Accreditation of cancer centres: Which ones?

1. Accreditation of cancer centres: Which ones? Process and rationale of selection of cancer centres Renee Otter October 2008

2. Hypothesis : hospital outcome Structure medical organization Patient satisfaction professionals R. Otter, M. Gort, 2005

3. Hypothesis : input hospital outcome Structure medical volume organization Patient satisfaction professionals R. Otter, M. Gort, 2005

4. Accreditation=Quality improvement instrument in oncology • Aim: improvement of outcome and patient’ satisfaction taking into account organisation, process and structure faster • Most of the existing accreditation systems: department oriented instead of patient centered (oncology is multidisciplinary and patient oriented) • Combination of available tools ánd usefull collaboration Accreditation ánd visitatie • Self assesment and annual follow-up • Peer review (once per 4 years) to discuss the self assessment results and to give recommendations • monitoring improvements, bench marking and exchange of best practices

5. OECI Definition of accreditation • Through peer reviews discuss, with managers and professionals of the institution, the differences between the local situation and the required norms and criteria with regard to the organisation, structure and process of the oncological care, in order to give recommendations for improving the quality of oncological care, research, innovation and education. • In a second step medical outcome criteria might be put into the system.

6. Conditions for participations • Based on: • Experience of the 7 pilots • Experience from accreditation institutes (NL, FR, Canada, UK) • Aim: • It has to make sense for the institute and the auditors to peer review

7. Needs for successful accreditation • Validated self evaluation electronic guide covering all the different domains in oncology and quality of care/cure • Auditors: criteria and professional training • Criteria with regard to the selection of institutes/ hospitals/centres to be visited • Transparent procedure with regard to the accreditation system

8. Conditions for the selection of institutes (1) • Members of the OECI • Sufficient cases of one of more different kind of cancer patients • Different disciplines involved in cancer diagnosis and treatment (f.e. more than one department or a radiotherapy centre only) • The management board of the institute supports and agrees with the participation of the accreditation • The institute has signed the expression of interest, including the fee for the accreditation procedure • The institute has transferred the fee to OECI before the accreditation has started

9. Conditions for the selection of institutes (2) • The institute has a trained quality manager with enough time to be in charge of the coordination of the electronic tool, the peer review and the follow up( preparation of improvement plan and realisation of the implementation). • The electronic tool is supported by a ICT specialist (institute board agrees on it) • The institute has filled in the electronic tool and will provide the documents requested if available

10. Conditions for the peer review (1) • Phase 1:the institute sends in a demand for an accreditation to the OECI • The form of expression of interest should have been signed • The fee is transferred

11. Conditions for the peer review (2) • Phase 2: Go – no Go decision • The self evaluation has been filled in and send to the OECI • All the documents available according to a list of required documents are also send to the OECI • The institute has discusses the results out of the SE with the professionals and the managers • A first draft on the conclusions (and how the quality might be improved has been set up) are send to the OECI • This set of information (SE,Documents,1st conclusions) is send to the auditors who will check the information (the situation of the quality of the institute with regard to the plan-de –check-act circle); there is a difference between the1st visit and the next one (after a first peer review with recommendations) • Go no-go decision will be made by the auditors and communicated to the institute.

12. Phase 3: (go) • Date, agenda and the auditors of the peer review are fixed • The auditors visit the institute and give the first conclusions • A concept report including the findings, the strengths and weaknesses, is send to the board of the institute to be checked on correct information (within 6 weeks). • The definitive report is send to the board of the institute including recommendations approved by the OECI accreditation board (within 3 months after the peer visit if the institute reacts within 4 weeks).

13. Phase 4: the accreditation “stamp” • Max. 6 months after the peer review the recommendations are send to the institute • Within 6 months the institute sends a QI action plan to the OECI • The auditors will check this plan in accordance to the recommendations and the norms • Within one month the OECI will let know whether the “stamp” will be delivered

14. The accreditation “stamp” • The conditions are • An evident presence of QI culture in the institute: • A QI plan (max 12 months after the 1st visit) and visual results (at the next visits) • Enough procedures to guarantee the quality • Implemented procedures to keep what is good or what has been recently implemented (described in the plan) • Monitoring and systematic checking of the results • A justifiable confidence in the quality of the institute • The auditors decide whether they are confident with the delivery of good enough quality of all the different domains covered by the peer review

15. Phase 5: future = next accreditation • Additional focus on • the implementation of the QI action plans • the guarantee to keep the good

16. Phase 2 First draft of QI plan send to auditors Decision Go no-go Peer review Self evaluation tool + documentation Checked by auditors Phase 3 Report recommendations Self evaluation tool Phase 1 Demand QI actionplan on all domains Phase5 Phase 4 Evaluation Implementation of action plan Implementation of QI actions Decision Accreditation stamp

17. In conclusion • QI is a continuing story • QI implementation needs the commitment of the management board and the staff • QI needs a Q manager • Accreditation is only one of existing tools to speed up the QI system • Advantages: focus on oncology, bench mark and identification of best practices