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The OECI model: the CRO Aviano experience

Abstract

In 2012, the “Centro di Riferimento Oncologico” (CRO) National Cancer Institute joined the accreditation program of the Organisation of European Cancer Institutes (OECI) and was one of the first institutes in Italy to receive recognition as a Comprehensive Cancer Center. At the end of the project, a strengths, weaknesses, opportunities, and threats (SWOT) analysis aimed at identifying the pros and cons, both for the institute and of the accreditation model in general, was performed. The analysis shows significant strengths, such as the affinity with other improvement systems and current regulations, and the focus on a multidisciplinary approach. The proposed suggestions for improvement concern mainly the structure of the standards and aim to facilitate the assessment, benchmarking, and sharing of best practices. The OECI accreditation model provided a valuable executive tool and a framework in which we can identify several important development projects. An additional impact for our institute is the participation in the project BenchCan, of which the OECI is lead partner.

Tumori 2015; 101(Suppl. 1): 10 - 13

Article Type: REVIEW

DOI:10.5301/tj.5000456

Authors

Lucia Da Pieve, Raffaele Collazzo, Monica Masutti, Paolo De Paoli

Article History

Disclosures

Financial support: This work was financially supported by the Ministry of Health-Italian Government within the Finalized Research Project Code: RF-2009-1532731. (Coord.: A. Paradiso, F. Belardelli).
Conflict of interest: The authors declare no conflict of interest.

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Introduction

In the more than 30 years since the establishment of the “Centro di Riferimento Oncologico” (CRO), the history of this institute has been marked by the ability to make innovation a key element of its organizational culture and mission.

Innovation, both in the clinical and organizational fields, means to give up focusing exclusively on perfecting the existent processes, and evidencing and integrating up-to-date results from analyses, research, and evidence-based best practices.

This awareness led CRO over time to adopt and integrate different continuous improvement systems, each one characterized by different aims and focus. Currently, CRO has joined in several programs, such as Organisation of European Cancer Institutes (OECI) accreditation, International Organization for Standardization (ISO) 9001 certification, Accreditation Canada International accreditation of excellence, and Joint Accreditation Committee of the ISCT and the EBMT (JACIE) transplantation accreditation.

In this context, the OECI accreditation process represented an important evolution of the quality management system: it was clear that adopting a tool to facilitate the self-assessment of specific elements (standards) related to our core activities, namely research and care in oncology, would widen the reference points as well as start a constructive debate at an international level.

The purpose of this article is to share our experience gained in the first cycle of accreditation with the OECI. The dissertation is structured on 2 distinct levels: a general level, or system level; and a more specific level, which concerns the impacts of the accreditation on our institute. The added value of international accreditation with a specific focus on research and oncology is made explicit, while challenges and proposals for improvement are included in the discussion.

OECI accreditation at CRO: evaluation 1 year after obtaining the designation of Comprehensive Cancer Center

The OECI project at CRO was coordinated by the Scientific Directorate and the quality team of the institute, supported by 6 internal working groups within which representatives of voluntary organizations and patients were also involved.

The outcome of 2 years of work by the coordinating group and the staff at all levels was the designation of Comprehensive Cancer Center status, which honors the quality of the job done in terms of clinical and research activities and recognizes the ability of the organization to evolve and remain competitive and innovative (Tab. I).

Timeline of the first cycle of Centro di Riferimento Oncologico accreditation

Preparatory meetings and activities Application and designation screening Self-assessment Go-no-go decision Peer review and reporting Drafting and approval of the improvement plan Certificate decision Improvement plans
Nov-Dec 2012 Jan-Mar 2013 Apr-Nov 2013 Dec 2013 Feb-Jun 2014 Jul-Aug 2014 Oct 2014 2015/2016

The CRO was among the first institutes in Italy to begin the process of OECI accreditation in 2012 (1), because of its previous experience in accreditation of excellence with ­Accreditation Canada, which was the knowledge base for the integration of the European protocol. This seniority required effort for the integration of different approaches and allowed us to evaluate the different systems from a privileged point of view.

Details on integration and complementarity between systems have been published previously (2).

Same priorities as other systems

One of the major strengths of the accreditation model of the OECI was the consistency of the priorities highlighted in the standards and priorities issued locally (regional programs), nationally (recommendations and ministerial programs), and internationally (Accreditation Canada, Program Qmentum International).

For example, some macro-themes that can be found across the different programs are processes and outcomes measurement, training and skills improvement, effective internal and external communication, an emphasis on technological innovation, patient safety, and patient involvement (3).

Among the advantages of a common approach to strategic priorities is the possibility to structure the improvement plans in terms of programs rather than single improvement actions, therefore limiting fragmentation of the interventions and increasing systemic actions.

Assessment vs reevaluation

Consistency among systems does not necessarily mean that they exchange information; this is the starting point on which we based our suggestions for improvement. It would seem beneficial for all stakeholders to invest in the development of sharing systems for mutual acknowledgment among accrediting bodies.

At present, each body is committed to the development and updating of standards but also the assessment of state-of-the-art healthcare facilities against the criteria, some of which are often similar to those reported in other manuals. The costs of this approach are particularly evident in the site visits, when they are often likely to activate a cumbersome process of revalidation, at least of part of the observations made by other surveyors. Our proposal is to create a common ground among the different bodies, for example taking advantage of experiences like ours, which allows optimization of available resources, mutually recognizing the certificates produced and allowing each other to focus more on each system’s specific characteristics during the evaluation.

One of the strong points of the OECI accreditation program that impacted our organization is the specificity of standards and recommendations, which brought to light real opportunities of organizational development.

Multidisciplinary approach to care

In particular, the OECI model provided substantial input to address the issue of a multidisciplinary approach to care in 2 main directions: clinical pathways and multidisciplinary teams management.

As regards the design of clinical pathways, attention was paid to the development of an analysis of rehabilitation needs perceived by patients and CRO professionals, aimed at assessing opportunities for improvement of the currently available services.

Another important opportunity came to light during this survey: a census of internal resources in terms of facilities and expertise. The ongoing project had a positive effect on our organization, especially in terms of the enhancement of available skills, and providing an early analysis of the rehabilitation needs of our patients and early intervention by supportive disciplines.

The OECI model has also had a positive influence on the management of multidisciplinary teams, as it allowed consideration of the opportunity of adopting a common and structured approach to multidisciplinary discussion, in which the ­different disciplines are represented and actively involved in the decision-making process, as well as improving the approach to recording the results of the plenary discussion. ­Special attention is paid to the involvement of the nursing staff.

Finally, we suggest to all organizations wishing to undertake the process of OECI accreditation to use the OECI standards as a self-assessment tool and as a starting point for creating control tools (e.g., checklists). In our case, the process control domain of the chapter “General standards, strategic plan and general management” of the qualitative manual (4) has been particularly helpful in the development of operative tools, such as regulation for the management of multidisciplinary teams.

Comparability of data

We encountered some challenges owing to weaknesses in the model, especially in self-assessment. We faced difficulties in extrapolating some quantitative data, making sure that they were comprehensive and coherent with the standards, such as personnel costs or disease volumes.

There are obstacles to the production of information adherent to the standards, often related to factors such as constraints of the IT system available, differences in the codifications used when entering data, or national regulations that require the recording of some indicators instead of others.

The problems that we detected are mainly related to difficulty in making the data comparable, which may partially affect benchmarking among institutes, as well as the designation process.

We partially overcame this obstacle by providing supporting documentation that allowed the assessor to contextualize the information and better understand its meaning.

Standardization vs enhancement peculiarities

The cultural sensitivity of standards is a critical component of the international improvement system, as it requires considerable effort to find a balance between standardization and enhancement of organizational features related to the political, economic, and organizational context of the facilities.

Discussion among our staff members on this topic led to the identification of some ideas to solve this problem, which can be summarized as follows:

Assess the feasibility of including in the training program of the audit team a specific focus on the characteristics of the context and possible limitations to the applicability of specific standards.

Include guidelines to reduce the misinterpretation of standards (5). Guidelines should include examples of strategies to collect information and hints to adapt the request in the specific context.

Focus on best practices

We propose sharing best practices gathered from the literature and the experiences of the institutes that have already obtained accreditation. This could be a strategy to improve performance by adapting and replicating successes.

It would be helpful to generalize some standards to avoid cultural bias that may correspond with nonfulfillment of the standard and focus more on evaluation of the outcome. Consider for example the issue of nursing specializations in Italy. Specific official training courses to obtain a certificate of specialization are not prevalent in our education system; nevertheless, the same expertise is ensured through different types of training courses.

Compatibility recommendations: context

The CRO managed to mediate a recommendation seemingly incompatible with the context and the need to provide a concrete answer to a real problem.

In our final report, the need for our institution to adopt a do not resuscitate (DNR) policy was pointed out. Our national legislation is not explicit in this regard and this made it difficult to draft an official document in which our institute could share its official stance.

The decision was therefore to establish a working group, with representatives of the different points of view such as a lawyer, a doctor, a psychologist, a patient representative, and the quality manager, with the aim of analyzing the subject, starting from the literature and national experience.

The output of the teamwork is a document entitled “Recommendations for the management and support of cancer patients at the end of life”, in which the following aspects can be found: a brief analysis of the Italian legislation and of the major issues of clinical bioethics concerning DNR, the short procedure for obtaining the opinion of the ethics committee for urgent cases, and a protocol for communication with the patient. This document, approved by the Ethics Committee of the Institute and Scientific Directorate, provides support to our staff in case of clinical disagreement during end-of-life management.

Table II provides a summary of the most relevant concepts presented in this article.

Strengths, weaknesses, opportunities, and threats (SWOT) analysis of the accreditation model at the system level according to the experience of the Oncological Referral Center of Aviano

Strengths Weaknesses Opportunities Threats
System Same priorities as other systems Assessment vs re-evaluation Focus on best practices Standardization vs enhancement: the peculiarities
Centro di Riferimento Oncologico Multidisciplinary approach to care Comparability of data Internal integrated auditing Compatibility recommendations: context

Lessons learned

Based on our experience in the OECI program, any organization desiring to take advantage of the opportunities available from the OECI accreditation process should ensure some key elements.

Commitment of leadership at all levels: The challenge of organizational improvement is a continuous process in which clear roles and responsibilities are fundamental, but perhaps even more important is strong cohesion at the top, which allows the development of short- and long-term strategies to achieve desired objectives.

Alignment of organizational processes with external inputs (6): It is critical for an institute to have analytical skills and flexibility in process management, in order to ensure consistency between the best international practices and its own established practices.

Change in monitoring and outcome measurement: Integrated quality management means ensuring internally consistent management of the various systems of improvement, also through effective monitoring and measuring tools and being able to provide a snapshot of the organization at all times.

Internal integrated auditing

Integrated internal audits performed at CRO since 2014 seem to be a particularly effective strategy. These audits have been conducted taking into consideration all norms and systems in use: health and safety requirements in the workplace (Legislative Decree 81/2008, BS-OHSAS 18001; 2007), certification requirements of the quality management systems (ISO 9001; 2008), institutional accreditation requirements (DGR 1436/2012), and international accreditation standards (Program Qmentum International Accreditation Canada, OECI, JACIE). These audits were conducted simultaneously by experts in quality and safety.

Patient involvement at every stage

Patients are experts on the needs and priorities of the service users, impartial and critical judges of our work, and supporters and promoters of the improvement of services and of the quality of research and treatment.

Conclusion

Application of the OECI model to all Italian cancer research centers led to the dissemination of a common background and facilitated the benchmark and the exchange of good practices. Particularly remarkable is the emphasis on the transfer of information from clinic to research, which is a complex issue, for which the model has provided practical and useful guidelines to meet the best standards.

Each accreditation system has strengths and weaknesses, which are more or less evident on the basis of the characteristics of the institution in which they are implemented. The OECI has areas for improvement as well; nevertheless, in our experience, the focus of the model on cancer centers has provided a valuable executive tool and a framework in which we can identify several important development projects. An additional impact for our institute is participation in the BenchCan project, of which the OECI is lead partner. As the pilot institute, we had the opportunity to implement a manual of indicators for the benchmarking of clinical pathways.

Critical analysis of strengths and areas for improvement at the institutional and system level can be useful in order to periodically redefine the standards and the system as a whole, and thus facilitate a process of improvement that leads to a rise in the threshold of quality of clinical, research, and organizational services and activities.

Disclosures

Financial support: This work was financially supported by the Ministry of Health-Italian Government within the Finalized Research Project Code: RF-2009-1532731. (Coord.: A. Paradiso, F. Belardelli).
Conflict of interest: The authors declare no conflict of interest.
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Authors

Affiliations

  • Clinical Risk Management and Accreditation Unit, Centro di Riferimento Oncologico (CRO), IRCCS, National Cancer Institute, Aviano (Pordenone) - Italy
  • Scientific Directorate, Centro di Riferimento Oncologico (CRO), IRCCS, National Cancer Institute, Aviano (Pordenone) - Italy

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