Dr. Mahasti Saghatchian Chairwoman OECI Accrediation WG OECI ACCREDITATION Kick Off

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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 OECILink

CoordinateInterdisciplinarity

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

4FOCUS 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

5PRINCIPLES 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

6The OECI Accreditation Working GroupNeed 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

7The 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

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 …

10Accreditation 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

13Demonstration 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 AgreementGoverns 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

16Timelines of Accreditation Porgramme E:\Timelines of the Audit process .d

oc

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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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CostsDuring the whole process,

OECI Accreditation Working Group covers

secretariat, administrative, coordination and management

costs: 95 000 € / year.

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Further actionsSupport 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 Europe at national level and all over Europe

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 patientsfacilitate 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 if Stimulation of quality improvement efforts if

the accreditation recommendations are 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