1 TOWARDS QUALITY, COMPREHENSIVENESS AND EXCELLENCE: THE ACCREDITATION PROGRAMME OF THE OECI FOR CANCER INSTITUTES Dr. Mahasti Saghatchian Chairwoman OECI Accrediation WG OECI ACCREDITATION Kick Off 16 October 2008, Paris
Dec 14, 2015
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TOWARDS QUALITY, COMPREHENSIVENESS AND EXCELLENCE: THE ACCREDITATION PROGRAMME OF THE OECI FOR CANCER INSTITUTES
Dr. Mahasti Saghatchian
Chairwoman OECI Accrediation WGOECI ACCREDITATION Kick Off
16 October 2008, Paris
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The mission of the OECI
LinkCoordinate
Interdisciplinarity Improve the quality of cancer care
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Cancer Care/researchProfessionals
and Organisations
(Research) Funders (Industry)
The Cancer World
Patients Health AuthoritiesThe Cancer
Centre/institute/Unit/department
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FOCUS OF THE PROGRAMME
Patient centered Planning and Organisation interactions among various
professionals for multidisciplinary care
integration and translation of research into care
Search for quality improvement
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PRINCIPLES OF THE PROGRAMME The focus is on the patient: the comments and level of
satisfaction of patients Safety of care: safety is one of the major dimensions of
quality of care, and one of the main expectations of patients.
Continuous quality improvement: quality management system
Involvement of professionals working in the health care organisation : It is essential that everyone participate in such initiatives, so that they will accept changes and adopt appropriate solutions.
Continuous assessment and improvement of the assessment process: research on indicators providing proof of principle
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The OECI Accreditation Working Group
Need for Members involved in everyday specialised patient care participating in medical care and research, in
healthcare institutions management researchers from national agencies involved
in Healthcare assessment or insurance. involvement of patient groups Support from professional cancer societies
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The OECI Accreditation Steering Group
Integration of activities through the involvement of a common steering
committee at every-decision making step
Wim van Harten, Amsterdam Renée Otter, Groningen, Ulrik Ringborg, Stockholm, Mahasti Saghatchian, Chair, Villejuif, Thomas Tursz, Villejuif, Dominique de Valeriola, Brussels Angelo Paradiso, Bari Chris Harrison, Manchester
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Auditors Panel
Link toNational Bodies
ResearchGroup
OnIndicators
Collaboration with
Professional Cancer
Societies
PATIENTS Standing
Committee
STEERINGGROUP
STEERINGGROUP
OECI ACCREDITATIONWORKING GROUP
OECI ACCREDITATIONWORKING GROUP
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PROFESSIONAL STAFF OECI AWG Programme ManagerHenk Hummel, Groningen OECI AWG e-tool designer and
webmasterBert Koot, Compusense OECI AWG coordination secretariatCecile Tableau, France
3 years of patient, tough, amazing 3 years of patient, tough, amazing hard work …hard work …
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Accreditation system : What is needed ? Standards and criteriaStandards and criteria for quality
multidisciplinary cancer care delivered in cancer centres throughout Europe,
A processA process allowing to survey the cancer centres in order to assess compliance with those standards,
A toolA tool to collect standardised and quality data from approved cancer centres, to measure treatments patterns and outcomes.
Results of self-evaluation + proof documents provided to auditors
2 Days meeting: Day 1: Auditors meeting: Review of self
evaluations S.G meeting: Day 2: S.G meeting: Consensus on peer To agree on changes to be made
review system (tasks and responsibilities to the questionnaire and the process of people involved in the auditors group)
Final Draft of questionnaire and process to be agreed at a S.G meeting
June End Nov. 2nd half Jan. May End June Sept. Dec. February 2007 2007 2008 2008 2008 2008 2008 2009
6-7 Feb 20-21 Feb 9-10 April 23-24 April 2008 2008 2008 2008 Group A: Renée Otter, Wim van Harten, Mia Bergenmar, Jean-Benoît Burrion, Henk Hummel, Cécile Tableau.
Self Peer review visits Analysis and Update Brussels Bari Dijon Budapest review of the of the Evaluation Group A Group B Group A Group B Pilot 2 results tool
Kick off meeting of the Accreditation
process with all OECI members
and partners
Recent Recent ProgressProgress
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Electronic OECI Electronic OECI accreditation toolaccreditation tool
(Web-based)(Web-based)
OECI Accreditation Tool now ready to use !Standards and criteria (qualitative questionnaire)
+ scoring system based on compliance level
+ Quantitative questions
Translated into an electronic manual
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Demonstration oeci.selfassessment.nu
14How to enter the OECI Accreditation programme ?Step 1 of the application process : “Applicant Cancer Institute” submits an
application to the OECI Accreditation working group, expressing interest in the OECI Accreditation Programme (deadlines in May and November).
The OECI Accreditation Steering Group will evaluate each of the expressions of interest primarily focusing on comprehensiveness
Following the review of applications, the best proposals from “Applicant Cancer Institute” will be invited to join the full programme : Programme Agreement proposal with starting date proposal
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Programme Agreement
Governs the Relationship between the Cancer Institute and the OECI Accreditation group
financial agreement confidentiality and intellectual property
rights Rights and obligations of all parties Individual Programme Timetable with exact
dates
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Timelines of Accreditation Porgramme
E:\Timelines of the Audit process .doc
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Costs
Costs covered by
Cancer Institute
OECI Accreditation
SG Step 1 : Application submission and approval Cancer Institute Applicant: Submits application OECI Acc SG : Reviews and selects applications OECI Secretariat: Notifies the Cancer Institute => Signature of programme agreement – Advance payment of Step 2 costs by the Cancer Institute (2500 €)
Free of charge
Covered by OECI WG (secretariat
costs)
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Costs
Costs covered by Cancer
Institute OECI
Accreditation SG
Step 2 : Self evaluation by Cancer Institutes using the Accreditation E-tool Cancer Institute: - Appoints Quality manager - Agrees on date for explanatory visit and inform Cancer Institute staff - Performs self evaluation OECI Acc SG: - Auditors selection and training - Quality manager training - Explanatory visit on site - Evaluation of self-evaluation results - Go / No go decision for peer-review => Go / No go decision – Planning for peer-review – Advance payment of Step 3 costs by cancer institutes
2500 €
2000 €
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Costs Costs covered by
Cancer Institute
OECI Accreditation
SG Step 3 : Peer review visit – Report and recommendations Cancer Institute: - Provide Proof documents - Appoint staff members participating in peer review visits OECI Acc SG: - Preparatory meeting for auditors - Peer review visit on site (6 visitors, 3 nights) - Report- recommendations – Certificate - Improvement plan meeting on site
Accreditation Programme Certificate
12500 €
4500 €
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Costs
During the whole process, OECI Accreditation Working
Group covers secretariat, administrative,
coordination and management
costs: 95 000 € / year.
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Further actions
Support and Approval of process Support and Approval of process
by Stakeholdersby Stakeholders Patients, professionals EC recognition and support : 7 FP Coherence with national programmes Tool update Designation Projects Benchmarking tool development
An Objective : Quality of cancer care An Objective : Quality of cancer care
A Goal : More ComprehensivenessA Goal : More Comprehensiveness
The challenge : Assessment / ValidationThe challenge : Assessment / Validation
A project : The OECI Accreditation A project : The OECI Accreditation ProjectProject
A tool : OECI Acc. ToolA tool : OECI Acc. Tool
Validation of tool / AcceptanceValidation of tool / Acceptance
Dissemination to OECI CentresDissemination to OECI Centres
Definition of Catgories of Cancer Definition of Catgories of Cancer StructuresStructures
Designation ProjectDesignation Project
Validation through quality indicators Validation through quality indicators
Link quality to outcome / BenchmarkLink quality to outcome / Benchmark
INTERNAL DEVELOPMENTSINTERNAL DEVELOPMENTS
23Collaboration : A Necessity for improvement
Quality standards/criteria must be approved by consumers and providersconsumers and providers (patients and health authorities)
Quality standards/criteria must be approved by professionalsprofessionals (professional societies and peers)
The process must be disseminated in cancer structures at national level and all over at national level and all over EuropeEurope
Harmonisation and integration is the key: overlapping and duplication should be avoided
An integrated and open approach An integrated and open approach is the leading principleis the leading principle
EXTERNAL DEVELOPMENTSEXTERNAL DEVELOPMENTS
Links with Links with FundersFunders
International International Links (US, Links (US,
Canada) Canada)
EU EU recognitionrecognition
In depth In depth Tumour Tumour Specific Specific AccreditationAccreditation
In depth In depth Professional Professional
AccreditationAccreditation
National National ApplicationApplication
Patients Patients InformationInformation
Public Public ReportingReporting
Driving Driving Industrial Industrial strategy strategy
OECI OECI AccreditationAccreditation
inform the authorities, public
and the patients
facilitate the sharing of expertise
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Long-term Impact Improved care to individualsImproved care to individuals Strengthened community confidence in the Strengthened community confidence in the
quality of continuous care in the hospitalquality of continuous care in the hospital Healthcare professional education on Healthcare professional education on
standards of high quality care standards of high quality care Stimulation of quality improvement efforts Stimulation of quality improvement efforts
if the accreditation recommendations are if the accreditation recommendations are implemented after the accreditation implemented after the accreditation processprocess
Objective evaluation of the hospital’s Objective evaluation of the hospital’s quality of care quality of care
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Long-term Impact Potential for improved liability insurance Potential for improved liability insurance
coveragecoverage Comparative assessment of care Comparative assessment of care
structures structures Provision of a more coherent overall Provision of a more coherent overall
vision with a clear evidence basevision with a clear evidence base Report provided to the public Report provided to the public More harmonisation and equity for More harmonisation and equity for
patientspatients
OECI Accreditation Programme
Cancer Care / Research
Professionalsand Organisations
(Research) Funders (Industry)
Patients Health AuthoritiesCancer
Centres
A c c r e d i t a t i o nA c c r e d i t a t i o n
A new alliance between the Cancer Institutes and their partners
in the continuous progress and search for excellence
of research and care in oncology