostly Partially No not applicable 2 4 1 1 1 The cancer centre participates in structured regional province county screening programmes 2 4 1 1 2 The cancer centre participates in structured national screening programmes 2 4 1 1 3 The cancer centre organises screening programmes 2 4 2 Participation in prevention and health education initiatives Does the cancer centre organise or participate in prevention and health education initiatives that meet the needs of the population 2 4 2 1 Mostly Partially No MAET lt 1 2 4 2 1 1 The cancer centre organises prevention programmes 2 4 2 1 2 The cancer centre organises health education initiatives programmes 2 4 2 1 3 The cancer centre participates in prevention programmes 2 4 2 1 4 The cancer centre participates in health education initiatives programmes 2 4 3 Availability of primary prevention clinics Does the institution have one or more specific primary prevention clinics 2 4 3 1 Partially No not applicab
57. research and it is therefore designated as COMPREHENSIVE CANCER CENTRE Issued on 2010 08 15 Validity date 2012 08 15 f sf Mahasti Saghatchian Chair OECI Accreditation Marco Pierotti OECI President Designation Programme Figure 8 OECI Accreditation and Designation certificate Action add newest version Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 25 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 10 1 Evaluation of the A amp D Programme Evaluation A amp D Programme figure 9 next page Executor OECI A amp D Coordinator and Cancer Centre The A amp D Coordinator will send an evaluation form to the institute 3 months after the final A amp D Certification approval Evaluation by teleconference Approximately five months after the final A amp D Certification approval the OEC A amp D Coordinator and the Executive Manager will plan a teleconference to discuss the evaluation form Representatives Cancer institute contact person Chair audit team OECI Executive Manager OECI A amp D Coordinator Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 26 o
58. responsibilities of all parties figure 6 Check draft peer review report Executor Cancer institute The Director and the accreditation contact person of the institute will receive the draft peer review report The institute will have 4 weeks to distribute the draft report within the cancer institute to whomever is concerned and to collect comments and feedbacks After four weeks the contact person that will have collected the comments within the institute will have to send the form to the OECI Coordinator Note All feedbacks and comments will be discussed by the audit team but the report will only be revised with reliable arguments and or new evidence Forward comments Executor OECI A amp D Coordinator The comments and feedbacks of the institute on the draft report will be forwarded to the audit team members They are requested to give their comments via e mail The institutes comments and response of the audit team members will be discussed with the chair of the audit team Discuss comments by teleconference Executor OECI Chair audit team Discuss the feedbacks and comments of the cancer institute The comments and response of the auditors will be discussed in a teleconference with the chair of the audit team and the OECI A amp D Coordinator Conclusions concerning the comments will be inserted in doc 22 Feedback and Comments form Formulate proposal for
59. seminars or theme specific conferences 4 4 1 1 2 Scientific programmes are used to guarantee that results from research will be translated into daily practice timely e g diagnostic tools treatment or prevention 4 4 2 Teaching programme for PhD students Is there a teaching programme for PhD students 4 4 2 1 4 4 2 1 1 There is a teaching programme for PhD students 4 4 3 Transfer of new scientific information to clinical practice Is there a procedure for the transfer of new scientific information to clinical practice 4 4 3 1 4 4 3 1 1 There is a procedure that guarantees that results from research will be translated into daily practice timely e g diagnostic tools treatment or prevention 4 5 Safeguarding the quality system 4 5 1 Periodical site visit review Is there a periodical site visit review of the total research organisation 4 5 1 1 There is a periodical review and or site visit with external reviewers of 4 5 1 1 1 the total research organisation 4512 each research group team activities 4 5 1 1 3 clinical translational research 4 5 1 1 4 research support facilities Appendix Il OECI Accreditation and Designation 21 5 Teaching and continuing education 5 1 Policy and organisation Does the cancer centre analyse the training needs to define an annual or multi annual programme 5 1 1 Analyse training needs 5 1 1
60. standard To view the full text click the little text icon N E 2 The board and or the 1 2 policy plan revision planned in 2011 and 2012 The full text of the note will be shown but can not be changed Clicking the little icon once more will close the note The second icon shows the number of improvement points that the institute descibes regarding to this standard The third icon showd the number of proof documents that the institute uploaded to support this standard 3 Report findings and scores after peer review After the peer review the auditors provide their notes and scores to the Accreditation Coordinator through the e tool e Note On standard level in the questionnaire for each standard e Score On Sub question level for each sub question e Strengths and opportunities if a standard is a strengths or an opportunity the auditor will also make a not on standard level to explain The coordinator will make a draft report with the notes of the auditors 3 4 1 Pain service Auto save in 150 r Click to insert your comments on the standard Space for the auditor to provide s notes after the peer review Does the cancer centre have a protocol guideline for pain control This is the auditors function changes to the auditor score will be saved Yes Mostly Partially No Not Delete Mar j applicable g E a The cancer centre applies uses a e 8e c C 8 r 0 0 guidelines regarding pain treatment
61. the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 3 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Organizing the auditors meeting Coordinating the peer review visit on site for accreditation and designation Coordinating the writing of the peer review report in cooperation with the audit team Processing the peer review report towards the final report Coordinating the follow up of the cancer institute Other specific tasks and responsibilities of the A amp D Coordinator are described in doc 43 3 1 4 3 OECI Accreditation Secretary General tasks General secretariat of the OECI Accreditation Programme under supervision of and following the instructions of the chair Informing the OECI A amp D Group about incoming information Specific tasks Organizing meetings and teleconferences Booking the rooms organising lunches and coffee if necessary checking availabilities of participants sending the agendas writing the minutes and sending it to the group Peer review visits Organizing the logistics of the visit booking hotels for auditors A amp D Agreements Arranging to complete the signed A amp D Agreement from institutes with signatures of the OECI A amp D Chair and the OECI President Financial Providing quarterly a detailed overview of income expenditure to the OECI A amp D Ch
62. the self assesment During the self assesment period the A amp D Coordinator will contact the cancer institute regularly to evaluate the progress of the self assesment How to score the standards The score is a indicator for the stage of implementation of each item of the standard The scoring system is based on the Plan Do Check Act circle or Deming circle These four stages of implementation are translated in the following possible answers Yes means that the indicator of the standard has been implemented on a wide scale in the cancer institute and the Deming cycle is completed at least twice gt in third cycle Mostly means that the indicator has been implemented in most of the critical places in the cancer institute and the Deming cycle is completed at least once gt in second cycle Partially means that the indicator is implemented on project bases or on a modest scale in the cancer institute or the Deming cycle has not been completed No means that the indicator does not get attention or there are plans to start working on the indicator Not applicable means that the indicator is not applicable in the cancer institute After filling out all the questions the e tool generates the results The results will be used as input for the peer review as well as input for a quality improvement plan of the institute Composition of the audit team Executor OECI A amp D Coordinator The OECI Executive Manager
63. to refer patients to the psycho oncology team 3 4 5 1 4 Procedures about how to refer the patients to the psycho oncology service including patients in psychological distress are clearly defined 3 4 6 Social Counselling Does the cancer centre have a guideline or policy on the psychosocial counselling of oncology patients 3 4 6 1 Mostly Partially No not applicable 3 4 6 1 1 Social counselling including social workers is available and accessible to all patients 16 OECI Accreditation and Designation Appendix II 3 4 7 Family involvement in care Is care organised for the patient s family during treatment the end of life and the immediate bereavement period 3 4 7 1 Yes Mostly Partially No not applicable 3 4 7 1 1 In agreement with the healthcare team the family can participate in some personal activities e g meals washing 3 4 7 1 2 Each ward offering palliative terminal care has a room for meeting the families 3 4 7 1 3 Visiting time restrictions are lifted and arrangements for relatives to stay sleep as well as for visiting by children are facilitated 3 4 8 Family involvement in care children Is there special attention paid to children with a parent who is dying 3 4 8 1 Yes Mostly Partially No not applicable 3 4 8 1 1 Specific support exists for families with children whose parent is dying trained staff guidelines
64. with an appropriate aspiration device 2 4 5 1 9 the cancer centre is labialized Smoke Free 14 OECI Accreditation and Designation Appendix II 3 Care 3 4 Process control 3 4 1 Pain service Does the cancer centre have a protocol guideline for pain control 3 4 1 1 Yes Mostly Partially No not applicable 3 4 1 1 1 The cancer centre applies uses guidelines regarding pain treatment for patients with cancer 3 4 1 1 2 There is regular staff education on pain management 3 4 1 1 3 Patients and their families receive oral and written information about any pain management 3 4 1 1 4 There is a pain score card as part of the guidelines 3 4 1 1 5 The use of the pain score card is regularly assessed 3 4 2 Palliative Supportive care team Does the cancer centre have written agreements for composition and tasks of the palliative supportive care team NB palliative AND OR supportive care 3 4 2 1 The palliative supportive care team Yes Mostly Partially No not applicable 3 4 2 1 1 intervenes in a timely way to request from all inpatients departments 3 4 2 1 2 replies to out patient requests with a help line service or consultation 3 4 2 1 3 provides education for different disciplinary specialists patients and families 3 4 3 Palliative Supportive and terminal care guideline Are there guide
65. 1 3 1 1 1 A written procedure concerning prescription of anti cancer drugs is available 1 3 1 1 2 A written procedure concerning preparation of anti cancer drugs is available 1 3 1 1 3 A written procedure concerning distribution of anti cancer drugs is available 1 3 1 1 4 The anti cancer drugs are prepared in a centralised unit 1 3 1 1 5 The anti cancer drugs are prepared under the direct supervision of a pharmacist Appendix Il OECI Accreditation and Designation 5 1 3 2 Are there protocols for the administration of cytostatic drugs Administration of cytostatic drugs 1 3 2 1 Mostly Partially No not applicable 1 3 2 1 1 The cancer centre has described procedures or guidelines on the administration of anti cancer drugs 1 3 2 1 2 The anti cancer drugs are as much as possible administrated in specialised wards e g administration of anti cancer drugs takes place only in some well defined wards medical oncology ward 1 3 2 1 3 There is a dedicated day care unit for the administration of anti cancer drugs 1 4 Process control 1 4 1 Continuity of care within the cancer centre Have agreements been reached concerning the continuity of care and replacement of nursing medical paramedical and support staff associated with oncology Is the care covered 7 days a week by specialised staff 1 4 1 1 1 4 1 1 1 Continui
66. 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 amp D Certificate Follow up An overview of the necessary supporting documents for the institute auditors and OECI A amp 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 amp D Programme 2 Timeline of the OECI A amp D Process 2 1 In ten steps to A amp D Certification 3 People and parties involved in the A amp D Programme 3 1 The OECI 3 2 Audit team and auditors 3 3 Cancer Institute 4 Confidentiality and conflict of interest 4 1 4 2 Confidentiality Conflict of interest 5 Ten steps A amp D Process in detail 5 1 5 2 5 3 5 4 5 5 5 6 5 7 5 8 5 9 5 10 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 assessment 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 impr
67. 2 14 1 6 Physiotherapist 2 14 1 7 General practitioner 2 14 1 8 Social worker 2 14 1 9 Dietician Appendix Ill OECI Accreditation and Designation 33 2 15 Facilities 2 15 1 On site Access to Not available 2 15 1 1 Do you have a tumour bank facility 2 15 1 2 Do you have a central pharmacy 2 15 2 Number of operating rooms excluding ambulatory services specific to oncology 2 15 3 Number of IC beds specific to oncology 2 15 4 Access to Not available 2 15 4 1 Do you have other specialised techniques on site 2 15 5 Do you have other specialised techniques on site Yes No 2 15 5 1 laser therapy 2015 52 Laparoscopy 2 15 5 3 sentinel node 2 15 5 4 Intra Operative Chemo Therapy 2 15 5 5 hyperthermia 2 15516 isolated limb perfusion 2 15 5 7 radio frequency ablation 211059 Others 34 OECI Accreditation and Designation Appendix III 3 Human resources 3 1 Human resources 1 3 1 1 Per doctor Per nurse day Per nurse night Legal number of hours for 1 Full Time Equivalent FTE X X X 3 1 2 Total FTE of employees in the cancer centre 3 1 3 Total FTE of employees dedicated to cancer patients 3 2 Human resources 2 3 2 1 Please specify the number X X X X X X X X X X of FTE surgeons
68. 3 Survey 1 3 1 Name of the Contact person for the survey at the cancer centre 1 3 2 Position of the Contact person for the survey 1 3 3 E mail address of the Contact person for the survey 1 4 Cancer centre structure 1 4 1 Cancer Unit Clinical Cancer 0 0 0 Cancer research Centre Comprehensive Centre cancer centre 1 4 1 1 In which category would you classify your cancer centre 1 4 6 academic public non profit private 1 4 6 1 What is the administrative status of your cancer centre Appendix Ill OECI Accreditation and Designation 27 1 4 7 at national level 1 4 7 1 Is your cancer centre part of a formalised network of institutions at regional level Presence of European or International Affairs Collaboration General accreditation by National Accreditation Organisation or other organisation 1 4 8 1 5 1 5 1 E92 1 5 3 1 5 4 1 5 5 Year of accreditation Distribution areas and budget of patients regional of patients national of patients international Planned annual budget for health care X in last year available Planned annual budget for research X in last year available 28 OECI Accreditation and Designation Appendix III 2 Infrastructures 2 1 Infrastructures with a focus on cancer care 1 of 7 2 1 1 per year x surgery medical radiation paediatric Haematol
69. 3 3 Human resources 3 3 3 1 Please specify the number of FTE gastro enterologists pneumonologists respiratory physicians gynaecologists haematologists paediatricians psychiatrists anaesthesiologists infectious disease specialists geneticians dermatologists pharmacist pharmacologists geriatricians neurologists intensive care specialists medical oncologists X cardiologists endocrinologists urologists plastic surgeons Appendix III OECI Accreditation and Designation 35 3 4 Human resources 4 3 4 1 Pathology Technicians Pathologists Please specify the number of FTE 3 4 2 Nuclear medicine technicians in physicians in physicists engineers nurses in nuclear medicine nuclear medicine nuclear medicine Please specify the number of FTE 3 4 3 Radiology Radiologists technicians in radiology nurses in radiology Please specify the number of FTE 3 4 4 Radiotherapy radiation therapists dosimetrists radiation technicians in radiotherapy Please specify the number of FTE 3 4 5 Supportive care Dieticians psychologists nutricians speech physiotherapists stoma social therapists therapists workers Please specify the number of FTE 36 OECI Accreditation and Designation Appendix III 4 Research Outside scope of Cancer Units 4 1 Research domains 4 1
70. 3 Care H 4 Research innovation and development H ad 5 Teaching and continuing education C 6 Patient related The first line shows the standard and the answer given by the centre you can read the complete standard by clicking the text of the question 3 4 1 Pain service Standard 5 w Click to insert your comments on the standard Question related to standards Does the cancer centre have a protocol guideline for pain control If the institute added a not the text cloud will be dark grey Click the icon to read the note of the institute If the institute added an improvement point click br If the institute added a document s click here Partially No Not Delete Mar applicable The cancer centre applies uses e e C B r guidelines regarding pain treatment for patients with cancer Auditor score femke auditor E C c a r Space for auditor to add your assessment Beneath the score of the centre the space for the auditor can be found to add an assessment of the topic You can score the question by clicking on the appropriate answer You can add notes notes in the same way as reviewing the institutes remark and you can place items on the discussion list by ticking the box 56 OECI Accreditation and Designation Appendix VI If an institute added a note to the standard to support the answer you can read the first line of the note underneath the
71. 4 3 1 2 Do you have a Unit of epidemiology 4 3 1 3 Do you have a biostatistic unit 4 3 1 4 Do you have a Unit of health economy 4 3 1 5 Do you have a data management unit trial bureau 4 3 1 6 Do you have a local cancer registry 4 3 2 Number of studies active that is open to patient accrual during year x X 4 3 3 Number of studies activated in year x Phase Phase Il Phase Ill Phase IV 4 3 4 Number of new investigator initiated local trials Percentage of new investigator initiated local trials 4 3 5 Number of new investigator initiated national trials Percentage 4 3 6 Number of new investigator initiated international trials Percentage 4 3 7 Number of new clinical trials with external industrial sponsor Percentage 4 3 8 Number of new patients in clinical trials indicator number of new patients included in clinical trials Number of new patients in the institute 4 3 9 Does your cancer centre have research collaboration with other cancer centres Yes No 4 3 9 1 at national level 4 3 9 2 at international level 38 OECI Accreditation and Designation Appendix Ill 4 4 Research budget including basic clinical translational 4 4 1 Total research budget cancer centre X 4 4 2 Nr of EU grants Nr of EU grants Public funding Charities unrestricted Industrial running in
72. 5 4 of 28 e Items for screening 5 4 of 28 e Designation Decision Schedule 5 5 of 28 E tool 5 10 of 28 e User manual institutes Appendix V 43 Follow up of accreditation 5 26 of 28 Glossary 1 2 of 2 Go No go 5 13 of 28 Improvement plan 5 24 of 28 OECI Executive Board OECI Board 3 1 of 8 OECI Accreditation and Designation 3 1 of 8 e Group A amp D Group 3 1 of 8 e Board A amp D Board 3 2 of 8 e Management Unit A amp D MU 3 3 of 8 e Committee A amp D Committee 3 4 of 8 e Advisory Group 3 5 of 8 Timeline A amp D process 2 1 of 2 Peer review report 5 22 of 28 Project plan self assesment cancer institute Appendix II 3 Self assesment 5 9 of 28 Step 1 Application of a cancer institute in the programme 5 1 of 28 Step 2 Payment stage 1 fee 5 7 of 28 Step 3 Explanatory visit and preliminary designation result 5 8 of 28 Step 4 Self assesment 5 9 of 28 Step 5 Go no go decision 5 13 of 28 Step 6 Payment stage 2 fee 5 14 of 28 Step 7 Peer review visit and designation check 5 15 of 28 Step 8 Reporting 5 19 of 28 Step 9 Formulate improvement plan 5 24 of 28 Step 10 OECI A amp D Certificate 5 25 of 28 Figures Figure 1 Timeline A amp D process 2 1 of 2 Figure 2 Organisational structure 3 2 of 8 Figure 3 Step 1 Application and designation screening 5 1 of 28 Figure 4 Step 4 Self assesment 5 9 of 28 Figure 5 Step 7 Peer review visit and designation check 5 15 of 28 Figure 6 Step 8 Reporting 5 19 of 28 Figure 7 Week 1 6 Reporting by t
73. CI President and the chair of OECI A amp D Board 3 1 7 2 Relation communication between the OECI A amp D Group and OECI General Affairs Manager and OECI Coordinating Secretariat liaison office Contact about the monthly newsletter annual programme General Assembly conferences and brochures and the annual OECI report Providing overview of the income expenditure to the OECI Executive Secretary every 6 months Providing the OECI Executive Secretary with the original invoices with attached the bank payment receipts in case of travelling by flight also the boarding passes must be added once a year or whenever requested 3 1 7 3 Relation communication between the OECI A amp D Board and OECI General Assembly The annual General Assembly has the following powers in relation to OECI A amp D Board Adoption of the annual accounts Approval of the annual report Adoption of the total budget and plan of activities for the following year Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 5 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 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 i
74. I Accreditation and Designation Appendix II 1 1 4 Cancer data registration institutional level Are the data on the patients types of cancers recorded in an institutional cancer database 1 1 4 1 Yes Mostly Partially No not applicable 1 1 4 1 1 The number of new oncology patients is known at an institutional level 1 1 4 1 2 The number of new cases for each type of cancer is known at an institutional level 1 1 4 1 3 There are diagnostic treatment and outcome data on patients with cancer available annually at an institutional level 1 1 4 1 4 The data are reported and analysed by a multidisciplinary group with recommendations for improvement of care 1 1 5 Complications registry Have agreements been reached concerning keeping and discussing a complications registry 1 1 5 1 Yes Mostly Partially No not applicable 1 1 5 1 1 There are specific protocols for reporting and recording of complications 1 1 5 1 2 The data are analysed at an institutional level 1 1 5 1 3 After analysis improvement measures are developed and action plans implemented in agreement with the departments concerned 1 3 Resources and materials 1 3 1 Cytostatic drugs prescription preparation and distribution Have agreements been reached concerning the prescription preparation and distribution of cytostatic drugs 1 3 1 1 Yes Mostly Partially No not applicable
75. March 2011 Planned peer review Early May 2011 Planned end date Communication reporting method To When time Method Owner Board of the institute e mail written form meeting Steering committee e mail written form meeting Project team e mail written form meeting Quality committee e mail written form meeting Others Staff Patients Intranet Institutional information media Communication of the final self assessment results To When time Method Participants Date at end of self How assessment period Which extra means are necessary Time considered needed Project leader in the institute OECI Accreditation Coordinator Time project members for each person Time blanks exercise for participants Pending further assessment according to identified needs Financial means Pending further assessment according to identified needs Planning payment of fee stage 1 and 2 Other resources e g training education meeting costs Pending further assessment according to identified needs 42 OECI Accreditation and Designation Appendix IV Appendix V Self assessment user manual for institutes 1 Log in Go to http oeci selfassessment nu AOEC OECI DETTY cick to go to tne ULEC Designation E tool Oacuesanon or Esasen Cancer bermris Prog sami Accreditation X Designation proce
76. Reporting by the auditors Process additional notes in the e tool Executor OECI Auditor The auditors have one week after the peer review to deliver additional scores and notes of the peer review interviews tours and presentation in the e tool Auditors deliver the scores and notes in the e tool arranged under the appropriate standard Auditors have one week after the peer review to deliver the short descriptions for each designation item and the final designation conclusion The OECI Coordinator processes the notes of the peer review in the first draft of the report The auditors are also asked to draw a list of strengths and opportunities per chapter of the standard This list will be discussed together with the feedback and comments of the cancer institute in week 11 12 Make draft report Executor OECI A amp D Coordinator In week 2 after the peer review the A amp D Coordinator will formulate the first draft report The A amp D Coordinator e Analyses the individual scores of the auditors and make a list of the deviations e Analyses the notes of the auditors per standard e Proposes the final text that supports the score of each standard e Makes a list of the standards that shall be discussed with the audit team The A amp D Coordinator discusses the first draft with the Executive Manager The A amp D Coordinator sends the draft to the audit team Owner OECI Organisation o
77. TEP 6 Payment stage 2 fee tp STEP 7 Peer revieve Month 8 10 Month 10 13 Sp STEP 8 Reporting Cancer centre Month 16 STEP amp Formulate improvement plan STEP 10 A amp D Certificate decision A ioe Go One year after Follow up certification op 4 years after End of A amp D round certification A Timeline A amp D process Owner OECI Organisation of European Cancer Institutes Chapter 2 Timeline of the OECI A amp D process Status Revised 24th January 2011 A amp D Working Group Page 1 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 2 1 1 General explanation of the ten steps The OECI A amp D Programme is offered by the OECI therefore the membership to the OECI is compulsory for those who want to apply to the programme Information about the OECI membership can be found on the following site www oeci eu STEP 1 Application and designation screening It takes at least 5 months from the application till the beginning of the self assessment period Within this period the institute applies to the programme through the electronic application on the website http oeci selfassessment nu including the cancer institute s judgement on the designation type The application will be examined by the OECI Accreditation and Designation A amp D Board After approval the designation screening takes place to assess the preliminary designatio
78. ach 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 amp 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 Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 6 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 3 2 3 OECI Auditor Profile A
79. air Follow up of the A amp D programme budget Confirming payments of institutes to the institute and Executive Manager Submitting to the A amp D Chair all invoices and reimbursement claims for a signature Making the reimbursements of travel expenses of the auditors and A amp D Group members through online payment within 10 working days unless absent within receipt of all original receipts and reimbursement claims Making the payment of the invoices regarding the A amp D Programme through online payment within 10 working days unless absent within receipt of all original invoices Coordinating the A amp D finances with the OECI Office and providing follow up status of the account sending all the original receipts and invoices on a yearly basis to the OECI Office for the accountant of the OECI Other Archiving all the documents of the programme Producing documents and presentations concerning the A amp D programme 3 1 5 OECI Accreditation and Designation Committee The Accreditation and Designation Committee A amp D Committee consists of five persons from different institutesand countries and with different backgrounds related to cancer care The A amp C Committee is coordinated by the Executive Manager A list with the names of the current A amp D Committee is published on http oeci selfassessment nu Profile Trained as an auditor and experiences as auditor Accreditation knowledge a
80. al options Appendix V OECI Accreditation and Designation 51 tena oo EERE o Print only the questions or Format the full results Fte format iwcrosart word z Peper forent ae Print in Word or PDF Ortentation Portret j Size A4 or A3 View Portrait or Landscape F Show page numbers F toute sided Footer ECI Quatitative Questionnaire v3 08 11 2010 Tithe page F Show titie page Tite fOECt Quaiitati ve Questionnaire v3 Sabtide Questions Show F Start eaeh chapter at anew page n Show help F Show standards F show mints Click for other options r Space for nores D Space for recommendations Space for documents Z Bookmarks 52 OECI Accreditation and Designation Appendix V Appendix VI User manual e tool for auditors This user manual gives an explanation of how OECI auditors can use the OECI electronic tool The great advantage of the tool is that the auditors of a team can communicate with each other regardless of their physical location An auditor can prepare a peer review individually by analysing the questionnaires and documents and an auditor can add notes to questions which are unclear or which the auditor would like to discuss with the audit team 1 Log on AOEC OECI Accreditation and Designation Oncaesanon oF Exnorean Cancer lesrireres Progra mme Exworcun Econom burenesy Ceoorme Home tool Accreditation A Designation process One effort two benefits ISQUA 2010 and ESMO 2970 prese
81. als 4 1 3 1 5 Itis the task of the unit to coordinate the clinical research activities as well as their funding 4 1 3 1 6 It is the task of the unit centralise the collection of the information about the trials and patients included 4 1 3 1 7 It is the task of the unit to provide and update information about the trials to all departments and external partners 4 1 3 1 8 Itis the task of the unit to assist in the conduct and monitoring of clinical trial activities 4 1 3 1 9 It is the task of the unit to provide an annual report on clinical trial activities 18 OECI Accreditation and Designation Appendix II 4 1 4 Periodical policy review Is there a periodical research policy review 4 1 4 1 Yes Mostly Partially No not applicable 4 1 4 1 1 There is a periodically defined research policy and research strategy plan 4 1 4 1 2 The research policy and research strategy plan are integrated into the general activities of the cancer centre 4 1 5 Scientific interaction and integration Is there a structure for integrating and stimulating the scientific interaction 4 1 5 1 The cancer centre promotes co operation between researchers and clinicians through Yes Mostly Partially No not applicable 4 1 5 1 1 Organised and formalised activities 4 1 5 1 2 Regular information and meetings about research ac
82. amme in the cancer centre through colloquia seminars or theme specific conferences 4 4 1 1 2 Scientific programmes are used to guarantee that results from research will be translated into daily practice timely e g diagnostic tools treatment or prevention 4 4 2 Teaching programme for PhD students Is there a teaching programme for PhD students 4 4 2 1 4 4 2 1 1 There is a teaching programme for PhD students 4 4 3 Transfer of new scientific information to clinical practice Is there a procedure for the transfer of new scientific information to clinical practice 4 4 3 1 4 4 3 1 1 There is a procedure that guarantees that results from research will be translated into daily practice timely e g diagnostic tools treatment or prevention 4 5 Safeguarding the quality system 4 5 1 Periodical site visit review Is there a periodical site visit review of the total research organisation 4 5 1 1 There is a periodical review and or site visit with external reviewers of 4 5 1 1 1 the total research organisation 4512 each research group team activities 4 5 1 1 3 clinical translational research 4 5 1 1 4 research support facilities Appendix Il OECI Accreditation and Designation 21 5 Teaching and continuing education 5 1 Policy and organisation Does the cancer centre analyse the training needs to define an annual or multi annual prog
83. and Designation Board Version 16 February 2011 5 2 Step 2 Payment stage 1 fee The institute receives the first payment order after approval of the application and the designation screening and before the explanatory visit Tasks of the Executive Manager Sending invoices to the institutes including the signed A amp D Agreement Controlling the payments of the institutes Providing the A amp D Chair and A amp D Secretary with a copy of invoices sent to the institutes Tasks of the A amp D Secretary Confirming payments of the institutes to the institute and Executive Manager The total fee depends on the designation type of the institute Stage 1 Stage 2 Total Cancer Unit 5 000 15 000 20 000 Clinical Cancer Centre 5 000 25 000 30 000 Comprehensive Cancer Centre CCC 5 000 25 000 30 000 The fee of stage one is equal for all types of institutes and covers primarily the costs for application and designation screening explanatory visit use of the e tool during the self assessment period the OECI support during the self assessment period the organisation of meetings for the A amp D Committee and A amp D Board for the go decision and labour costs of the A amp D Management Unit Difference in fee The peer review visit in a Cancer Unit possibly takes one day instead of two full days in clinical cancer centres and CCC s
84. and advice from the multidisciplinary meeting will be evaluated and by whom Appendix Il OECI Accreditation and Designation 9 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 Yes Mostly Partially No not applicable 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 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 Yes Mostly Partially No not applicable 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 certifi
85. and neck cancer nasapharynx C11 head and neck cancer thyreoid C73H head and neck cancer others 30 OECI Accreditation and Designation Appendix Ill 2 6 Infrastructures with a focus on cancer care 6 of 7 2 6 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients haematological malignancies Hodgkin Lymphoma C81 haematological malignancies Non Hodgkin Lymphoma C82 haematological malignancies Myeloma C90 haematological malignancies All leukaemia neuro oncological Central nervous system C71 C72 neuro oncological others 2 7 Infrastructures with a focus on cancer care 7 of 7 2 7 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients paediatric malignancies all cancers age 0 lt 15 bone and soft tissue tumours primary bone C40 bone and soft tissue tumours Soft tissue C49 bone and soft tissue tumours melanoma of the sk
86. ans for research activities 4 3 1 1 4 Funding of research activities follows clearly defined procedures 4 3 1 1 5 The use of financial resources and accounting of research activities is controlled monitored and reported according to rules 4 3 2 Intellectual property and innovation Is there a policy for the protection of intellectual property 4 3 2 1 4 3 2 1 1 There is a strategy for innovation 4 3 2 1 2 There is support for protection and exploitation of intellectual property 4 3 2 1 3 There is support for business development of research projects 4 3 2 1 4 There is a technology transfer service available 4 3 3 Biobank 4 3 3 1 Yes Mostly Partially No not applicable 4 3 3 1 1 The cancer centre has a policy for biobanking patient related samples 4 3 3 1 2 There is a SOP defining the collection the storage the registration and the use of the biological samples 4 3 3 1 3 There is a centralised registration of the data related to the biological material 20 OECI Accreditation and Designation Appendix II 4 4 Process control 4 4 1 Structured scientific programme Is there a structured scientific exchange programme in the cancer centre colloquia seminars theme specific conferences 4 4 1 1 Yes Mostly Partially No not applicable 4 4 1 1 1 There is a structured documented and up to date scientific progr
87. asks of the A amp D Secretary Confirming payments of institutes to the institute and Executive Manager The total fee depends on the designation type of the institute Stage 1 Stage 2 Total Cancer Unit 5 000 15 000 20 000 Clinical Cancer Centre 5 000 25 000 30 000 Comprehensive Cancer Centre CCC 5 000 25 000 30 000 The fee of stage two is not equal for different designation types The fee covers primarily the costs for OECI support to the audit team to prepare the peer review visit organizing the preparation meeting for the audit team organizing the peer review OECI support to prepare the institute for the peer review visit OECI support to the auditors to make the peer review report organizing A amp D Committee meetings and A amp D Board meetings printing and sending the report and the A amp D Certificate follow up of accreditation one year after certification and labour costs of the A amp D Management unit Difference in fee The peer review visit in a Cancer Unit possibly takes one day instead of two full days in clinical cancer centres and CCC s The peer review visit in a Cancer Unit does not include the full set of standards Standards related to chapter 4 Research innovation and development are not assessed The audit team possibly includes less than four auditors Note lf there is a discrepancy between the designation judgement of the
88. ave agreements been reached on the harmonisation of integrated care between the various disciplines involved in the diagnosis treatment and counselling of oncology patients 1 4 9 1 Yes Mostly Partially No not applicable 1 4 9 1 1 The responsibilities of the different disciplines involved in the diagnosis of the patient in the cancer centre are described 1 4 9 1 2 The responsibilities of the different disciplines involved in the treatment of the patient in the cancer centre are described 1 4 9 1 3 The responsibilities of the different disciplines involved in the follow up of the patient in the cancer centre are described 1 4 9 1 4 The multidisciplinary team advises on the inclusion of patients in clinical trials 1 4 9 1 5 The name of the physician responsible for the coordination of the care of the patient is defined and communicated to the patient 1 4 10 Selection criteria for the oncology team meeting Are the selection criteria concerning which patient should be discussed in the multidisciplinary setting clear and documented 1 4 10 1 Yes Mostly Partially No not applicable 1 4 10 1 1 Criteria are defined for the selection of patients to be discussed in the multidisciplinary team meetings 1 4 10 1 2 These selection criteria are clear documented and based on a consensus between the different disciplines 1 4 11 Procedure for the oncological multidisci
89. be distinguished Cancer Unit Specialised Clinical Cancer Centre Cancer Research Centre and Comprehensive Cancer Centre CCC The definition of each category is given in Table 1 The type of cancer organisation indicates the comprehensiveness of the services and the degree of specialisation The objective of designation A designation system in combination with an exclusive OECI accreditation programme for each designation type of cancer centre will create platforms in which synchronization and benchmarking of cancer institutes will be possible on a European scale Definitions of the designation categories are Cancer Units are defined as clinical facilities or hospital departments covering at least radiotherapy and medical or surgical oncology Additionally they have a formalized collaboration with other hospital specialties The Clinical Cancer Centre is characterised by the clinical capacity covering a sufficient degree of all medical surgical and radiotherapy services and occasionally a limited degree of clinical research The Cancer Research Centre is characterised by the capacity in cancer research focusing on one or more areas in the field of fundamental and translational oncology The Comprehensive Cancer Centre CCC is probably the hardest category to define as many different interpretations on a CCC already exist Based on available information and many definitions on the concept of a CCC the following
90. cation 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 Poneke Patients or patients relatives should be part of these organisations 10 OECI Accreditation and Designation Appendix II 1 5 2 Quality and risk management and safety requirements 1 5 2 1 1 5 2 1 1 There is a patients committee or association for consultative advice about quality of care and risk management 1 2A There is a preventive maintenance programme for equipment and access to accurate and reliable diagnostic tests 1 5 2 1 3 There is a monitoring system for the appropriate use of diagnostic services 1 5 2 1 4 There is a monitoring system for the appropriate use of radio therapeutic services
91. cent pian not older than five ONS contiruing 5 e yems Click on all questions for this list Choose one of the options All questions and the show tree will only show the marked or Mandatory unanswered Marked Unanswered 50 OECI Accreditation and Designation Appendix V 3 Quantitative questionnaire Questionnaires 2 OEC Qualitative 08 08 osar W s t jail ae o TT Questionnaire v3 2009 2010 264 100 pt lt E amp L E ia W lt 7 De CEC Quantitative 08 08 30 06 Mo 662 ee ga PANI 0 k Questionnaire v2 2009 2010 1 1 Cancer centre Qe Menegeme t Sure Concer contre strectere Cissrdution evees ond Sudge Project OECI Quality Improvement Project Working Group Accreditation WGA Nome of the concer cectre ct 2 Itnfrestructeres amp 3 Humes resources E M Reveores v Gjt vaten Address The show tree with all The quantitative questionnaire has hanters arid domiaiti also an option for adding notes to enablers sara Corals clarify an answer lt a Questionnaires Documents Report Progress Start es OEC Qualitative 08 08 osar M264 t pa i py ve T Questionnaire v3 2009 2010 264 100 amp g A 2 ig t es CECI Quantitative 08 08 30 06 Wo 662 i oy gt Questionnaire v2 2009 2010 0 amp The following screen appears with sever
92. cer centre logistics research education multidisciplinary teams are part of the annual report 1 1 2 Cooperation with universities 1 1 2 1 The cancer centre has formal cooperation or agreement with at least one university for Yes Mostly Partially No not applicable 1 1 2 1 1 care activities WPI 2 educational activities 1 1 2 1 3 research activities 1 1 3 Cooperation with external partners Have agreements been reached about the allocation of tasks such as a hospital or radio therapeutic institute in the case of referrals 1 1 3 1 Yes Mostly Partially No not applicable 1 1 3 1 1 Cooperation arrangements with other cancer centres are clearly documented in written agreements covering the goals of the cooperation tasks responsibilities and competences of the cancer centre and the cooperating partners 1 1 3 1 2 There are written agreements with home care organisations 1 1 3 1 3 There are written defined and documented cooperation arrangements with general practitioners 1 1 3 1 4 There are written agreements with nursing home rest house palliative care institutions etc 1 1 3 1 5 There are written agreements with special cancer care service providers such as radiotherapy centre pathology laboratory specialised surgery unit etc 4 OECI Accreditation and Designation Appendix II
93. cer patients within Europe an equal access to high quality of cancer care Helping European cancer institutes to implement a quality system for oncology care using the OECI standards and peer review system There have been two rounds of pilot projects in eight different cancer institutes between 2006 and 2008 In the first round four cancer institutes used a tool for self assesment In the second round four other cancer institutes were involved to use the improved self assesment tool and a team of auditors visited three of the institutes for an assessment peer review on site The pilot projects resulted in improvement and development of the accreditation programme the electronic self assesment tool and validation of the quality standards The programme has been launched in October 2008 OECI standards Standards describe the demands the quality system has to meet and what has to be arranged The OECI accreditation programme is based upon the OECI standards for high qualitative cancer care The standards are validated through the pilot projects The standards are translated in two questionnaires a qualitative and a quantitative to assess the current quality in a cancer institute Both are integrated in an electronic tool e tool for self assesment The content of the questionnaires is accessible on the website http oeci selfassessment nu cms node 53 OECI peer review visit An OECI peer review is a systematic and independent examinatio
94. cess control 10 30 Chapter 4 Research innovation and developments 14 45 17 4 1 Policy and organisation 7 25 4 3 Resources and materials 3 12 4 4 Process control 3 4 4 5 Safeguarding the quality system 1 4 Chapter 5 Education and teaching 4 19 7 5 1 Policy and organisation 1 7 5 4 Process control 3 12 Chapter 6 Patient related 6 30 11 6 4 Process control 4 21 6 5 Safeguarding the quality system 2 9 6 4 3 Informing patients about results treatment and counseling Sa asi Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counseling in terms of how it is done and what it means 5 x Yes Mostly Partially No Not Delete Markeer i Q The cancer centre has procedures or guidelines 0 0 regarding information transfer on diagnostics treatment follow up and supervision of the patient Sub standard Possible scores The score is an indicator for the stage of implementation of each item of the standard The scoring system is based on the Plan Do Check Act circle or Deming circle These four stages of implementation are translated in the following possible answers e Yes means that the indicator of the standard has been implemented on a wide scale in the cancer institute and the Deming cycle is completed at least twice gt in third cycle e Mostly means that the indicator has been implemented in most of the critical places in the
95. chologist 2 14 1 5 Anaesthesist 2 14 1 6 Physiotherapist 2 14 1 7 General practitioner 2 14 1 8 Social worker 2 14 1 9 Dietician Appendix Ill OECI Accreditation and Designation 33 2 15 Facilities 2 15 1 On site Access to Not available 2 15 1 1 Do you have a tumour bank facility 2 15 1 2 Do you have a central pharmacy 2 15 2 Number of operating rooms excluding ambulatory services specific to oncology 2 15 3 Number of IC beds specific to oncology 2 15 4 Access to Not available 2 15 4 1 Do you have other specialised techniques on site 2 15 5 Do you have other specialised techniques on site Yes No 2 15 5 1 laser therapy 2015 52 Laparoscopy 2 15 5 3 sentinel node 2 15 5 4 Intra Operative Chemo Therapy 2 15 5 5 hyperthermia 2 15516 isolated limb perfusion 2 15 5 7 radio frequency ablation 211059 Others 34 OECI Accreditation and Designation Appendix III 3 Human resources 3 1 Human resources 1 3 1 1 Per doctor Per nurse day Per nurse night Legal number of hours for 1 Full Time Equivalent FTE X X X 3 1 2 Total FTE of employees in the cancer centre 3 1 3 Total FTE of employees dedicated to cancer patients 3 2 Human resources 2 3 2 1 Please specify the number X X X X X X X X X X of FTE surgeons
96. cology 2 1 Number of inpatient beds for overnight stays for surgery oncology medical oncology radiation therapy paediatric oncology haematology other units and in total for oncology in year x 2 1 Number of ambulatory day care beds chairs in year x 2 1 FTE physicians dedicated to oncology 2 1 Radiology In detail number of CT scanners number of facilities for MRI number of MRI spectroscopy and number of mammography 2 9 Legal number of hours for 1 Full Time Equivalent FTE In detail Per physician per nurse day per nurse night 3 1 Number of FTE surgeons In detail breast surgery urologic surgery thoracic surgery digestive surgery neurosurgery gynaecological surgery head and neck surgery soft tissue surgery orthopaedic surgery plastic and reconstructive surgery 3 2 Number of FTE from medical oncology 3 3 Number of studies active that is open to patient accrual during year x 4 3 2 Number of studies activated in year x In detail Phase Phase Il Phase Ill and Phase IV 4 3 3 Total research budget of the cancer institute 4 4 1 Research funding sources total amount received in year x In detail Number of EU grants running in year x number of EU grants coordinated in year x public funding charities unrestricted grants and industrial partnership funding 4 4 2 Number of peer reviewed publications per year year x national 4 4 4 Nu
97. conclusions strengths and opportunities of the cancer institute for the final report Process conclusions teleconference Executor OECI A amp D Coordinator The A amp D Coordinator will process the conclusions of the teleconference which will include Corrections to make with regard to the comments and feedbacks of the cancer institute The formulated general remarks strengths and opportunities conclusions The A amp D Coordinator will send the third draft to the chair of the audit team for a final check Analyse draft final report Executor OEC A amp D Committee The A amp D Committee will receive the draft final report with a proposal for the conclusions strengths and opportunities from the audit team The A amp D Committee will analyse the conclusions strengths and opportunities that are drafted by the audit team and give final advice to the Accreditation Board about the complete final report If the A amp D Committee makes major changes in the report the coordinator of the A amp D Committee the Executive Manager will send the report for a final check to the chair of the audit team If there are only minor changes the report will be sent directly to the A amp D Board for the final approval Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 22 of 28 Appr
98. de the descriptions to support the designation type The auditors have a personal username and password to enter the e tool and to go to the peer review report of the institute Auditors can process their notes in the e tool at the same time The answers need to provide evidence proof for the scores given to the standard The report needs to be Recognisable Concrete Compact Separate minor and major points Strength and weaknesses from appendices in text Objective statements Examples Reasonable arguments for subjective statements Unanimously agreed by the auditors team Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 18 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 8 Step 8 Reporting After the peer review visit it will take about 4 months to finish the final peer review report figure 5 The reporting period will be split in two phases In week 1 to 6 the auditors will be working on the draft report This is outlined and explained in the sub process Reporting by audit team figure 6 Week 1 6 Reporting by audit ob Cancer centre Week 7 to 10 Check draft peer Comments centre Y review report _ OFC A amp D Coordinator J Forward comments CECI Chair audi
99. development Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 7 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 3 Step 3 Explanatory visit and preliminary designation result During the explanatory visit two delegates of the OECI A amp D Group will meet with delegates of the institute Board of directors Heads of Departments Head of Nurses Quality Managers IT expert for e tool All other interested staff in the institute Generally the visit includes three parts 1 A general presentation for all staff in the institute interested in the OECI Programme 2 A meeting with the key persons project group in the programme to discuss the steps and the template project plan doc 5 in detail 3 A tour in the institute During the presentation and meeting the following subject will be explained and discussed The accreditation and designation programme The preliminary designation type according to the designation screening and the judgement of the institute The designation type is the starting point for accreditation Timelines of the programme Self assesment period and access to the e tool Project plan of the institute doc 5 Required documents doc 9 for peer review Obligations of the canc
100. dual preparation of the auditors team meeting includes Analysing the self assesment reports of the cancer institute e quantitative report including scores notes and improvement points e quantitative report Analysing the documents the cancer institute has attached to the e tool Formulation of main topics for the peer review visit Designation checklist doc 34 Booking the hotel for the auditors meeting Executor OECI Secretary The OECI secretary will book the hotel for the auditors for the auditors meeting and for the peer review visit Complete peer review agenda Executor Cancer institute While the audit team is getting ready for the auditors meeting the institute will prepare and complete the peer review visit agenda The concept agenda will be approved by the auditors chair during the self assessment period The concept agenda has to be completed by the cancer institute The auditors will have interviews with employees of the cancer institute The institute has to plan the persons from the requested departments and the location room where the interviews will take place Completion deadline 1 week before the auditors preparation meeting Sending the agenda Executor OECI A amp D Coordinator The agenda of the preparation meeting will be sent one week before the meeting and will include the concept peer review agenda Owner OECI Organisation
101. dures numbers RT Y N Y N Y N RT referred numbers patients patients gastrointestinal cancer oesophagus C15 gastrointestinal cancer stomach C16 gastrointestinal cancer colon C18 gastrointestinal cancer rectum C20H gastrointestinal cancer liver C22 gastrointestinal cancer pancreas C25 gastrointestinal cancer Others 2 4 Infrastructures with a focus on cancer care 4 of 7 2 4 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways _ patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients gynaecological cancer ovary C56H gynaecological cancer cervix C53 gynaecological cancer endometrial C54 gynaecological cancer Others 2 5 Infrastructures with a focus on cancer care 5 of 7 2 5 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways _ patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients head and neck cancer larynx C32 head and neck cancer hypopharynx C13 head and neck cancer oropharynx C10 head
102. e and preliminary designation type Approve disapprove the self assessment results of cancer institute to plan a peer review visit on site go no go decision Approve disapprove the final peer review report including designation type Approve disapprove the Improvement plan of a cancer institute Dealing with and solving major issues between the A amp D Management Unit and cancer institute in case of complaints or other issues Decision making To increase independent examinations in essential steps in the A amp D process the A amp D Board will be advised by the OECI A amp D Committee 3 1 5 The A amp D Committee will propose their conclusions on the essential steps to the OECI A amp D Board as input for final approval The advice of the A amp D Committee is not binding Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 2 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 3 1 3 1 OECI Accreditation and Designation Board Chair The OECI A amp D Chair is leading the activities of the OECI Accreditation and Designation group chairing the OECI Accreditation Designation Board and representing the group in the OECI Board The chair is a co opted member of the OECI board Assessing quarterly income expenditure compared t
103. e questionnaires the following screen appears COmpARSssS How to start Questionnaires INTRODUCTION The OECI Accreditation Project A Process to Evaluate and improve Quality in European Cancer Centres The OFC helps health care professionals and Cancer Centres to improve the organisation of care To this end the OFC accrediation working group has developed norms centona and ha them in an electronic self evaluation guide By using this guide cancer centres can find out w Questionnaires es CECI Qualitative 08 08 OS t1 M264 r ce gt Questionnaire v3 2009 2010 264 100 pt a L p TE r t D CEC Quantitative 03 08 30 06 Wo 662 R pi um ere onnaire v2 2009 2010 0 amp Click to open the questionnaire 44 OECI Accreditation and Designation Appendix V 2 Three steps to fill out the qualitative questionnaire e Step 1 Give a score to all items in the questionnaire The quality questionnaire consists of Chapter 1 General standards strategic plan and 26 121 47 general management 1 1 Policy and organisation 5 22 1 3 Resources and materials 2 8 1 4 Process control 12 54 1 5 Safeguarding the quality system 7 37 Chapter 2 Screening and primary prevention and 5 19 7 health education 2 4 Process control 5 19 Chapter 3 Care 10 30 11 3 4 Pro
104. edium one year result for result low Names and department 1 1 1 Check implementation improvement plan The A amp D Board will receive a report of the cancer institute with the progress of the implementation of the goals and activities set in the improvement plan Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 27 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Intermediate self assessment optional Executor Cancer institute The A amp D Programme fee includes four years access to the self assessment e tool The institute has the option to perform an intermediate self assessment to measure the improvements according to the OECI Quality Standards two years after the peer review visit Note This intermediate self assessment will not be analysed by the OECI It will be a voluntary exercise of the institute to check the improvements Start new round A amp D Programme Executor Cancer institute Four years from the date of issue of the previous OECI A amp D Certificate the A amp D Certificate will expire If the cancer institute wants to keep the accreditation and designation it will be necessary to apply for a new round of the A amp D Programme six months b
105. eer review of an auditor the auditor shall sign a confidentiality agreement Conflict of interest form doc 15 Before every peer review each auditor shall sign a conflict of interest form Engagement form for the management of the auditors doc 13 By signing the engagement form the management board of the auditors provides permission to the auditor to perform the peer review Composition sent to the institute Executor OECI A amp D Coordinator The composition of the audit team will be sent to the institute to provide the opportunity to express any potential conflict of interest against one more of the audit team members Auditors reply on invitation Executor OECI Auditor Within the timeframe set in the invitation letter the auditors confirm to the A amp D Coordinator Availability on the date of the preparation meeting Availability on the dates of the peer review Doc 14 Confidentiality agreement Doc 15 Conflict of interest form Signed engagement letter from the management of the auditor Receive confirmation from auditors Executor OECI A amp D Coordinator The OECI Accreditation Coordinator receives the confirmation from the auditors This shall include Doc 13 Signed engagement letter of management Doc 14 Signed Confidentiality Agreement Doc 15 Signed Conflict of Interest Form Check confidentiality agreement auditors Exec
106. efore the certificate expires Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 28 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 6 Where to find the documents needed in the programme The appendix of this manual contains the documents that are useful to start the Accreditation and Designation programme However most documents are available when an institute or an auditor logs in the e tool The following table shows the needed and useful documents and how to access them Documents available for the auditors institutes and the public Nr Name Auditor Applicant institutes Public Doc 1 Application form and designation screening Website Website electronically Doc 5 Template project plan for cancer institute Appendix IV E tool Appendix IV E tool Doc 6 Accreditation and Designation Agreement Send by OECI Doc 7 Template agenda explanatory visit Send by OECI Doc 8 Template payment order stage 1 Send by OECI Doc 9 List required documents E too E too Website Doc 10 E tool user manual institute Appendix V Appendix V E tool Doc 14 Confidentiality agreement E too E too Doc 15 Conflict of interest form E too E too Doc 16 Template peer review agenda E too Doc 19 Temp
107. ember as contact person referent for oncology care 1 4 7 Communication between the members of the supportive care staff What is the focus of the communication between nursing paramedic and supportive disciplines 1 4 7 1 Communication amongst members of the supportive care staff nursing paramedical and supportive disciplines occurs through 1 4 7 1 1 Consultation 1 4 7 1 2 Data transmission 1 4 7 1 3 Transfer of knowledge 1 4 7 1 4 Information and implementation of guidelines Have agreements been reached within the cancer centre concerning who is authorised to refer patients to paramedical and or support disciplines and under what circumstances 1 4 8 1 Yes Mostly Partially No not applicable 1 4 8 1 1 It is made clear for which problems related to cancer and at which moment paramedical disciplines should be consulted 1 4 8 1 2 It is made clear for which problems related to cancer and at which moment supportive disciplines should be consulted 1 4 8 1 3 There are written procedures on the circumstances for calling on and referral to paramedical disciplines 1 4 8 1 4 There are written procedures on the circumstances for calling on and referral to supportive disciplines 8 OECI Accreditation and Designation Appendix II 1 4 9 Multidisciplinary harmonisation integrated care Have agreements been reached on the harmonisat
108. ents with cancer are treated there are nurses trained in oncology 1 4 5 1 2 Anticancer drugs are administered by specially educated oncology nurses 1 4 5 1 3 The cancer centre has nurses with expertise with regard to the tumours treated e g breast colo rectal head and neck gynaecological cancer 1 4 5 1 4 There are procedures describing the tasks and responsibilities of oncology nurses 1 4 5 1 5 Roles and responsibilities of nurses with different expertises oncology palliative care are described regarding special involvement in oncology care 1 4 5 1 6 The nursing discipline has one staff member as contact person for oncology care Appendix Il OECI Accreditation and Designation 7 1 4 6 Roles and tasks of the members of the supportive care staff Have agreements been reached concerning the roles and tasks of the supportive care staff 1 4 6 1 Yes Mostly Partially No not applicable 1 4 6 1 1 Roles and responsibilities for each of the paramedical disciplines are described regarding the involvement in oncology care 1 4 6 1 2 Roles and responsibilities for each of the supportive disciplines are described regarding the involvement in oncology care 1 4 6 1 3 Each of the paramedical discipline has one staff member as contact person referent for oncology care 1 4 6 1 4 Each of the supportive disciplines has one staff m
109. er institute The OECI s role At the end of the explanatory visit the cancer institutes and the OECI delegates agree upon the preliminary designation type of the institute as a starting point for the self assesment period After the explanatory visit the institute Will prepare and plan the self assesment with the project team Will receive an username and password to enter the e tool Project group and project planning The OECI A amp D Group offers a template project plan doc 5 containing the following items Who are involved in the project group professionals and staff from the different departments Planning project group meetings to discuss the progress of the questionnaires Schedule for evaluating the progress and intermediate results to Board of Directors Management Schedule and methods to inform about the progress to all professionals and staff within the institute Deadline for finishing the questionnaires including notes and required documents Moment and method of informing the final results to all professionals and staff The OECI A amp D Group recommends the value of a project team and project plan to raise commitment involvement and responsibility of professionals and staff from different departments This may be useful in all parts of the programme Answering the questions with widely accepted answers during the self assesment period Sharing the results of the self asses
110. ess 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 amp D process Within the EurocanPlatform Programme 7FP Programme all participating Centres will be requested to take part in the OECI A amp 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 amp 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 t
111. eting pathways _ patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients gastrointestinal cancer oesophagus C15 gastrointestinal cancer stomach C16 gastrointestinal cancer colon C18 gastrointestinal cancer rectum C20H gastrointestinal cancer liver C22 gastrointestinal cancer pancreas C25 gastrointestinal cancer Others 2 4 Infrastructures with a focus on cancer care 4 of 7 2 4 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways _ patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients gynaecological cancer ovary C56H gynaecological cancer cervix C53 gynaecological cancer endometrial C54 gynaecological cancer Others 2 5 Infrastructures with a focus on cancer care 5 of 7 2 5 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways _ patients admitted and procedures numbers RT Y N Y N Y N RT referred numbers patients patients head and neck cancer larynx C32 head and neck cancer hypopharynx C13 head
112. evant aspects of oncology to general practitioners 6 4 1 1 3 The written information includes information about diagnostic examinations and methods of treatment 6 4 1 1 4 The written information includes information about clinical trials 6 4 1 1 5 The written information includes information about supportive care complementary care and palliative care 6 4 2 Inform patients on admission Have procedures been established on informing cancer patients about cancer centre admission procedures 6 4 2 1 Yes Mostly Partially No not applicable 6 4 2 1 1 There is detailed information about the admission procedure 6 4 2 1 2 This information is available and communicated to the patient 6 4 2 1 3 The admission procedure is regularly assessed for efficiency 6 4 2 1 4 The cancer centre can accept patients during day and night in the event of an emergency admit them if necessary or refer them to another institute 24 OECI Accreditation and Designation Appendix Il 6 4 3 Informing patients about results treatment and counselling Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counselling in terms of how it is done and what it means 6 4 3 1 6 4 3 1 1 The cancer centre has procedures or guidelines regarding information transfe
113. f 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 11 Follow up There is a period of four years from the date of issue of the certification and the expiring date Within this period the institute will work to achieve the goals of the improvement plan Cancer centre Evaluation form to z 3 months after Evaluation peer __ oy Certification A review ee Evaluaton form to cancer centre 5 months after peer Evaluation by A L review teleconference Cancer centre 1 year after certicaban Send progress report Report progress n date A improvement plan gt improvement plan ora A amp D Board Check implementaton improvement plan Cancer centre 2 years after Optional Intermediate b cernificabon date self assessment Cancer centre gt Within 4 years after Start new round ASD certification date A Prograrrene Figure 9 Follow up of the A amp D Programme Send progress report improvement plan Executor Cancer institute One year after the peer review visit the institute will report the progress of the goals and activities set in the improvement plan to the to the OECI A amp D Board The institute can add a column to the improvement plan Standard Opportunity Action Goal Actions Who is Start Evaluation Dead Priority Progress SMART description involved and date date line high after desired responsible date m
114. f European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 20 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Check draft Executor OECI Auditor The first draft of the report will be send to the audit team to analyse The scores of the auditors The proposed text per standard to support the audit team scores The list of standards with different findings among the auditors in the scores and notes deviations The proposed designation type with the short descriptions for each item The proposed designation conclusion The auditors are requested to give feedback and comments on the draft report Discuss draft by teleconference Executor OECI Chair audit team The A amp D Coordinator will discuss the draft report and feedback of the auditors with the chair of the audit team by teleconference The input of the teleconference is a list of deviations sent by the A amp D Coordinator Make final draft Executor OECI A amp D Coordinator The A amp D Coordinator Processes the conclusions of the teleconference with the chair of the audit team Discusses the final draft with the Executive Manager Sends the final draft to the cancer institute with a feedback and comments form Check final draft Executor OECI Chair
115. f the supportive disciplines has one staff member as contact person referent for oncology care 1 4 7 Communication between the members of the supportive care staff What is the focus of the communication between nursing paramedic and supportive disciplines 1 4 7 1 Communication amongst members of the supportive care staff nursing paramedical and supportive disciplines occurs through 1 4 7 1 1 Consultation 1 4 7 1 2 Data transmission 1 4 7 1 3 Transfer of knowledge 1 4 7 1 4 Information and implementation of guidelines Have agreements been reached within the cancer centre concerning who is authorised to refer patients to paramedical and or support disciplines and under what circumstances 1 4 8 1 Yes Mostly Partially No not applicable 1 4 8 1 1 It is made clear for which problems related to cancer and at which moment paramedical disciplines should be consulted 1 4 8 1 2 It is made clear for which problems related to cancer and at which moment supportive disciplines should be consulted 1 4 8 1 3 There are written procedures on the circumstances for calling on and referral to paramedical disciplines 1 4 8 1 4 There are written procedures on the circumstances for calling on and referral to supportive disciplines 8 OECI Accreditation and Designation Appendix II 1 4 9 Multidisciplinary harmonisation integrated care H
116. features are considered to be essential for this particular category e A highly innovative character and multidisciplinary approach using the potential of basic translational and clinical research and clinical facilities and activities organised in a sufficiently identifiable entity e A direct provision of an extensive variety of cancer care tailored to the individual patient s needs and directed towards learning and A OE Cl improving the professional organisational and relational quality of care Oacanesimen oF Experian Cancer besrrments Errosa Econom bren Grocers e Broad activities in the area of prevention Ragstered nanter OE CHEE 8 001 education and external dissemination x of knowledge and innovation In order to CERTIFICATE OF ACCREDITATION accentuate the differences with other cancer AND DESIGNATION centres a CCC separates itself in the following points OECI e High level of infrastructure expertise hereby certifies that the and innovation in the field of oncology research YOUR cancer INSTITUTE e Maintenance of an extensive network Town Country including all aspects of oncology treatment meets the quality standards for cancer care and research and research and it is therefore designated as e Related to an academic university centre or COMPREHENSIVE CANCER CENTRE is an academic centre issuedon 20100815 Validity date 20120815 Glossary Both questionnaires contain a glossary doc 42 The intention
117. follow up plans 6 4 4 1 7 At discharge information is provided to the patients about contact details with cancer centre Appendix Il OECI Accreditation and Designation 25 6 5 Safeguarding the quality system 6 5 1 Patient satisfaction experiences Does the cancer centre evaluate the patient s satisfaction experiences related to cancer care 6 5 1 1 Yes Mostly Partially No not applicable 6 5 1 1 1 The cancer centre has a survey method for obtaining the patients opinion about their experiences during consultation 6 5 1 1 2 The cancer centre has a survey method for obtaining the patients opinion about their experiences during day care 6 5 1 1 3 The cancer centre has a survey method for obtaining the patients opinion about their experiences during hospitalisation 6 5 1 1 4 The survey is regularly analysed and corrective measures are planned 6 5 1 1 5 There is a group of patients representing patients and serving as a link between the cancer centre and the patients for advisory and consultation 6 5 2 Conciliatory commission for complaints Does the cancer centre have an identified conciliator or a conciliatory commission for complaints related to cancer care 6 5 2 1 Yes Mostly Partially No not applicable 6 5 2 1 1 The cancer centre has a clearly identified conciliator or a conciliatory commission sometimes known as a
118. for patients with cancer lt w Auditor score femke auditor Cc C C 2 B p Appendix VI OECI Accreditation and Designation 57 To view the remarks and the score of the other auditors Questions Note View graphs Feedback a Pain service Does the cancer centre have a protocol guideline for pain control Auditor remarks Auditor remarks Femke auditor 4 The final draft report The Accreditation Coordinator makes a draft report of all the notes remarks scores and strengths and opportunities The auditor will give his her comments and feedback on the draft before it will be send to the institute as explained in the procedures 58 OECI Accreditation and Designation Appendix VI
119. gistration institutional level is Complications registry Standard Oncology policy plan and general report is gt 50 but also needs attentions Standard Cooperation with university needs attention Appendix V OECI Accreditation and Designation 49 e Close the questionnaire if you will not change or add anything else Questionnaires These are the most recent questionnaires Close the book CECI Qualitative 08 08 05 11 E 264 r g aw of gt Questionnaire v3 2009 2010 264 100 12 L L L L L L a CECI Quantitative 08 08 30 06 Mo 662 al gt a gt Questionnaire v2 2009 2010 0 o amp e Other options Mark questions to discuss in project group meetings Make a note for other people working in the questionnaire Show only the marked or unanswered questions Mark questions that you want to discuss with other people Make a note for other people working on the questions fan went Sar eye Sere t wenrerw f men Rae re Quastessere ty sng crganizetic tel polity Sopersticn sih w poperstign ah ma dala egib Comshtatsns eg sumes end mater es 9 contre ot a5 pard ng the qual app cabie Wg S e ans pomery pre 8 E a The board and or the ec c c it eos t0 0 manegement of the cancer centre has an official recent pian not older than five ONS contir
120. gnation Board Version 16 February 2011 Designation questionnaire Executor Cancer institute After the approval of the application in the A amp D Programme the institute continues with the designation screening that will be accessible through the website http oeci selfassessment nu with the same username and password as for the application All items requested for designation are also requested in the quantitative questionnaire for self assesment The institute fills in these items only once The numbers are automatically copied on the quantitative questionnaire The institute fills out all items in the designation screening questionnaire The questionnaire requests the figures of a specific year The institute can state the year from which the figures derived The institute should use the figures of the last completed administrative year An exception to this rule is made when available figures from the last year are asked The numbers between brackets are the question numbers in the quantitative questionnaire Designation screening items Planned annual budget for health care in last year available 1 5 4 Planned annual budget for research in last year available 1 5 5 Number of newly registered diagnosed cancer patients per year year x In detail surgery oncology medical oncology radiation therapy paediatric oncology haematology other units and in total for on
121. gy oncology Number of newly X X X X X X X registered diagnosed cancer patients any type Number of inpatient beds for X X X X X X X overnight stays Number inpatient visits for overnight stays Mean duration of stay for inpatients Number of outpatient visits in consultation Waiting time before 1st visit mean Waiting time treatment decision first treatment mean Number of ambulatory day care X beds chairs Number of ambulatory day hospital patient visits FTE physicians dedicated to X oncology into human resources FTE vacant positions FTE board certified nurses dedicated to oncology FTE vacant positions 2 2 Infrastructures with a focus on cancer care 2 of 7 2 2 1 per year x breast cancer C50 lung cancer C34 urological cancer bladder C67 urological cancer kidney C64H urological cancer Others Male genital organs cancer prostate C61H Male genital organs cancer testis C62 Male genital organs cancer Others Appendix Ill OECI Accreditation and Designation 29 2 3 Infrastructures with a focus on cancer care 3 of 7 2 3 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines meeting pathways _ patients admitted and proce
122. he auditors 5 20 of 28 Figure 8 OECI Accreditation and Designation Certificate 5 25 of 28 Figure 9 Follow up of the A amp D Programme 5 27 of 28 Owner OECI Organisation of European Cancer Institutes Chapter 8 Register Status Revised 24th January 2011 A amp D Working Group Page lof2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Owner OECI Organisation of European Cancer Institutes Chapter 8 Register Status Revised 24th January 2011 A amp D Working Group Page 2 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Appendix I Designation Decision Schedule Not for public release Designation Decision Schedule Nr of beds lt 20 Nr of specialists O and If ves Nr of patients O and Nr of scientific papers gt 40 and Budget research gt 500 k and Budget care lt 500 k Cancer unit or clinical cancer centre or CCC Nr of beds and ambulatory day care beds lt 50 Or Nr of patients lt 500 Or Nr of specialists lt 30 Or Nr of scientific publications lt 10 Cancer unit And Centre covered radiotherapy and medical oncology or surgical oncology Clinical cancer centre or CCC Budget for care gt 5000 k Budget for research gt 3000 k Cancer research Centre
123. he 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 amp 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 amp D with supporting documentation The OECI A amp 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 amp 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
124. ical or outpatient s department where patients with cancer are treated there are nurses trained in oncology 1 4 5 1 2 Anticancer drugs are administered by specially educated oncology nurses 1 4 5 1 3 The cancer centre has nurses with expertise with regard to the tumours treated e g breast colo rectal head and neck gynaecological cancer 1 4 5 1 4 There are procedures describing the tasks and responsibilities of oncology nurses 1 4 5 1 5 Roles and responsibilities of nurses with different expertises oncology palliative care are described regarding special involvement in oncology care 1 4 5 1 6 The nursing discipline has one staff member as contact person for oncology care Appendix Il OECI Accreditation and Designation 7 1 4 6 Roles and tasks of the members of the supportive care staff Have agreements been reached concerning the roles and tasks of the supportive care staff 1 4 6 1 Yes Mostly Partially No not applicable 1 4 6 1 1 Roles and responsibilities for each of the paramedical disciplines are described regarding the involvement in oncology care 1 4 6 1 2 Roles and responsibilities for each of the supportive disciplines are described regarding the involvement in oncology care 1 4 6 1 3 Each of the paramedical discipline has one staff member as contact person referent for oncology care 1 4 6 1 4 Each o
125. ict 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 amp D Board will decide whether the auditor shall be replaced by another auditor Owner OECI Organisation of European Cancer Institutes Chapter 4 Confidentiality and conflict of interest Status Revised 24th January 2011 A amp D Working Group Page lof2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Owner OECI Organisation of European Cancer Institutes Chapter 4 Confidentiality and conflict of interest Status Revised 24th January 2011 A amp D Working Group Page 2 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 Ten steps A amp D process in detail The following paragraphs describe in detail the ten steps towards the A amp D Certificate and the follow up of continuous and comprehensive quality improvements It describes the activities and obligations of each of the parties involved in the A amp D Programme 5 1 Step 1 Application of a cancer institute in the programme Step 1 is the application of the A amp D Programme and filling the designation screening list Figure 3 shows the details of this step Cancer centre Filing out application A ECI A amp D Coordinator Registration of A application form Pore A amp D Board go CC A
126. iew report e Delivering an improvement plan e Delivering a report with the progress and results of the goals set in the improvement plan e Optional Intermediate selfassesment after two years Owner OECI Organisation of European Cancer Institutes Chapter 7 Overview of obligations and tasks of a cancer institute Status Revised 24th January 2011 A amp D Working Group Page lof 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Owner OECI Organisation of European Cancer Institutes Chapter 7 Overview of obligations and tasks of a cancer institute Status Revised 24th January 2011 A amp D Working Group Page 2 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Auditors 3 6 of 8 e Team 3 6 of 8 e Chair 3 6 of 8 e Preparation peer review 5 17 of 28 e Preparation meeting 5 17 of 28 e Designation checklist for auditors 5 18 of 28 e Writing notes 5 18 of 28 e Reporting by auditors 5 20 of 28 Cancer institute 3 8 of 8 e Board of Directors 3 8 of 8 e Contact person cancer institute 3 8 of 8 Criteria for application cancer institute 5 2 of 28 Director cancer institute 3 8 of 8 Confidentiality 4 1 of 2 Conflict of interest 4 1 of 2 Designation
127. iliatory commission sometimes known as a mediator or mediation service or as the complaints officer or complaints department 6 5 2 1 2 The role of the conciliator or the conciliatory commission is to reply to any request for information or complaints from the patients or their families 6 5 2 1 3 The actions undertaken by the conciliator are recorded in a file that is used to produce an annual report 6 5 2 1 4 The conciliator gives feedback on his her findings to the professional who is the subject of the complaint 26 OECI Accreditation and Designation Appendix II Appendix III OECI Quantitative questionnaire Please fill in the following OECI quantitative questionnaire not for public release The italic items are already filled out in the application form And the underlined items are filled out for the designation screening Chapter 4 Research outside the scope of the OECI Accreditation of Cancer Units 1 General Questions 1 1 Cancer centre 1 1 1 Project OECI Quality Improvement Project Working Group Accreditation WGA 1 1 2 Name of the cancer centre 1 1 3 Address 1 1 4 Telephone 1 1 5 Fax 1 1 6 Internet site 1 2 Management 1 2 1 Administrative Director 1 2 2 E mail Administrative Director 1 2 3 Medical Director 1 2 4 E mail Medical Director 1 2 5 Scientific Director 1 2 6 E mail Scientific Director 1
128. in C43 skin cancer Others C44 2 8 Radiotherapy 2 8 1 Number of accelerators for radiation therapy 2 8 2 Number of cobolt units 2 8 3 Resources for proton therapy 2 8 3 1 Do you have resources for proton therapy 2 8 4 Number of conventional RT patients per year 2 8 5 Number of bracytherapy patients per year 2 8 6 Number of IMRT patients per year 2 8 7 Number of IORT patients per year 2 8 8 Number of stereo tactic RT single and fractionated patients per year Appendix Ill OECI Accreditation and Designation 31 2 9 Radiology 2 9 1 Number of CT scanners X 2 9 2 Number of facilities for MRI X 2 9 3 Number of MRI spectroscopy X 2 9 4 Number of mammography X 2 9 5 Waiting time for CT scanners 2 9 6 Waiting time for MRI 2 9 7 Waiting time for mammography 2 9 8 Do you have digitalised imaging PACS 2 9 8 1 2 9 9 Do you have resources for interventional techniques On site Access to Not Available 2 9 9 1 2 10 Nuclear medicine unit 2 10 1 Number of cameras 2 10 2 On site Access to Not available not applicable 2 10 2 1 Pet scan facilities 211012127 pet CT facilities 2 10 2 3 Radio nucleotide treatment facilities 2 11 Laboratory 2 11 1 On site Access to Not available 2 11 1 1 Do you ha
129. ing of research activities follows clearly defined procedures 4 3 1 1 5 The use of financial resources and accounting of research activities is controlled monitored and reported according to rules 4 3 2 Intellectual property and innovation Is there a policy for the protection of intellectual property 4 3 2 1 4 3 2 1 1 There is a strategy for innovation 4 3 2 1 2 There is support for protection and exploitation of intellectual property 4 3 2 1 3 There is support for business development of research projects 4 3 2 1 4 There is a technology transfer service available 4 3 3 Biobank 4 3 3 1 Yes Mostly Partially No not applicable 4 3 3 1 1 The cancer centre has a policy for biobanking patient related samples 4 3 3 1 2 There is a SOP defining the collection the storage the registration and the use of the biological samples 4 3 3 1 3 There is a centralised registration of the data related to the biological material 20 OECI Accreditation and Designation Appendix II 4 4 Process control 4 4 1 Structured scientific programme Is there a structured scientific exchange programme in the cancer centre colloquia seminars theme specific conferences 4 4 1 1 Yes Mostly Partially No not applicable 4 4 1 1 1 There is a structured documented and up to date scientific programme in the cancer centre through colloquia
130. ion and Designation Certificate with agreed final designation type 3 3 2 Contact person cancer institute During the A amp D Programme the contact person of the institute communicates with people from the A amp D Group concerning several issues With the A amp D Secretary with regard to A amp D Agreement Planning of the explanatory visit Information about accommodation for peer review visit With the A amp 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 amp D Programme With the Executive Manager with regard to Concerning payment of the A amp D Programme fee in two stages Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 8 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 4 Confidentiality and conflict of interest The OECI A amp D Programme and the persons and parties inv
131. ion of European Cancer Institutes Chapter 6 Where to find the document needed in the programme Status Revised 24th January 2011 A amp D Working Group Page lof 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Owner OECI Organisation of European Cancer Institutes Chapter 6 Where to find the document needed in the programme Status Revised 24th January 2011 A amp D Working Group Page 2 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 7 Overview of obligations and tasks of a cancer institute General obligations 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 No major changes problems expected management change merger housing movements financial crisis Following the steps of the A amp D programme with care and within the required timeline Involvement in oncology research and education programmes Cancer care is performed on an identifiable unit with an identifiable budget management and organisational structure The institute has a preliminary designation as cancer unit cancer research centre clinical cancer centre or Comprehensive Cancer Centre There is an agreement on the
132. ion of integrated care between the various disciplines involved in the diagnosis treatment and counselling of oncology patients 1 4 9 1 Yes Mostly Partially No not applicable 1 4 9 1 1 The responsibilities of the different disciplines involved in the diagnosis of the patient in the cancer centre are described 1 4 9 1 2 The responsibilities of the different disciplines involved in the treatment of the patient in the cancer centre are described 1 4 9 1 3 The responsibilities of the different disciplines involved in the follow up of the patient in the cancer centre are described 1 4 9 1 4 The multidisciplinary team advises on the inclusion of patients in clinical trials 1 4 9 1 5 The name of the physician responsible for the coordination of the care of the patient is defined and communicated to the patient 1 4 10 Selection criteria for the oncology team meeting Are the selection criteria concerning which patient should be discussed in the multidisciplinary setting clear and documented 1 4 10 1 Yes Mostly Partially No not applicable 1 4 10 1 1 Criteria are defined for the selection of patients to be discussed in the multidisciplinary team meetings 1 4 10 1 2 These selection criteria are clear documented and based on a consensus between the different disciplines 1 4 11 Procedure for the oncological multidisciplinary team meetings Is there a procedure
133. ion of the Board A list with the names of the current OEC Executive Board members is published on www oeci eu 3 1 2 OECI Accreditation and Designation Working Group The Executive Board or the General Assembly may assign some tasks to Working Groups as the Accreditation and Designation Working Group The Working Groups may include persons not belonging to the Executive Board or who do not represent Members The Working Groups are accountable to the Executive Board or to the General Assembly for the tasks which have been entrusted to them and shall draw a report of their activities The rules of procedure of the Working Groups are laid down in the Internal Regulation OECI Statutes The OECI Accreditation and Designation Working Group A amp D Group includes OECI Accreditation and Designation Board A amp D Board 3 1 3 OECI Accreditation and Designation Management Unit A amp D MU 3 1 4 The tasks and responsibilities of the members of the A amp D Group is described in the following paragraphs A list with the names of the current A amp D Group members is published on http oeci selfassessment nu The OECI A amp D Group has monthly meetings by teleconference Once during the three months there will be a face to face meeting Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 1 of 8 Approved
134. ip funding Research funding sources total X X X X X amounts received 2008 4 4 3 Number of patents over the last 5 years 4 4 4 Number of peer reviewed publications X per year year x national 4 4 5 Number of peer reviewed publications X per year year x international 4 4 6 Impactfactor cumulative 4 4 7 Number of publications with X impactfactor gt 10 Appendix Ill OECI Accreditation and Designation 39 5 Education 5 1 Education 5 1 1 Planned annual budget for education year x Euros 5 1 2 On site Access to Not available not applicable 6 1 2 1 An information centre for cancer patients 5112727 Medical library 5 1 2 3 Online access via internet 5 1 3 Yes No not applicable 5 1 3 1 Educational courses organised by the cancer centre on site 51192 with local audience 5 1 3 3 with national audience 5 1 3 4 with international audience 5 1 4 Number of medical students per year 5 1 5 Number of graduate postgraduate students 5 1 6 Number of physicians under specialist training per year 5 1 7 Number of nurses under specialist training per year 5 1 8 Number of nurses students per year 5 1 9 Number PhD students 5 1 10 Number of PhD theses per year average last 5 years 5 1 11 Number of University Faculty associate Professors
135. ittle text icon N E 2 The board and or the 1 2 policy plan revision planned in 2011 and 2012 The full text of the note will be shown but can not be changed Clicking the little icon once more will close the note The second icon shows the number of improvement points that the institute descibes regarding to this standard The third icon showd the number of proof documents that the institute uploaded to support this standard 3 Report findings and scores after peer review After the peer review the auditors provide their notes and scores to the Accreditation Coordinator through the e tool e Note On standard level in the questionnaire for each standard e Score On Sub question level for each sub question e Strengths and opportunities if a standard is a strengths or an opportunity the auditor will also make a not on standard level to explain The coordinator will make a draft report with the notes of the auditors 3 4 1 Pain service Auto save in 150 r Click to insert your comments on the standard Space for the auditor to provide s notes after the peer review Does the cancer centre have a protocol guideline for pain control This is the auditors function changes to the auditor score will be saved Yes Mostly Partially No Not Delete Mar j applicable g E a The cancer centre applies uses a e 8e c C 8 r 0 0 guidelines regarding pain treatment for patients with cancer lt w Audito
136. l Committee 12 OECI Accreditation and Designation Appendix II 2 Screening and primary prevention and health education 2 4 Process control 2 4 1 Availability of screening programmes In the setting of private health policy does the cancer centre organise or participate in screening programmes 2 4 1 1 Mostly Partially No not applicable 2 4 1 1 1 The cancer centre participates in structured regional province county screening programmes 2 4 1 1 2 The cancer centre participates in structured national screening programmes 2 4 1 1 3 The cancer centre organises screening programmes 2 4 2 Participation in prevention and health education initiatives Does the cancer centre organise or participate in prevention and health education initiatives that meet the needs of the population 2 4 2 1 Mostly Partially No MAET lt 1 2 4 2 1 1 The cancer centre organises prevention programmes 2 4 2 1 2 The cancer centre organises health education initiatives programmes 2 4 2 1 3 The cancer centre participates in prevention programmes 2 4 2 1 4 The cancer centre participates in health education initiatives programmes 2 4 3 Availability of primary prevention clinics Does the institution have one or more specific primary prevention clinics 2 4 3 1 Partially No not applicable 2 4 3 1 1 The cancer centre ha
137. late final peer review report E too E too Doc 21 Reimbursement form E too E too Doc 22 Template Feedback and comments form institute E too Doc 23 Template improvement plan E too Doc 26 Evaluation form cancer institute E too Doc 27 Evaluation form audit team E tool Doc 31 Application form auditors chairs Website E too Website Doc 32 Travel policy rules E tool E too Doc 37 Auditors e tool user manual E tool Doc 42 Glossary E tool E too Documents for internal use of the OECI A amp D Group Doc 2 Template letter approval application Doc 3 Template letter disapproval application not existing yet Doc 11 Template letter invitation auditors Doc 13 Engagement employer auditor Doc 18 Template auditors meeting agenda Doc 20 Planning institutes Doc 24 Template letter approval accreditation Doc 25 Accreditation Certificate valid for four years Doc 28 Template letter of thanks to institute not existing yet Doc 29 List ID nr institutes Doc 30 Accountability fact sheet for A amp D fee Doc 33 Complaints form cancer institute not yet existing Doc 35 PPT Explanatory visit Doc 36 Template letter notification GO Doc 38 PPT auditors meeting Doc 39 PPT peer review introduction and preliminary results Doc 40 Letter presenting draft report Doc 41 Planning auditors Doc 43 Financial procedure included in this user manual Owner OECI Organisat
138. le 2 4 3 1 1 The cancer centre has a specific primary prevention clinic or at least one specific primary prevention programme 2 4 4 Oncogenetic clinic outpatient department Does the institution have an oncogenetic clinic 2 4 4 1 Partially No not applicable 2 4 4 1 1 The cancer centre has an oncogenetic clinic for identifying high risk individuals by molecular genetics e g breast cancer ovarian cancer colo rectal cancer endocrine tumours 2 4 4 1 2 Formal relationships exist between the cancer centre and reference genetic laboratories Appendix Il OECI Accreditation and Designation 13 2 4 5 Smoking control in the cancer centre Is there a policy for non smoking in the cancer centre 2 4 5 1 Yes Mostly Partially No not applicable 2 4 5 1 1 a non smoking policy is clearly documented 2 4 5 1 2 support is provided to workers who decide to quit smoking 2 4 5 1 3 any public part of the cancer centre is clearly identified as a smoke free area 2 4 5 1 4 explanations about smoking regulation in the institution are available for patients 2 4 5 1 5 patients are encouraged to quit smoking 2 4 5 1 6 workers are encouraged to quit smoking 2 4 5 1 7 appropriate and specific support is provided to patients who want to quit smoking 2 4 5 1 8 smoking is prohibited to patients possibly with the exception of a restricted smoking room equipped
139. lines to palliative and terminal care NB palliative AND OR supportive care 3 4 3 1 Yes Mostly Partially No not applicable 3 4 3 1 1 The cancer centre uses guidelines on palliative supportive and terminal care 3 4 3 1 2 Written procedures exist on referral of patients to palliative terminal care Appendix Il OECI Accreditation and Designation 15 3 4 4 Palliative and terminal care Is the management of the specific needs of patients at the end of their life considered within and outside the cancer centre NB palliative AND OR supportive care 3 4 4 1 3 4 4 1 1 All patient cases referred for palliative terminal care are discussed during scheduled meetings with the palliative care team 3 4 4 1 2 Agreements exist with other cancer centre s for transferring patients at the end of their life if necessary 3 4 4 1 3 Services provided by the cancer centre after patients are discharged are clearly defined 3 4 4 1 4 These services are known by terminal patients and relevant workers 3 4 5 Psycho oncology service Does the cancer centre have a psycho oncology team or department 3 4 5 1 Yes Mostly Partially No not applicable 3 4 5 1 1 There is a psycho oncology service with competence in oncological psychiatry and psychology 3 4 5 1 2 The staff are trained to detect patients with psychological suffering or distress 3 4
140. lliative AND OR supportive care 3 4 3 1 Yes Mostly Partially No not applicable 3 4 3 1 1 The cancer centre uses guidelines on palliative supportive and terminal care 3 4 3 1 2 Written procedures exist on referral of patients to palliative terminal care Appendix Il OECI Accreditation and Designation 15 3 4 4 Palliative and terminal care Is the management of the specific needs of patients at the end of their life considered within and outside the cancer centre NB palliative AND OR supportive care 3 4 4 1 3 4 4 1 1 All patient cases referred for palliative terminal care are discussed during scheduled meetings with the palliative care team 3 4 4 1 2 Agreements exist with other cancer centre s for transferring patients at the end of their life if necessary 3 4 4 1 3 Services provided by the cancer centre after patients are discharged are clearly defined 3 4 4 1 4 These services are known by terminal patients and relevant workers 3 4 5 Psycho oncology service Does the cancer centre have a psycho oncology team or department 3 4 5 1 Yes Mostly Partially No not applicable 3 4 5 1 1 There is a psycho oncology service with competence in oncological psychiatry and psychology 3 4 5 1 2 The staff are trained to detect patients with psychological suffering or distress 3 4 5 1 3 Structured screening methods are used
141. lly to help all types of cancer Centres fulfil accreditation requirements This Manual is the product of the integrated Accreditation Programme and Designation project which is offered to OECI cancer Centres since September 2010 after approval during the OECI General Assembly in June 2010 Budapest The detailed policies are designed to be easily adaptable for use by Centres of all sizes Our OECI A amp D team is available to assist with adaptation if necessary The A amp D Manual tells you everything you need to know to prepare for your accreditation designation site visit The OECI A amp D Manual was written by the OECI A amp D team who has the experience of the OECI A amp D Programme for several years and over many OECI cancer Centres The EurocanPlatform NoE has an extensive communication and dissemination programme targeting the whole European cancer community with the final goal to improve the quality of research and care This activity is assigned to the WP 14 of the Platform The Dissemination of the Platform s outputs includes therefore the Accreditation and Designation activity This Manual as well as the other fundamental outputs coming from the Platform WPs is distributed to the OECI members and to other European Cancer Institutes potentially interested in the improvement and recognition of their quality The electronic version of the Manual is also spread through the OECI website and e cancermedicalscience the official jo
142. lly when the institute prefers the CCC level Group dinner Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 17 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Performing the peer review Executor OECI audit team Performing the peer review according to the peer review agenda doc 16 During the peer review and in the evenings the auditors will work on scoring the standards Yes Mostly Partially No for the report and drawing the preliminary conclusions strengths and opportunities Designation checklist during the peer review visit Ask the list on scientific publications including an overview of the authors papers in the hospital First second and last author should be clarified Overview is enough when doubt on the correction of the numbers check impact factor and especially in the impact factor gt 10 Ask on site at different wards at least two times the number of beds e Cross check yes or no Ask on site at the day care the number of beds chairs total e Cross check yes or no Ask in two different interviews the number of physicians from different specialties Ask on site the number of active clinical trials e Cross check yes or no Check the facilities the availability of the radiotherapy
143. locations files and documents needed for assessment during the on site peer review e The executed language during the peer review is English The cancer institute staff involved in interviews need to understand and to speak in English If not the OECI requires the presence of an independent person who is able to translate Meaning of a no go Generally a no go decision means that the peer review visit will be postponed A possibility for a no go decision iS an inconvenient input for the audit team to prepare and perform the peer review in a reliable way It might be possible that additional information notes or evidence documents are needed Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 13 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 6 Step 6 Payment stage 2 fee If the self assesment of the institute is approved for a Go the institute will receive the invoice for stage two of the A amp D fee The amount of the fee depends on the designation type of the institute Tasks of Executive Manager Sending invoices to the institutes including the signed A amp D Agreement Controlling the payments of the institutes Providing the A amp D Chair and the A amp D Secretary a copy of invoices sent to the institutes T
144. m A Month 9 Auditors team L meetng CEC Auditor J Prepare peer review ora audit team Meetng day before peer review ore audit team Month 10 Performing peer Peer review notes d Figure 5 Step 7 Peer review visit and designation check 5 7 1 Step 7 activities and responsibilities of all parties involved figure 5 Step 7 starts with parallel activities for A amp D Coordinator the auditors and the institute Information sent to the auditors Executor OECI A amp D Coordinator The auditors receive an e mail with a notification of the go decision of the A amp D Board including information of the continuation of the accreditation programme The e mail contains information about Preparation of the peer review Access to the information of the cancer institute in the e tool Designation checklist doc 34 Login instructions in the user manual doc 37 Auditors meeting and the agenda doc 18 Travel and booking instructions for the auditors meeting and the peer review visit doc 32 and doc 21 Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 15 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Preparation of the auditors team meeting Executor OECI Auditor The indivi
145. mber of peer reviewed publications per year year x international 4 4 5 Number of publications with impact factor gt 10 4 4 7 Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 4 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Define preliminary designation type Executor OECI A amp D Coordinator With the data provided in the designation screening the A amp D Coordinator will define the preliminary designation type for the applied institute according to the Designation Decision Schedule appendix The quantitative norms can be found in the Appendix Required criteria for Cancer Research Centre e 2 1 Number of beds year x e 2 1 Number of specialists year x e 2 1 Number of new patients year x e 4 4 4 4 4 5 Number of scientific papers year x e 1 5 5 Annual budget research year x e 1 5 4 Annual budget care year x If the institute does not meet the required criteria for Cancer Research Centre the institute can be a Cancer Unit or Clinical Cancer Centre or Comprehensive Cancer Centre CCC Required criteria for Cancer Unit e 2 1 Total number of beds 2 1 ambulatory day care beds e 2 1 Or number of new patients year x e 2 1 Or number of specialists year x e 4 4 4 4 4 5 Or nu
146. mber of scientific publications year x And e Institute covers radiotherapy and medical oncology or surgical oncology If the institute does not meet the required criteria for a Cancer Unit the institute can be a Clinical Cancer Centre or Comprehensive Cancer Centre CCC Required criteria for first selection CCC e 1 5 4 Annual budget for care year x e 1 5 5 Annual budget for research year x e 2 1 Total number of beds 2 1 ambulatory day care beds year x e 4 3 2 Active clinical trials year x e 4 4 4 4 4 5 Number of scientific papers year x e Nr scientific papers with impact factor gt 10 year x The confirmation and second check takes place during the peer review visit If these criteria are not met the institute can be either a clinical cancer institute or a CCC The final decision for the designation type will be checked during the peer review visit according to an additional checklist 5 7 1 Deviation in designation judgement of the institute and the preliminary designation result The application form for institutes includes the question to classify itself in one of the four designation types The occurrence of a discrepancy between the judgement of the institute and the designation screening result preliminary designation is feasible This discrepancy will be discussed during the explanatory visit step 3 Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D proce
147. mediator or mediation service or as the complaints officer or complaints department 6 5 2 1 2 The role of the conciliator or the conciliatory commission is to reply to any request for information or complaints from the patients or their families 6 5 2 1 3 The actions undertaken by the conciliator are recorded in a file that is used to produce an annual report 6 5 2 1 4 The conciliator gives feedback on his her findings to the professional who is the subject of the complaint 26 OECI Accreditation and Designation Appendix II Appendix III OECI Quantitative questionnaire Please fill in the following OECI quantitative questionnaire not for public release The italic items are already filled out in the application form And the underlined items are filled out for the designation screening Chapter 4 Research outside the scope of the OECI Accreditation of Cancer Units 1 General Questions 1 1 Cancer centre 1 1 1 Project OECI Quality Improvement Project Working Group Accreditation WGA 1 1 2 Name of the cancer centre 1 1 3 Address 1 1 4 Telephone 1 1 5 Fax 1 1 6 Internet site 1 2 Management 1 2 1 Administrative Director 1 2 2 E mail Administrative Director 1 2 3 Medical Director 1 2 4 E mail Medical Director 1 2 5 Scientific Director 1 2 6 E mail Scientific Director 1 3 Survey 1 3 1 Name of the Contact perso
148. meetings about research results 4 1 5 1 4 Promotion of integration of research activities into clinical activities 4 1 5 1 5 Organisation of integration of research activities into clinical activities 4 1 6 Internal review and evaluation of grant proposals Is there a procedure in place for internal review of grant proposals before submissions 4 1 6 1 Yes Mostly Partially No not applicable 4 1 6 1 1 There is an internal review of grant proposals before submission to the funding organisation 4 1 6 1 2 There is an internal evaluation of the success of the grant proposals 4 1 7 suspected scientific misconduct Is there a procedure in case of suspected scientific misconduct 4 1 7 1 Mostly Partially No not applicable 4 1 7 1 1 There is a procedure for dealing with scientific misconduct Appendix Il OECI Accreditation and Designation 19 4 3 Resources and materials 4 3 1 Means for conducting research activities Does the cancer centre have the means for conducting its research activities 4 3 1 1 Yes Mostly Partially No not applicable 4 3 1 1 1 The budget for cancer research is clearly and yearly defined 4 3 1 1 2 The cancer centre provides access to facilities for research activities 4 3 1 1 3 The cancer centre provides resources and means for research activities 4 3 1 1 4 Fund
149. ment Preparing the agenda for the peer review visit it is not necessary to explain the purpose Giving feedback and comments to the draft peer review report Sharing the results from the peer review visit Formulating and performing actions for the improvement following the peer review results Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 8 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 4 Step 4 Self assesment Step 4 of the A amp D programme is the six months of self assesment of the cancer institute figure 4 Cancer cenire Cm Between mort 0 2 Start self assessment Eo period CEC ASD Coordinator Composition of auditors team Doc13 Engagement letter employer CEC ABD Coordinator Send inv ation audi Doc14 Confidentiality team eyeement A CEC ASD Coordinator WA Send composition to on invitation centre _ CEC ASD Coordinator confirmation i i DoctS Contict of I i I i I A auditors t month interest form OFC ASD Coordinator em tomenth Check confidentiality ie A agreement auditors CEC ASD Coordinator i Between morth 6 6 Composition of peer Approval chair EO redea agenda auctors team Cance
150. ment H ad 5 Teaching and continuing education C 6 Patient related The first line shows the standard and the answer given by the centre you can read the complete standard by clicking the text of the question 3 4 1 Pain service Standard 5 w Click to insert your comments on the standard Question related to standards Does the cancer centre have a protocol guideline for pain control If the institute added a not the text cloud will be dark grey Click the icon to read the note of the institute If the institute added an improvement point click br If the institute added a document s click here Partially No Not Delete Mar applicable The cancer centre applies uses e e C B r guidelines regarding pain treatment for patients with cancer Auditor score femke auditor E C c a r Space for auditor to add your assessment Beneath the score of the centre the space for the auditor can be found to add an assessment of the topic You can score the question by clicking on the appropriate answer You can add notes notes in the same way as reviewing the institutes remark and you can place items on the discussion list by ticking the box 56 OECI Accreditation and Designation Appendix VI If an institute added a note to the standard to support the answer you can read the first line of the note underneath the standard To view the full text click the l
151. mory stick application update release 23 April 2008 e Memory stick database update release 23 April 2008 Documents that can be useful for the auditors during the programme Manu roc 05_Template_Project plan cancer centre doc Doc 09 _List requested documents self assessment centres do Doc 14 Confidentiality agreement auditors doc Doc 15 Conflict Of Interest form doc Doc 19_ Template final peer review report docx Doc 21_Template_reimbursoment form auditors _v2 xls Doc 32_OECI Travel policy and coverage rules_revised 10 11 2010 goc Doc 34 Accreditation Glossary xls Joc 34_ Designation form auditors 16 08 2010 doc Auditors user manual eTool_vi doc In the Workspace you can go to the questionnaires of the institutes that have been assigned to you by the OECI Accreditation Coordinator 54 OECI Accreditation and Designation Appendix VI sapja aH Home Questionnaires Show help Logout femke auditor Workspace Wir Click on the institute of your choice the table with the qualitative AND quantitative questionnaire of that institute will appear From this window there are several options for the auditor Question Progress 3 Go to the document the institute has attached including the documents requested by the OECI 4 Go to the document the institute has attached to a specific question Question Progress Sy 1 Open qualitative
152. mpleted at least once gt in second cycle e Partially means that the indicator is implemented on project bases or on a modest scale in the cancer institute or the Deming cycle has not been completed e No means that the indicator does not get attention or there are plans to start working on the indicator e Not applicable means that the indicator is not applicable in the cancer institute Appendix V OECI Accreditation and Designation 45 6 4 3 Informing patients about results treatment and counseling Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counseling in terms of how it is done and what it means Yes Mostly Partially No Not Delete Markeer The cancer centre has procedures or guidelines bd ad c c c C 8 0 regarding information transfer on diagnostics treatment follow up and supervision of the patient 1 Select a score for each 2 Depending on the selected substandard it will turn black score the bullet appears in green yes partly green or in red no 3 Before moving to the next item provide evidence for your score e Step 2 Provide evidence for the given score through e Attaching a document to a specific question in the e tool that provides the evidence or e Referring to a document that is already attached in an earlier item OR e Adding a note to jus
153. mulation of the improvement plan The opportunities stated in the final peer review report are an input to write the improvement plan doc 23 template improvement plan The plan has to show the willingness to improve the opportunities described in the peer review report as well as a systematic improvement approach The plan contains Standard Opportunity Action Goal Actions Who is involved Start Evaluation Dead Priority SMART description and responsible date date line high desired for result Names date medium result and department low 1 1 1 etc A cancer institute may choose a lay out for an improvement action plan such as Lay out as used in the institute E tool function for describing improvement points non compliances OECI A amp D template doc 23 The institute will have three months to produce the improvement plan Based upon the improvement plan the Accreditation and Designation Certificate can be awarded by the OECI A amp D Board Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 24 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 10 Step 10 OECI A amp D Certificate Within 1 month month 17 after the OECI received the improvement plan from the institute the OECI A amp D
154. n 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 e speaks and writes fluently in English e has a good overview of the field of oncology in a cancer institute e is a team player e has an objective and analytic way of thinking e has a quality improvement attitude e s 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 interview
155. n for the survey at the cancer centre 1 3 2 Position of the Contact person for the survey 1 3 3 E mail address of the Contact person for the survey 1 4 Cancer centre structure 1 4 1 Cancer Unit Clinical Cancer 0 0 0 Cancer research Centre Comprehensive Centre cancer centre 1 4 1 1 In which category would you classify your cancer centre 1 4 6 academic public non profit private 1 4 6 1 What is the administrative status of your cancer centre Appendix Ill OECI Accreditation and Designation 27 1 4 7 at national level 1 4 7 1 Is your cancer centre part of a formalised network of institutions at regional level Presence of European or International Affairs Collaboration General accreditation by National Accreditation Organisation or other organisation 1 4 8 1 5 1 5 1 E92 1 5 3 1 5 4 1 5 5 Year of accreditation Distribution areas and budget of patients regional of patients national of patients international Planned annual budget for health care X in last year available Planned annual budget for research X in last year available 28 OECI Accreditation and Designation Appendix III 2 Infrastructures 2 1 Infrastructures with a focus on cancer care 1 of 7 2 1 1 per year x surgery medical radiation paediatric Haematology Total oncology oncology therapy oncolo
156. n take place in month 10 STEP 8 Reporting It takes about 3 months to finish the final peer review report including general conclusions strengths opportunities and the final designation type in month 13 STEP 9 Formulate improvement plan The institute shall present an improvement plan in month 16 STEP 10 Approval Accreditation and Designation Certificate The final accreditation decision will be taken by the OECI A amp D Board within 1 month after the OECI received the improvement plan of the institute month 1 7 FOLLOW UP of Accreditation and Designation Programme One year after the peer review visit the cancer institute provides a written report with the progress of the goals actions and time schedule set in the improvement plan OECI Accreditation and Designation is valid for four years from the date of issue of the OECI A amp D Certificate The institute should have started a new round of the A amp D programme at least 6 months before the expiring date of the certificate Owner OECI Organisation of European Cancer Institutes Chapter 2 Timeline of the OECI A amp D process Status Revised 24th January 2011 A amp D Working Group Page 2 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 3 People and parties involved in the A amp D programme This chapter explains the profiles tasks and obligations of the people and parties involved in the OECI A amp D Programme
157. n 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 Incase 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 amp 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 E
158. n to determine whether on a level of quality and the coherent results activities correspond to the planned measures and whether these measures are suitable and have been effectively implemented to achieve the objectives of the organisation The peer review applies to the quality system of the organisation or its elements The added value of a peer review is that it should lead to improvement of the quality system working process and products and services of the organisation It puts the daily routine and its results to the test of quality standards If differences are found corrective measures are taken to upgrade the quality system Though it is not solely a compulsory activity On the other hand a peer review does not aim to assault the quality system of the cancer institute and those responsible Scoring system A scoring system is included in the qualitative questionnaire The scoring system is based on the Plan Do Check Act circle or Deming circle With the scoring system it is possible to assess the stage of development for each item in the standard After filling out all the questions the e tool generates the results The results will be used for the content of the peer review as well as input for a quality improvement plan of the institute Background of the designation programme The developments in accreditation have urged the OECI to develop and implement an additional system in which European cancer institutes can also be designated f
159. n type of the institute Both the judgement of the institute and the outcome of the designation screening are the starting point for the next steps STEP 2 Payment fee stage one 5000 The cancer institute receives the first payment order of 5000 after the approved application and designation screening and before the explanatory visit The total amount of fees stage one and two is different according to the designation types Stage one is equal for all designation types STEP 3 Explanatory visit with preliminary designation type result The explanatory visit takes place when the application of the cancer institute is approved and the designation screening is finished STEP 4 Self assesment according to the quality standards The accreditation programme for an institute starts at month O with the self assesment The self assesment period will take 6 months The set of quality standards varies for the different designation types STEP 5 Approval Go No go The final go or no go decision will be taken by the OECI A amp D Board within 2 months after finishing the self assesment with the input of the analysis and proposal of the A amp D Committee STEP 6 Payment fee stage two the amount of the fee depends on the designation type The payment order will be sent after the go decision of the OECI A amp D Board STEP 7 Peer review An audit team will have 2 months to prepare the peer review before the peer review visit ca
160. nd affinity Quality improvement attitude The management board of the institute supports the application Working as a professional Helicopter view Capacity to work in a team Good interpersonal properties Capacity to distinguish core issues and side issues objective Fluent English spoken as well as written Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 4 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Analytic way of thinking Tasks To analyze and examine the self assesment reports for the go no go decision before the peer review visit To analyze the availability of the required proof documents and additional appropriate documents for peer review To advise the A amp D Board about a go no go decision with regard to the scores notes and documents in the self assesment report To analyse the conclusions strengths and opportunities that are drafted by the audit team and to give final advice to the A amp D Board about the complete final report including the designation type To analyze and examine the improvement plan of the institute and advising the A amp D Board for final accreditation according to procedures and standards of the institute The
161. nd hierarchical structure of the RID organisation 4 1 1 1 Yes Mostly Partially No not applicable 4 1 1 1 1 There is an organisational and hierarchical structure specifically for research innovation and development 4 1 1 1 2 A Scientific Advisory Board meets on a regular basis and advice the board of the cancer centre on its research activities 4 1 1 1 3 The Scientific Advisory Board verifies the quality of the research activities 4 1 1 1 4 The Scientific Advisory Board verifies the coherence of the objectives of the different research programmes and the cancer centres objectives and strategy at least annually 4 1 2 Research collaboration 4 1 2 1 4 1 2 1 1 The cancer centre has a strategy on collaboration and networking 4 1 2 1 2 The cancer centre participates in national and international research projects 4 1 3 Organisation of clinical research 4 1 3 1 Yes Mostly Partially No not applicable 4 1 3 1 1 There is a dedicated clinical research management unit 4 1 3 1 2 It is the task of the unit to have a strategy for promoting the conduct of clinical trials 4 1 3 1 3 It is the task of the unit to ensure the management that the conduct of clinical trials is according to the Clinical trials protocols 4 1 3 1 4 It is the task of the unit to ensure administrative scientific and ethical legal review and approval of new Clinical tri
162. nit to coordinate the clinical research activities as well as their funding 4 1 3 1 6 It is the task of the unit centralise the collection of the information about the trials and patients included 4 1 3 1 7 It is the task of the unit to provide and update information about the trials to all departments and external partners 4 1 3 1 8 Itis the task of the unit to assist in the conduct and monitoring of clinical trial activities 4 1 3 1 9 It is the task of the unit to provide an annual report on clinical trial activities 18 OECI Accreditation and Designation Appendix II 4 1 4 Periodical policy review Is there a periodical research policy review 4 1 4 1 Yes Mostly Partially No not applicable 4 1 4 1 1 There is a periodically defined research policy and research strategy plan 4 1 4 1 2 The research policy and research strategy plan are integrated into the general activities of the cancer centre 4 1 5 Scientific interaction and integration Is there a structure for integrating and stimulating the scientific interaction 4 1 5 1 The cancer centre promotes co operation between researchers and clinicians through Yes Mostly Partially No not applicable 4 1 5 1 1 Organised and formalised activities 4 1 5 1 2 Regular information and meetings about research activities 4 1 5 1 3 Regular information and
163. note box icon A note box appears under the specific question To close the box just click with your mouse somewhere on the page Now there is a note in the note box the icon will be changed with bold lines The cancer centre has procedures or C C C 0 0 guidetines regarding information transfer on diagnostics treatment follow up and supervision of the patient Refer to the question where the document is already attached How to add a note to justify the score If there is no document that can provide evidence for the given score or the document policy procedure is not available please justify the given score by putting a note in the note box as explained above It is also possible that the institute cannot answer the question literally for example because the institute is not responsible for the standard questioned please also use the note box to explain this issue How to add the documents requested by the OECI When you log in to the e tool you will see the following screen with some tabs above the two questionnaires In the underneath figure the tab that is blue Questionnaires is open Go to the tab documents Tab documents Questionnaires Sy Questionnaires These are the most recent questionnaires p CECI Qualitative 08 08 05 11 E 264 R Z um og D r gt Questionnaire v3 2009 2010 264 100 3 2 t D i t es CEC Quantitative 08 08 30 06 Mo 662 Pd
164. ntations onbre gt Home gt pout us ISQUA 2010 and ESMO 2010 presentations online JECI present on SQue 2010 Pans DECI present on ESMO 7010 Moan a Background Accreditation Background Designation Organizational structure Go to the E tool Octoder 21 2010 by Aamiustratar integration Designate and gt Description ASD process Go to presentations in the menu PEROT 4i oA A C htitpjoeci selassessment nu cms node 7 Applied cancer institutes July 2010 Accreditation anc gt OEG standards Adiminestrator s blo Dangnation Newsletter Vol 4 is 7 How to apply anina Go to http oeci selfassessment nu compass user or through the website http oeci selfassessment nu An Auditor s username has been supplied with a password use this to log in to the application Log on Use your username and password to login Username password When successfully logged in you will find the following screen Appendix VI OECI Accreditation and Designation 53 Home User Questionnaires Show heip Logout femke auditor Instructions Workspace Go to the questionnaires of the institute that has been assigned to you Home LaOECI Orcansanon oF European Cancer Instrrures Enrortan Economie Interest Gaosewe You are an auditor You have the following options Internet connection normal operation No internet connec
165. o provisional budget Reporting the financial status quarterly to the members of the A amp D Board and Executive Manager Checking and validating invoices and reimbursement claims with a signature before payment according to the following general rules Doc 32 OECI A amp D Travel policy e In case of prolonged absence or holiday of the A amp D Chair the signature will be delegated to the A amp D Secretary The A amp D chair will check and countersign the documents afterwards Providing overview of income expenditure to the OECI Board Executive Secretary every 6 months Providing the OECI Board Executive Secretary with the original invoices with attached the bank payment receipts once a year or whenever requested In case of travel by flight also the boarding passes must be added Proposing and reporting annual budget to the OECI Board and OECI A amp D Board 3 1 4 OECI Accreditation and Designation Management Unit The A amp D Management Unit consists of OECI Executive Manager OECI A amp D Coordinator OECI A amp D Secretary Subcontractor Compusense for designation administration and technical support of the self assessment e tool 3 1 4 1 OECI Executive Manager General tasks Daily management of the A amp D Programme Providing a quarterly report for the OECI A amp D Board chair new applications visited institutes achieved accreditation etc Supervising the OECI Accreditation and Designati
166. o 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 amp 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 amp 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 Accreditat
167. of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 12 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 5 Step 5 Go no go decision The final go or no go decision will be taken by the OECI A amp D Board Before the Board takes the decision the A amp D Committee will analyse the self assesment results according to the criteria for selfassesment The Committee proposes to the A amp D Board a go or no go decision The go decision is made at least two months in advance of the planned peer review visit Meaning of go A go means that the OECI A amp D Board has approved the institute for a go after the OECI A amp D Committee has given its independent examination for this approval concerning the criteria The institute has provided convenient input of evidence and information to make it possible for an audit team to do a reliable peer review visit on site The input includes 1 All items are scored 2 The questionnaires should be useful for the auditors to prepare the audit which means that the institute ee transparency in the available evidence written documents and explanations notes Scores are justified with a note or a document with evidence unless the score does not need explanation e The relevant documents procedures guideline
168. ogy Total oncology oncology therapy oncology oncology Number of newly X X X X X X X registered diagnosed cancer patients any type Number of inpatient beds for X X X X X X X overnight stays Number inpatient visits for overnight stays Mean duration of stay for inpatients Number of outpatient visits in consultation Waiting time before 1st visit mean Waiting time treatment decision first treatment mean Number of ambulatory day care X beds chairs Number of ambulatory day hospital patient visits FTE physicians dedicated to X oncology into human resources FTE vacant positions FTE board certified nurses dedicated to oncology FTE vacant positions 2 2 Infrastructures with a focus on cancer care 2 of 7 2 2 1 per year x breast cancer C50 lung cancer C34 urological cancer bladder C67 urological cancer kidney C64H urological cancer Others Male genital organs cancer prostate C61H Male genital organs cancer testis C62 Male genital organs cancer Others Appendix Ill OECI Accreditation and Designation 29 2 3 Infrastructures with a focus on cancer care 3 of 7 2 3 1 per year x New patients Number of Number of Total number Working with Multidisciplinary Clinical Number of newly surgical Chemotherapy of sessions guidelines me
169. olved 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 amp D programme of a cancer institute different persons will have access to the information and data of the cancer institute The OEC A amp 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 amp 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 amp D Group or to the respective cancer institute The persons who have to sign the confidentiality agreement doc 14 are e Members of the OECI A amp D Board e Members of the OECI A amp D Management unit e Members of the OECI A amp D Committee e All auditors including the chairs Freedom of Information Acts which may be applicable in a given state province or country do not
170. on Coordinator Financial tasks Sending invoices to the institutes and controlling the payments of the institutes Providing to the A amp D Chair and A amp D Secretary a copy of invoices sent to the institutes Specific tasks and responsibilities of the Executive Manager are described in Doc 43 3 1 4 2 OECI Accreditation and Designation Coordinator The OECI A amp D Coordinator is supervised by the Executive Manager General tasks Contact person for all parties involved in A amp D Programme Collecting structuring and making accessible the relevant information and documentation internal and external on the website and e tool Monitoring the ongoing processes and outcomes with regard to the A amp D procedures Identifying improvements in the procedures organisation e tool and standards Specific tasks Coaching and advising cancer institutes in all steps of the A amp D programme Processing application and designation screening Preparation of explanatory visit Supervision during self assesment Preparation of the peer review with the cancer institute Supervision in follow up of the peer review outcomes Organizing and performing the peer review Composing the audit team together with the Executive Manager Providing the audit team with documents for preparing the peer review Owner OECI Organisation of European Cancer Institutes Chapter 3 People and parties involved in
171. oved by OECI Accreditation and Designation Board Version 16 February 2011 Final check Executor OECI Chair audit team lf the A amp D Committee changes major parts in the report the report will be sent back to the chair of the audit team The chair will have the opportunity to check the report f the chair of the audit team agrees with the major changes of the A amp D Committee the draft final report will be sent to the A amp D Board for approval Approval final report Executor OECI A amp D Board In week 14 after the peer review the OEC A amp D Board will have a teleconference to approve the final report including the strengths opportunities and conclusions Send final report to Cancer institute Executor Chair A amp D Group Within 14 to 16 weeks after the peer review the cancer institute will receive A letter to present the final report The final report including the final designation Anexplanation of the minimum criteria of an improvement action plan Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 23 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 9 Step 9 Formulate improvement plan The next step for the cancer institute will be the for
172. ovement plan Step 10 OECI A amp D Certificate 5 11 Follow up Where to find the documents needed in the programme Overview of obligations and tasks of a Cancer Institute Register Appendix Designation Decision Schedule Appendix Il OECI Quality standards Appendix Ill OECI Quantitative questionnaire Appendix IV Project plan Appendix V Self assesment user manual for institutes Appendix VI User manual e tool for auditors oO WON RRP FP FP O ODO RY FY YF N N RDO FF FB e e N oO A A OO ON HB W of of of of of of of of of PM RP MR CO CW 0 CM PM PNM PP of of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 28 of 2 of 2 of 2 27 41 43 53 1 Introduction of the OECI A amp D Programme The Organisation of European Cancer Institutes The mission of the Organisation of European Cancer Institutes OECI is to bring together the cancer research and care institutions in the European Union in order to create a critical mass of expertise and competence With the view of building and maintaining a consensus on the best models of oncology developing concrete affordable and realistic solutions to effectively combat cancer and fostering the widest deployment of oncology models and solutions to improve the quality of life for the patients in the EU Background of the accreditation programme The OECI launched the Accreditation Programme in 2002 to fulfil its goals To provide can
173. p including directors Chief Officers heads of departments and physicians 1 5 6 1 2 The results of evaluation are documented and used for building future strategies of the institution with alignment of the departments 1 5 6 1 3 Relevant training is provided to all staff according to their level of responsibility 1 5 6 1 4 HR policy includes a formal individual evaluation at least once or twice a year 1 5 6 1 5 Training records of all staff are available 1 5 6 1 6 Skills competences and expertises are assessed in case of recruitment at managerial level 1 5 6 1 7 Specific psychological support is available for the cancer centre s employees including physicians 1 5 7 Privacy protection of personal data Are there procedures for privacy protection of personal data 1 5 7 1 Yes Mostly Partially No not applicable 125 711 There is a Patient Charter an official set of principles a document defining the commitments of both the cancer centre AND the patient In this Charter the cancer centre commits itself to respect and to guarantee the patient s privacy TO iE2 There is a secure procedure for the storage preservation consultation and transmission of personal data according to the national European regulations 1 5 7 1 3 Protocols for clinical trials guarantee the protection of the patient s personal data This point is checked and validated by an Ethica
174. parent is dying trained staff guidelines 3 4 8 1 2 Families are proactively informed on the available support 3 4 9 Rehabilitation Is there access to a rehabilitation unit with mono and multidisciplinary interventions 3 4 9 1 3 4 9 1 1 There is access to a functional rehabilitation department focused on cancer patients 3 4 9 1 2 The rehabilitation unit manages the psychosocial and physical rehabilitation of the patient starting at an early stage of the treatment and continuing during the post therapeutic care period 3 4 10 Prosthetic surgery Do patients receive information and advice about the possibilities of prosthetic surgery 3 4 10 1 Yes Mostly Partially No not applicable 3 4 10 1 1 The person s in charge of providing information on prosthetic surgery is are clearly identified 3 4 10 1 2 The patient is informed about how to get information 3 4 10 1 3 This information includes the potential risks 3 4 10 1 4 Prosthetic and reconstructive surgery is available and accessible to all appropriate patients Appendix Il OECI Accreditation and Designation 17 4 Research innovation and development Note Cancer Units are excluded for the questions in this chapter 4 4 1 Policy and organisation 4 1 1 Organisational and hierarchical structure Is there a description of the organisational a
175. pecific question To close the box just click with your mouse somewhere on the page Now there is a note in the note box the icon will be changed with bold lines The cancer centre has procedures or C C C 0 0 guidetines regarding information transfer on diagnostics treatment follow up and supervision of the patient Refer to the question where the document is already attached How to add a note to justify the score If there is no document that can provide evidence for the given score or the document policy procedure is not available please justify the given score by putting a note in the note box as explained above It is also possible that the institute cannot answer the question literally for example because the institute is not responsible for the standard questioned please also use the note box to explain this issue How to add the documents requested by the OECI When you log in to the e tool you will see the following screen with some tabs above the two questionnaires In the underneath figure the tab that is blue Questionnaires is open Go to the tab documents Tab documents Questionnaires Sy Questionnaires These are the most recent questionnaires p CECI Qualitative 08 08 05 11 E 264 R Z um og D r gt Questionnaire v3 2009 2010 264 100 3 2 t D i t es CEC Quantitative 08 08 30 06 Mo 662 Pd um 2 gt Questionnaire v2 2009 2010 0
176. plinary team meetings Is there a procedure for the oncological multidisciplinary team meetings 1 4 11 1 There are procedures describing how the regular multidisciplinary team meetings apply following criteria 1 4 11 1 1 One of the specialist in charge of the care of the patient is present during the discussion of the patient Yes Mostly Partially No not applicable 1 4 11 1 2 During the presentation of patients diagnostic results and examination results are available 1 4 11 1 3 The necessary facilities to show diagnostic and examination results are available 1 4 11 1 4 Conclusions and advice resulting from the multidisciplinary team meeting are documented in the patient s medical record 1 4 11 1 5 There is a clear description of the way to inform all the members of the multidisciplinary team about which patients will be discussed 1 4 11 1 6 There is a clear description of the communication of the advice resulting from the discussion to all the physicians and other disciplines involved in the care of the given patients 1 4 11 1 7 There is a clear description of the communication of the advice resulting from the discussion to the concerned patients 1 4 11 1 8 Each final decision about care of the patient that differs from the advice and conclusions of the multidisciplinary team is documented and recorded in the patient s medical record 1 4 11 1 9 There is
177. pportive disciplines psychologists etc 5 4 1 1 6 other disciplines please specify in the note 22 OECI Accreditation and Designation Appendix Il 5 4 2 Types of teaching programmes provided Does the cancer centre participate in teaching for PhD BSc MSc degree s in oncology nursing 5 4 2 1 Does the cancer centre provide Yes Mostly Partially No not applicable 5 4 2 1 1 academic teaching in oncology 5 4 2 1 2 continuous medical education CME 5 4 2 1 3 BSc MSc and PhD programmes related to cancer research 5 4 3 Types of teaching programmes organised Does the cancer centre participate in organising for PhD BSc MSc degree s in oncology nursing 5 4 3 1 Does the cancer centre organise coordinate 5 4 3 1 1 academic teaching in oncology 5 4 3 1 2 continuous medical education CME 5 4 3 1 3 BSc MSc and PhD programmes related to cancer research Appendix Il OECI Accreditation and Designation 23 6 Patient related 6 4 Process control 6 4 1 Educational material Has policy been defined concerning the production distribution and administration of educational material relating to oncology 6 4 1 1 The cancer centre delivers Yes Mostly Partially No not applicable 6 4 1 1 1 written information on relevant aspects of oncology to the patients 6 4 1 1 2 written information on rel
178. priate use of radio therapeutic services 1 5 2 1 5 There is a regular internal audit system 1 5 2 1 6 There is a quality and risk dashboard of the cancer centre with an annual evaluation of the results and if necessary revision of its content 1 5 3 Accuracy of the diagnostic services Are the diagnostic services safe efficient and accurate for workers and patients 1 5 3 1 Yes Mostly Partially No not applicable 1 5 3 1 1 Security checking of devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are part of the maintenance contracts 1E5312 Latest security checks have been done on time TESA Calibration of devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are part of the maintenance contracts 1 5 3 1 4 Latest calibrations have been done on time 1 5 3 1 5 Devices and technical equipment used for diagnosis biology pathological anatomy imaging functional tests are periodically certified by an authorised company Expiration date is still valid 1 5 3 1 6 There is a reporting system for near miss accidents during the use of the devices and equipment 1 5 4 Quality and risk management of research and new techniques Are there monitoring systems for quality and risk management associated with the introduction of new techniques new p
179. r centre Ta Month amp Finishing Requered documents Eo selfassessment P0 Committee Tga Figure 4 Step 4 Self assesment Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 9 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 4 1 Step 4 activities and responsibilities of all parties involved figure 4 Start self assesment period Executor Cancer institute Within one month after the explanatory visit the institute has organised a project team and planning to start the self assessment period The self assesment takes 6 months The deadline of the self assesment period is at least 2 weeks before the next TC of the OECI A amp D Committee to prepare the go no go decision for the OECI A amp D Board E tool see chapter 8 The cancer institute fills out the quantitative and qualitative questionnaire The cancer institute makes notes remarks at the questions to explain the score answers The cancer institute attaches documents if available to questions to support the answers The cancer institute attaches minimally the documents required by the OECI The cancer institute describes non compliances improvement points in the e tool that can be used to make an improvement plan Progress of
180. r on diagnostics treatment follow up and supervision of the patient Yes Mostly Partially No not applicable 6 4 3 1 2 Policies are defined about who is informing the patient relatives and close friends about the result of an examination further treatment or supervision 6 4 3 1 3 Policies are defined about when this information is delivered 6 4 3 1 4 Policies are defined about how the transmission of information to the people involved in treatment and patient care is organised 6 4 3 1 5 Policies are defined about how the relevant information transferred to the patient is described in the patient s file such as information about the further treatment that can be expected the plan of treatment about requesting a consultation of another medical specialist the consequence of potential side effects 6 4 4 Discharge procedure Does the cancer centre have a discharge procedure 6 4 4 1 6 4 4 1 1 There is a written discharge procedure 6 4 4 1 2 This procedure is regularly assessed 6 4 4 1 3 At discharge information is provided to the patients about patients associations 6 4 4 1 4 At discharge information is provided to the patients about self helping groups 6 4 4 1 5 At discharge information is provided to the patients about home care 6 4 4 1 6 At discharge information is provided to the patients about treatment and
181. r score femke auditor Cc C C 2 B p Appendix VI OECI Accreditation and Designation 57 To view the remarks and the score of the other auditors Questions Note View graphs Feedback a Pain service Does the cancer centre have a protocol guideline for pain control Auditor remarks Auditor remarks Femke auditor 4 The final draft report The Accreditation Coordinator makes a draft report of all the notes remarks scores and strengths and opportunities The auditor will give his her comments and feedback on the draft before it will be send to the institute as explained in the procedures 58 OECI Accreditation and Designation Appendix VI Appendix I Designation Decision Schedule Not for public release Designation Decision Schedule Nr of beds lt 20 Nr of specialists O and If ves Nr of patients O and Nr of scientific papers gt 40 and Budget research gt 500 k and Budget care lt 500 k Cancer unit or clinical cancer centre or CCC Nr of beds and ambulatory day care beds lt 50 Or Nr of patients lt 500 Or Nr of specialists lt 30 Or Nr of scientific publications lt 10 Cancer unit And Centre covered radiotherapy and medical oncology or surgical oncology Clinical cancer centre or CCC Budget for care gt 5000 k Budget for research gt 3000 k Cancer research Centre
182. ractice 1 5 4 1 Yes Mostly Partially No not applicable 1 5 4 1 1 Identification of any risk associated with the introduction of a new technology or new practice is performed systematically 1 5 4 1 2 There is a quality assurance programme for clinical research 1 5 4 1 3 There is a procedure for Serious Adverse Events and Sudden Unexpected Serious Adverse Reaction handling and reporting 1 5 4 1 4 The SOP s are regularly updated and are accessible Appendix Il OECI Accreditation and Designation 11 1 5 5 Quality assurance in all areas Does the cancer centre promote and develop the practice of quality assurance in all areas 1 5 5 1 The quality assurance programmes are included in the global policy for quality and risk management Yes Mostly Partially No not applicable 1 5 5 1 1 Thereis one quality assurance programme in each oncology healthcare area chemotherapy surgery radiotherapy and at risk units anaesthesiology critical care etc 1 5 5 1 2 There is at least one quality assurance programme in areas other than the oncology healthcare area 1 5 5 1 3 All activities of cancer centre follow when applicable the guidelines of Good clinical Practice Good laboratory Practice and Good manufacturing Practice 1 5 6 Quality assurance in all areas HR 1 5 6 1 1 5 6 1 1 Evaluation of the employees is a part of the human
183. ramme 5 1 1 Analyse training needs 5 1 1 1 Yes Mostly Partially No not applicable 5 1 1 1 1 The cancer centre analyses the training needs regularly 5L Based on the analysis the institution defines an annual or multi annual training educational programme for physicians 5 1 1 1 3 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for researchers 5 1 1 1 4 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for nurses 5 1 1 1 5 Based on the analysis the cancer centre defines an annual or multi annual training educational programme for paramedics Sll Based on the analysis the cancer centre defines an annual or multi annual training educational programme for supportive disciplines psychologists etc 5 TAL Based on the analysis the cancer centre defines an annual or multi annual training educational programme for other disciplines please specify in the note 5 4 Process control 5 4 1 Participation in teaching oncology Do the physicians researchers nurses and psychologists in the cancer centre participate in the teaching of undergraduate theoretical courses in oncology 5 4 1 1 Does the cancer centre provide teaching to Yes Mostly Partially No not applicable 5 4 1 1 1 physicians 5 4 1 1 2 researchers 5 4 1 1 3 nurses
184. rescription of anti cancer drugs is available 1 3 1 1 2 A written procedure concerning preparation of anti cancer drugs is available 1 3 1 1 3 A written procedure concerning distribution of anti cancer drugs is available 1 3 1 1 4 The anti cancer drugs are prepared in a centralised unit 1 3 1 1 5 The anti cancer drugs are prepared under the direct supervision of a pharmacist Appendix Il OECI Accreditation and Designation 5 1 3 2 Are there protocols for the administration of cytostatic drugs Administration of cytostatic drugs 1 3 2 1 Mostly Partially No not applicable 1 3 2 1 1 The cancer centre has described procedures or guidelines on the administration of anti cancer drugs 1 3 2 1 2 The anti cancer drugs are as much as possible administrated in specialised wards e g administration of anti cancer drugs takes place only in some well defined wards medical oncology ward 1 3 2 1 3 There is a dedicated day care unit for the administration of anti cancer drugs 1 4 Process control 1 4 1 Continuity of care within the cancer centre Have agreements been reached concerning the continuity of care and replacement of nursing medical paramedical and support staff associated with oncology Is the care covered 7 days a week by specialised staff 1 4 1 1 1 4 1 1 1 Continuity of specialised care is warranted 24 hours
185. rm 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 amp 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 amp D Coordinator The OECI A amp D Coordinator receives the application form through the e tool OECI A amp D Coordinator sends a delivery note to the applicant s institute Examination of the application Executor OECI A amp D Board New applications are discussed in the next teleconference of the OECI A amp 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 amp D Board will make the final decision of approving or disapproving the application Note The OECI A amp D Programme for Cancer Research Centres is not yet developed this is
186. rog sami Accreditation X Designation process QUT e ain coprenemivnetsantrcotoce UES One effort two benefits Home ISQUA 2010 and ESMO 2010 gt About us presentations online SIDER enih ISQUA 2010 and ESMO 2010 5 pe crate ibaa tate Pad jnarlasiousd SRE presentations online CECI present on ESMO 2010 Organizational structure October 21 2010 by Administrator Miran Oescnpton ASD process Go fo Dresemialons in Gre menu Pace i a me Appned cancer insitutes Nttpriceci selfassessmentnulcms node7 Judy 2010 Accreditation and gt OEG stanaaras Adtrintstrsion s blog Desagnation Newslattar Vol 4 is gt How to apply caine You can also go directly to the e tool log in screen as it is illustrated underneath via http oeci selfassessment nu compass user In the log in screen you can use your username and password to enter the e tool application When logged in you can enter the e tool in the following screen Appendix V OECI Accreditation and Designation 43 Go to the qualitative and quantitative questionnaire Home Announcements Move your mouse over the message to view the contents B ole MA OE L cures ty no messages Ovcsnrsanon or Eveootu Cancer Ismus Esnoreas Econame hurrness Gasorwe Or use this link for Useful documents Dac 10_Centre wher monud eTo doc Doe 15 Cantirt Of terest fanm coe oc Ji Accreditation Gossary xt If you go to th
187. rom September 2010 onwards Such a system creates a platform in which synchronization and benchmarking of cancer activities will be possible on an international scale Additionally it is a tool for cancer institutes to ensure and improve their quality level By making an effort to gain a designation status the organisation will be stimulated to disseminate knowledge and to form coalitions with other institutes in Europe that are also designated This allows cancer institutes to benefit from one another and to reach a critical mass in cancer services Owner OECI Organisation of European Cancer Institutes Chapter 1 Introduction of the OECI A amp D Programme Status Revised 24th January 2011 A amp D Working Group Page 1 of 2 Approved by OECI Accreditation and Designation Board Version 16 February 2011 The keyword in the designation of European cancer institutes is the level of comprehensiveness of both professional infrastructure and performance The philosophy behind comprehensiveness is If all relevant competences skills resources and tools concerning cancer care and research are brought together and integrated it will lead to an outcome that is larger on the whole than the sum of its parts Ringborg 2008 Comprehensiveness in that sense can be seen as the new basic principle on how cancer activities institutionally should be organised Four different types of cancer institutes organisations will
188. rovided to the patients about treatment and follow up plans 6 4 4 1 7 At discharge information is provided to the patients about contact details with cancer centre Appendix Il OECI Accreditation and Designation 25 6 5 Safeguarding the quality system 6 5 1 Patient satisfaction experiences Does the cancer centre evaluate the patient s satisfaction experiences related to cancer care 6 5 1 1 Yes Mostly Partially No not applicable 6 5 1 1 1 The cancer centre has a survey method for obtaining the patients opinion about their experiences during consultation 6 5 1 1 2 The cancer centre has a survey method for obtaining the patients opinion about their experiences during day care 6 5 1 1 3 The cancer centre has a survey method for obtaining the patients opinion about their experiences during hospitalisation 6 5 1 1 4 The survey is regularly analysed and corrective measures are planned 6 5 1 1 5 There is a group of patients representing patients and serving as a link between the cancer centre and the patients for advisory and consultation 6 5 2 Conciliatory commission for complaints Does the cancer centre have an identified conciliator or a conciliatory commission for complaints related to cancer care 6 5 2 1 Yes Mostly Partially No not applicable 6 5 2 1 1 The cancer centre has a clearly identified conciliator or a conc
189. s 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 Chapter 3 People and parties involved in the A amp D programme Status Revised 24th January 2011 A amp D Working Group Page 7 of 8 Approved by OECI Accreditation and Designation Board Version 16 February 2011 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 amp D programme and encourage them t
190. s a specific primary prevention clinic or at least one specific primary prevention programme 2 4 4 Oncogenetic clinic outpatient department Does the institution have an oncogenetic clinic 2 4 4 1 Partially No not applicable 2 4 4 1 1 The cancer centre has an oncogenetic clinic for identifying high risk individuals by molecular genetics e g breast cancer ovarian cancer colo rectal cancer endocrine tumours 2 4 4 1 2 Formal relationships exist between the cancer centre and reference genetic laboratories Appendix Il OECI Accreditation and Designation 13 2 4 5 Smoking control in the cancer centre Is there a policy for non smoking in the cancer centre 2 4 5 1 Yes Mostly Partially No not applicable 2 4 5 1 1 a non smoking policy is clearly documented 2 4 5 1 2 support is provided to workers who decide to quit smoking 2 4 5 1 3 any public part of the cancer centre is clearly identified as a smoke free area 2 4 5 1 4 explanations about smoking regulation in the institution are available for patients 2 4 5 1 5 patients are encouraged to quit smoking 2 4 5 1 6 workers are encouraged to quit smoking 2 4 5 1 7 appropriate and specific support is provided to patients who want to quit smoking 2 4 5 1 8 smoking is prohibited to patients possibly with the exception of a restricted smoking room equipped with an appropriate aspiration device 2 4
191. s cooperation agreements etc that are requested in the standards are attached e The list of documents requested by the OECI are attached to the e tool If the documents are not available in English an English summary of the documents should be provided e For questions scored as partially or no are described in a non compliance improvement point The e tool manual for institutes explains how to put the evidence in the e tool Appendix and doc 10 Task Chair of the A amp D Group The Board of Directors of the institute will receive a notification letter of the go decision doc 36 signed by the chair of the A amp D Group Task A amp D Coordinator The contact person of the institute will receive information about the continuation of the programme Concept empty peer review agenda including the audit team doc 16 Explanation on how to fill and complete the agenda Deadline of sending the completed agenda Obligations of the cancer institute for a successful peer review visit e Availability of the staff involved in the peer review visit at the time and location they are expected to be present at according to the agenda e Facilitation of the maintenance of the audit team as agreed in the A amp D Programme Agreement e Providing permission to observe activities or procedures in the cancer institute during the peer review visit e On request of the OECI audit team the institute shall provide access to all relevant
192. s formal cooperation or agreement with at least one university for f l x Yes ZI i a care activities 0 3 You have identified a mon compliance By clicking this link you can dofine or cdit the action to bo taken and sober t the appropriato catosory educational activities Or by clicking on the EP improvement point icon 48 OECI Accreditation and Designation Appendix V Click on Save and new entry in the screen that appears and fill in the items for the improvement 7 ae improvement point Question Title Description educational activities Answer Non compliance Improvement point g planready C O p start Ce p status Click here and a note box will appear to describe the SMART formulated actions E Required state after change pH non compliance p Required actions W prionty p who p deadine e Check the level of quality the institute has achieved per standard Open the qualitative questionnaire Open the show tree OECI Qualitative Questionnaire v3 3 1 General Standards Strategic Plan and General Management lt EQ Policy and organization Domain click on the domain to view the graphs scores eR Oncological policy plan and general report ER Cooperation v th universities 5 Standards in domain Eg Cooperation with external partners Mean scores for each of the 5 standards in the domain Policy and Organi
193. sation in Chapter 1 eg Cancer data registration institutional level is Complications registry Standard Oncology policy plan and general report is gt 50 but also needs attentions Standard Cooperation with university needs attention Appendix V OECI Accreditation and Designation 49 e Close the questionnaire if you will not change or add anything else Questionnaires These are the most recent questionnaires Close the book CECI Qualitative 08 08 05 11 E 264 r g aw of gt Questionnaire v3 2009 2010 264 100 12 L L L L L L a CECI Quantitative 08 08 30 06 Mo 662 al gt a gt Questionnaire v2 2009 2010 0 o amp e Other options Mark questions to discuss in project group meetings Make a note for other people working in the questionnaire Show only the marked or unanswered questions Mark questions that you want to discuss with other people Make a note for other people working on the questions fan went Sar eye Sere t wenrerw f men Rae re Quastessere ty sng crganizetic tel polity Sopersticn sih w poperstign ah ma dala egib Comshtatsns eg sumes end mater es 9 contre ot a5 pard ng the qual app cabie Wg S e ans pomery pre 8 E a The board and or the ec c c it eos t0 0 manegement of the cancer centre has an official re
194. ss QUT e ain coprenemivnetsantrcotoce UES One effort two benefits Home ISQUA 2010 and ESMO 2010 gt About us presentations online SIDER enih ISQUA 2010 and ESMO 2010 5 pe crate ibaa tate Pad jnarlasiousd SRE presentations online CECI present on ESMO 2010 Organizational structure October 21 2010 by Administrator Miran Oescnpton ASD process Go fo Dresemialons in Gre menu Pace i a me Appned cancer insitutes Nttpriceci selfassessmentnulcms node7 Judy 2010 Accreditation and gt OEG stanaaras Adtrintstrsion s blog Desagnation Newslattar Vol 4 is gt How to apply caine You can also go directly to the e tool log in screen as it is illustrated underneath via http oeci selfassessment nu compass user In the log in screen you can use your username and password to enter the e tool application When logged in you can enter the e tool in the following screen Appendix V OECI Accreditation and Designation 43 Go to the qualitative and quantitative questionnaire Home Announcements Move your mouse over the message to view the contents B ole MA OE L cures ty no messages Ovcsnrsanon or Eveootu Cancer Ismus Esnoreas Econame hurrness Gasorwe Or use this link for Useful documents Dac 10_Centre wher monud eTo doc Doe 15 Cantirt Of terest fanm coe oc Ji Accreditation Gossary xt If you go to the questionnaires the following screen appears
195. ss in detail Status Revised 24th January 2011 A amp D Working Group Page 5 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Send signed accreditation and designation agreement Executor Cancer institute The AD Agreement shall be signed by the Director Board of Directors of the cancer institute and sent to the A amp D Secretary The A amp D Secretary will manage to complete the A amp D Agreement with the signatures of the OECI A amp D Chair and of the OECI President Preparation of explanatory visit Executor OECI Accreditation Coordinator The OECI A amp D Coordinator Receives the confirmation of the explanatory visit date and the signed A amp D agreement from the institute or OECI Secretary Drafts the concept explanatory agenda for the cancer institute doc 7 Sends the concept agenda to the cancer institute to complete the agenda with the participants doc 7 Sends the template project plan doc 05 as an example on how to organise the self assessment period in the institute Accommodation and transport for the explanatory visit are booked by the delegates of the OECI A amp D Group Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 6 of 28 Approved by OECI Accreditation
196. st one university for f l x Yes ZI i a care activities 0 3 You have identified a mon compliance By clicking this link you can dofine or cdit the action to bo taken and sober t the appropriato catosory educational activities Or by clicking on the EP improvement point icon 48 OECI Accreditation and Designation Appendix V Click on Save and new entry in the screen that appears and fill in the items for the improvement 7 ae improvement point Question Title Description educational activities Answer Non compliance Improvement point g planready C O p start Ce p status Click here and a note box will appear to describe the SMART formulated actions E Required state after change pH non compliance p Required actions W prionty p who p deadine e Check the level of quality the institute has achieved per standard Open the qualitative questionnaire Open the show tree OECI Qualitative Questionnaire v3 3 1 General Standards Strategic Plan and General Management lt EQ Policy and organization Domain click on the domain to view the graphs scores eR Oncological policy plan and general report ER Cooperation v th universities 5 Standards in domain Eg Cooperation with external partners Mean scores for each of the 5 standards in the domain Policy and Organisation in Chapter 1 eg Cancer data re
197. t team Week 11 12 Discuss comment by Conclusion to centre teleconference e CEC A amp D Coordinator Process conclusions Draft teleconference aD Committee Week 13 14 Analyse draft final vV report CECI Chair audit team g LEMMA oec A amp D Board fr Week 15 vA Approval final report S Template letter Chair A amp D Group approval accreditation _ 0 Week 16 Send final reportto Cancer centre Final report and ia recommendations ON is ns Example explanation improvement plan Figure 6 Step 8 Reporting Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 19 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 5 8 1 Week 1 6 Reporting by the auditors figure 7 CEC Auditor Week 1 Process additional q ke notes in eTool CEC A amp D Coordinator D Week 2 1 Make draft report Draft to audit team EC Auditor gt Week 3 Check draft Comments auditor 3 v CEC Chair audit team gt Week 4 Discuss draft by k teleconference CEC A amp D Coordinator J Make final draft CEC Chair audit team D Week 5 f Check final draft CEC A amp D Coordinator Week 5 and 6 Proceed final Final draft to cancer A corrections centre Figure 7 Week 1 6
198. tarting the project Which goal s would you To achieve a like to achieve Try to define according to the SMART method Specific Measurable Achievable Realistic Time related Steering committee Is there a steering committee present Names of participants and functions Composition of the project team One two persons from each sub project group The sub project groups are small teams of people who are together responsible for a part of the questionnaires One two of the group also participate in the project team Name Position function Responsibilities Project leader in the institute Name e mail Position function Secretary Name e mail Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Member Name Position function Appendix IV OECI Accreditation and Designation 41 Planning of the project Start Explanatory visit 29 June 2010 Number of planned internal meetings When periodically meetings Self assessment period September 2010 as proposed February 2011 1St evaluation with OECI Coordinator Date and with whom and evaluation with OECI Coordinator Date and with whom 3rd evaluation with OECI Coordinator Date and with whom Go no go decision Early
199. te Executor OECI A amp D Coordinator If the OECI A amp D Board approves the institute the A amp 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 amp D Secretary If an institute is approved to apply to the A amp D Programme The A amp 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 amp D Chair The concept planning designation screening explanatory visit self assesment peer review is mentioned in the e mail The A amp D Secretary will plan the explanatory visit date in cooperation with the contact person of the cancer institute and delegates of the A amp D Group Attached to the e mail and letter of approval e A amp D Agreement to be signed doc 6 e Accreditation and Designation Manual with timeline doc 0 Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 3 of 28 Approved by OECI Accreditation and Desi
200. tegory of staff on those issues 6 OECI Accreditation and Designation Appendix II 1 4 3 Compliance with guidelines Have agreements been reached concerning the use of guidelines relating to diagnosis treatment follow up and research 1 4 3 1 Yes Mostly Partially No not applicable 1 4 3 1 1 The medical specialists and the employees of the cancer centre apply the local regional national international guidelines on diagnostics treatment follow up and research 1 4 3 1 2 The guidelines are easily accessible 1 4 3 1 3 The guidelines are updated on a regular basis depending on medical developments 1 4 3 1 4 Each decision that differs from the guidelines is recorded in the file of the patient 1 4 4 Compliance with guidelines Do you report the compliance with multidisciplinary guidelines 1 4 4 1 Yes Mostly Partially No not applicable 1 4 4 1 1 Compliance with guidelines is measured through the registration of the patients cancer data 1 4 4 1 2 Deviations from guidelines are analysed 1 4 4 1 3 Deviations from guidelines are discussed 1 4 4 1 4 Deviations from guidelines are reported annually 1 4 5 Tasks and responsibilities of the oncology nurses Have agreements been reached concerning the tasks and responsibilities of nurses working at the oncology department 1 4 5 1 1 4 5 1 1 For each technical clin
201. tify the score if there is no document available AND e Adding the requested documents How to attach a document to a specific question Click on the globe 2 icon and the following screen appears The question where you are attaching a document at The cancer centre has procedures or guidelines regarding information transfer on diagnostics treatment follow up and supervision of the patient There are no documents Upload new file Orn een nieuw document toe te voegen gaat u met de knop Zoeken naar de lokatie waar het document staat Kiik vervolgens op Toevoegen 1 Browse for the document in the institute s document 2 Click to add the document 3 Return to the questions Under the a has appeared nr 1 between brackets for one attached document To get an overview of the specific questions that contain a document you can close the questionnaire and click on the icon in the table under evidence Questionnaires ES Questionnaires These are the most recent questionnaires EA CECI Qualitative 08 08 05 11 E 264 Pi am Ley oY gt Questionnaire v3 2009 2010 264 100 E amp L L L D Ye CECI Quantitative 08 08 30 06 o 662 a Questionnaire v2 2009 2010 0 46 OECI Accreditation and Designation Appendix V How to refer to a document that is already attached Click on the note box icon A note box appears under the s
202. tion 4 1 1 1 Yes Mostly Partially No not applicable 4 1 1 1 1 There is an organisational and hierarchical structure specifically for research innovation and development 4 1 1 1 2 A Scientific Advisory Board meets on a regular basis and advice the board of the cancer centre on its research activities 4 1 1 1 3 The Scientific Advisory Board verifies the quality of the research activities 4 1 1 1 4 The Scientific Advisory Board verifies the coherence of the objectives of the different research programmes and the cancer centres objectives and strategy at least annually 4 1 2 Research collaboration 4 1 2 1 4 1 2 1 1 The cancer centre has a strategy on collaboration and networking 4 1 2 1 2 The cancer centre participates in national and international research projects 4 1 3 Organisation of clinical research 4 1 3 1 Yes Mostly Partially No not applicable 4 1 3 1 1 There is a dedicated clinical research management unit 4 1 3 1 2 It is the task of the unit to have a strategy for promoting the conduct of clinical trials 4 1 3 1 3 It is the task of the unit to ensure the management that the conduct of clinical trials is according to the Clinical trials protocols 4 1 3 1 4 It is the task of the unit to ensure administrative scientific and ethical legal review and approval of new Clinical trials 4 1 3 1 5 Itis the task of the u
203. tion e Export audits to memory stick e Memory stick application update release 23 April 2008 e Memory stick database update release 23 April 2008 Documents that can be useful for the auditors during the programme Manu roc 05_Template_Project plan cancer centre doc Doc 09 _List requested documents self assessment centres do Doc 14 Confidentiality agreement auditors doc Doc 15 Conflict Of Interest form doc Doc 19_ Template final peer review report docx Doc 21_Template_reimbursoment form auditors _v2 xls Doc 32_OECI Travel policy and coverage rules_revised 10 11 2010 goc Doc 34 Accreditation Glossary xls Joc 34_ Designation form auditors 16 08 2010 doc Auditors user manual eTool_vi doc In the Workspace you can go to the questionnaires of the institutes that have been assigned to you by the OECI Accreditation Coordinator 54 OECI Accreditation and Designation Appendix VI sapja aH Home Questionnaires Show help Logout femke auditor Workspace Wir Click on the institute of your choice the table with the qualitative AND quantitative questionnaire of that institute will appear From this window there are several options for the auditor Question Progress 3 Go to the document the institute has attached including the documents requested by the OECI 4 Go to the document the institute has attached to a specific question
204. tion and Designation 51 tena oo EERE o Print only the questions or Format the full results Fte format iwcrosart word z Peper forent ae Print in Word or PDF Ortentation Portret j Size A4 or A3 View Portrait or Landscape F Show page numbers F toute sided Footer ECI Quatitative Questionnaire v3 08 11 2010 Tithe page F Show titie page Tite fOECt Quaiitati ve Questionnaire v3 Sabtide Questions Show F Start eaeh chapter at anew page n Show help F Show standards F show mints Click for other options r Space for nores D Space for recommendations Space for documents Z Bookmarks 52 OECI Accreditation and Designation Appendix V Appendix VI User manual e tool for auditors This user manual gives an explanation of how OECI auditors can use the OECI electronic tool The great advantage of the tool is that the auditors of a team can communicate with each other regardless of their physical location An auditor can prepare a peer review individually by analysing the questionnaires and documents and an auditor can add notes to questions which are unclear or which the auditor would like to discuss with the audit team 1 Log on AOEC OECI Accreditation and Designation Oncaesanon oF Exnorean Cancer lesrireres Progra mme Exworcun Econom burenesy Ceoorme Home tool Accreditation A Designation process One effort two benefits ISQUA 2010 and ESMO 2970 presentations onbre gt Home
205. tion and developments 14 45 17 4 1 Policy and organisation 7 25 4 3 Resources and materials 3 12 4 4 Process control 3 4 4 5 Safeguarding the quality system 1 4 Chapter 5 Education and teaching 4 19 7 5 1 Policy and organisation 1 7 5 4 Process control 3 12 Chapter 6 Patient related 6 30 11 6 4 Process control 4 21 6 5 Safeguarding the quality system 2 9 6 4 3 Informing patients about results treatment and counseling Sa asi Have agreements been reached on informing oncology patients about the results of diagnostic tests about treatment and follow up treatment and about counseling in terms of how it is done and what it means 5 x Yes Mostly Partially No Not Delete Markeer i Q The cancer centre has procedures or guidelines 0 0 regarding information transfer on diagnostics treatment follow up and supervision of the patient Sub standard Possible scores The score is an indicator for the stage of implementation of each item of the standard The scoring system is based on the Plan Do Check Act circle or Deming circle These four stages of implementation are translated in the following possible answers e Yes means that the indicator of the standard has been implemented on a wide scale in the cancer institute and the Deming cycle is completed at least twice gt in third cycle e Mostly means that the indicator has been implemented in most of the critical places in the cancer institute and the Deming cycle is co
206. tivities 4 1 5 1 3 Regular information and meetings about research results 4 1 5 1 4 Promotion of integration of research activities into clinical activities 4 1 5 1 5 Organisation of integration of research activities into clinical activities 4 1 6 Internal review and evaluation of grant proposals Is there a procedure in place for internal review of grant proposals before submissions 4 1 6 1 Yes Mostly Partially No not applicable 4 1 6 1 1 There is an internal review of grant proposals before submission to the funding organisation 4 1 6 1 2 There is an internal evaluation of the success of the grant proposals 4 1 7 suspected scientific misconduct Is there a procedure in case of suspected scientific misconduct 4 1 7 1 Mostly Partially No not applicable 4 1 7 1 1 There is a procedure for dealing with scientific misconduct Appendix Il OECI Accreditation and Designation 19 4 3 Resources and materials 4 3 1 Means for conducting research activities Does the cancer centre have the means for conducting its research activities 4 3 1 1 Yes Mostly Partially No not applicable 4 3 1 1 1 The budget for cancer research is clearly and yearly defined 4 3 1 1 2 The cancer centre provides access to facilities for research activities 4 3 1 1 3 The cancer centre provides resources and me
207. ty of specialised care is warranted 24 hours a day on the medical paramedical nursing and supportive levels This can among other things be achieved by planning continuity of care during nights week ends holidays illness attendance at conferences or other reasons for absence within each discipline 1 4 1 1 2 Patients are informed about all the aspects of the continuity of care and eventually referred to another hospital 1 4 1 1 3 The patient receives information about the contact person for medical and nursing oncological matters 1 4 2 Waiting and throughput times Have norms standards been defined concerning the maximum waiting and throughput times for oncological patients with regard to first outpatients visit admission and tests treatment 1 4 2 1 There are guidelines for different types of tumours for the maximum waiting times between 1 4 2 1 1 referral by the general practitioner or referring specialist and the first visit to the outpatient s Clinic or the admission into the cancer centre 1 4 2 1 2 first visit and the time of definitive diagnosis 1 4 2 1 3 definitive diagnosis and first treatment 1 4 2 1 4 There is a record of those waiting times 1 4 2 1 5 There is continuous measurement and analysis of those waiting times leading to improvements when needed 1 4 2 1 6 There is a clear definition of the roles of each ca
208. uing 5 e yems Click on all questions for this list Choose one of the options All questions and the show tree will only show the marked or Mandatory unanswered Marked Unanswered 50 OECI Accreditation and Designation Appendix V 3 Quantitative questionnaire Questionnaires 2 OEC Qualitative 08 08 osar W s t jail ae o TT Questionnaire v3 2009 2010 264 100 pt lt E amp L E ia W lt 7 De CEC Quantitative 08 08 30 06 Mo 662 ee ga PANI 0 k Questionnaire v2 2009 2010 1 1 Cancer centre Qe Menegeme t Sure Concer contre strectere Cissrdution evees ond Sudge Project OECI Quality Improvement Project Working Group Accreditation WGA Nome of the concer cectre ct 2 Itnfrestructeres amp 3 Humes resources E M Reveores v Gjt vaten Address The show tree with all The quantitative questionnaire has hanters arid domiaiti also an option for adding notes to enablers sara Corals clarify an answer lt a Questionnaires Documents Report Progress Start es OEC Qualitative 08 08 osar M264 t pa i py ve T Questionnaire v3 2009 2010 264 100 amp g A 2 ig t es CECI Quantitative 08 08 30 06 Wo 662 i oy gt Questionnaire v2 2009 2010 0 amp The following screen appears with several options Appendix V OECI Accredita
209. um 2 gt Questionnaire v2 2009 2010 0 amp 7 Appendix V OECI Accreditation and Designation 47 The following screen will appear Follow step 1 2 and 3 Start Questionnaires Documents Report Progress Documents These are the documents that are of value to you as a user and to the auditors They are only visible to you as user and to th auditors that have been assigned You can add documents to the list by selecting them select a folder and press Upload Large documents may take a while to be uploaded please be patient in that case 1 Click to choose the kind of document you are going to add Map 38 2 Guidetir i These are the options the Document system will arrange the documents Guidelines v Feedback ae Guidelines 2 Search for the document in your system 3 Upload the document Audit reports Action lists Requested documents Risk related documents Quality documents Other documents e Step 3 Add a non compliance improvement point If you have scored a question with partially or no a red sentence appears under the question that a non compliance point has been identified This means that quality improvement can be made regarding this substandard by the institute The institute is required to describe an improvement point by Clicking on the red line 1 1 2 Cooperation with universities he cancer centre ha
210. urnal of the OECI that the Platform chose as official dissemination body The Authors thank the OECI in its role of Publisher of this first Edition and for the financial support coming from WP14 of EurocanPlatform managed by the OECI Coordinating Secretariat and Liaison Office headed by Claudio Lombardo As a result of these combined efforts the OECI Accreditation and Designation A amp D Group is proud to release the First version of the OEC A amp D Manual We hope this Manual will support Cancer Centres in a successful A amp D Programme On behalf of the OECI A amp D Group abd Mahasti Saghatchian MD OECI A amp D Chair 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 amp D programme on multidisciplinary global and integrated cancer care and research with a major focus on comprehensiven
211. utor OECI A amp D Coordinator The OECI Accreditation Coordinator will check if all the auditors have replied and signed doc 13 14 and 15 Composition of peer review agenda Executor OECI A amp D Coordinator Specify the template peer review agenda for the cancer institute Send concept agenda to the chair of the audit team for approval Owner OECI Organisation of European Cancer Institutes Chapter 5 Ten steps A amp D process in detail Status Revised 24th January 2011 A amp D Working Group Page 11 of 28 Approved by OECI Accreditation and Designation Board Version 16 February 2011 Finishing self assesment Executor Cancer institute Six months after the beginning of the self assessment period the institute has completed the questionnaires and closed the self assessment in the e tool Quantitative questionnaire Qualitative questionnaire Notes to support scores Requested proof documents and other proof documents attached to questions Described non compliance points improvement points Analyse self assesment results Executor OEC A amp D Committee To analyze and examine the self assesment reports before peer review To analyze the proof documents for peer review To analyse the results of the self assesment To advise the Accreditation Board concerning a go no go decision Owner OECI Organisation
212. ve a cytology laboratory mlilelees Do you have a histopathology laboratory 2 11 2 If on site Yes No 2 11 2 1 immunofluorescence techniques 2A 2 Histochemistry 2 11 2 3 flow cytomitry 2 11 2 4 Techniques for molecular biology and genetics by cytology by biopsyon large pieces of excision Please specify the number of samples for tumour pathological diagnosis per year at your cancer centre 32 OECI Accreditation and Designation Appendix III 2 12 Haematology unit 2 12 1 On site Access to Not available 2 12 1 1 Do you have a transfusion centre 2 12 1 2 Do you have a bone marrow bank 2 12 2 Number of laminar flow rooms 2 12 3 Allogenic stem cell Autologous bone marrow Autologous stem cell Please specify the number of bone marrow stem cell transplants per year 2 13 Oncology Multidisciplinary team 2 13 1 Members are Yes No 2 13 1 1 Medical oncologist or equivalent 2A E2 Surgical Oncologist 2 13 1 3 Radiotherapist 2 13 1 4 Radiologist 2 13 1 5 Pathologist BM BolhlS Nurses 2 13 1 7 Others 2 14 Palliative care team 2 14 1 Members are Yes No not applicable 2 14 1 1 Anaesthetist Physician specialising in pain treatment 2 14 1 2 Medical specialists including psychiatrist and medical oncologist 2 14 1 3 Nurses 2 14 1 4 Psychologist 2 14 1 5 Anaesthesist
213. with whom Go no go decision Early March 2011 Planned peer review Early May 2011 Planned end date Communication reporting method To When time Method Owner Board of the institute e mail written form meeting Steering committee e mail written form meeting Project team e mail written form meeting Quality committee e mail written form meeting Others Staff Patients Intranet Institutional information media Communication of the final self assessment results To When time Method Participants Date at end of self How assessment period Which extra means are necessary Time considered needed Project leader in the institute OECI Accreditation Coordinator Time project members for each person Time blanks exercise for participants Pending further assessment according to identified needs Financial means Pending further assessment according to identified needs Planning payment of fee stage 1 and 2 Other resources e g training education meeting costs Pending further assessment according to identified needs 42 OECI Accreditation and Designation Appendix IV Appendix V Self assessment user manual for institutes 1 Log in Go to http oeci selfassessment nu AOEC OECI DETTY cick to go to tne ULEC Designation E tool Oacuesanon or Esasen Cancer bermris P
214. year x coordinated in year x grants partnership funding Research funding sources total X X X X X amounts received 2008 4 4 3 Number of patents over the last 5 years 4 4 4 Number of peer reviewed publications X per year year x national 4 4 5 Number of peer reviewed publications X per year year x international 4 4 6 Impactfactor cumulative 4 4 7 Number of publications with X impactfactor gt 10 Appendix Ill OECI Accreditation and Designation 39 5 Education 5 1 Education 5 1 1 Planned annual budget for education year x Euros 5 1 2 On site Access to Not available not applicable 6 1 2 1 An information centre for cancer patients 5112727 Medical library 5 1 2 3 Online access via internet 5 1 3 Yes No not applicable 5 1 3 1 Educational courses organised by the cancer centre on site 51192 with local audience 5 1 3 3 with national audience 5 1 3 4 with international audience 5 1 4 Number of medical students per year 5 1 5 Number of graduate postgraduate students 5 1 6 Number of physicians under specialist training per year 5 1 7 Number of nurses under specialist training per year 5 1 8 Number of nurses students per year 5 1 9 Number PhD students 5 1 10 Number of PhD theses per year average last 5 years 5 1 11 Number of University Faculty associate Professors

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