Pathway to accreditation

Accreditation

Accreditation process

    1.  Introduction
      Cancer Care Commission’s (CCC) business is to support partner organisations’ ambition to deliver high quality cancer care by:
      Providing a multidisciplinary framework, integrating the necessary medical specialties, cancer care pathways and treatment guidelines
      Offering continuing medical education and training for client staff using a variety of linked methods (face to face in Oxford; on line CME; access to published material eg. oxford Textbook of Oncology)
      Accrediting the quality of client organisations’ cancer care using a unique tool which captures both process and clinical outcomes and permits benchmarking with internationally acclaimed cancer hospitals
      Providing second opinions on patients, with referrals to Oxford Clinical Faculty in UK-Establishing and supporting clinical research within these, organisation.
    2.  Accreditation
      One of Cancer Care Commission’s key activities (above) is Accreditation of Cancer Care Services.
      Accreditation is the formal recognition that an organisation is competent to perform specific processes, activities, or tasks in a reliable credible and accurate manner. In the healthcare environment,  accreditation provides reassurance to patients, commissioners, health and social care providers, that the service provided has been independently evaluated against recognised standards. Accreditation underpins  quality and confidence in health care, providing consistency in the delivery of healthcare services to patients and commissioners. It seeks to validate and recognise success, as well as drive up the quality and consistency of service by aspiring towards excellence and the sharing of good practice with quality patient outcomes at its core.
      Accreditation which is objective, transparent and effective, is recognised as a desirable asset. In Cancer Care Commission (CCC), the accreditation process is performed by highly professional  assessors and technical experts that are reliable, ethical and competent in both accreditation processes and the relevant clinical environments.
      From a commercial perspective, accreditation delivers a Competitive Advantage, it provides independent assurance that your staff is competent and you provide a quality service. It establishes differentiation from the competition, and identifies your organisation as being progressive, forward thinking and keen to drive quality improvement in service provision and patient care. It can highlight gaps in capability, thereby providing the opportunity for improved organisational efficiency and outputs.
      Accreditation also expands market access, it is increasingly specified and recognised by a growing number of public and private sector organisations, and a knowledgeable, informed general public.
    3.  What is assessed and accredited?
      Cancer Care Commission has a framework of 5 broad questions. Are the services; 1)Safe 2)Effective, 3)Caring, 4)Responsive to patient needs, and are they 5)Well led? These questions are answered following a detailed assessment of resources, clinical treatment and patient outcomes as noted below:

      • Cancer Service Line Assessment
        • Accreditation/certifications
        • Leadership
        • Services and Support
        • Healthcare IT Services
        • Partnerships & Affiliations
        • Clinical research
      • Breast/Colorectal/Lung/Prostate programme assessments
        • Programme Feature
        • Leadership infrastructure
        • Care co-ordination
        • Treatment approach
        • Physician expertise
        • Diagnostic Technology
        • Treatment Technology
        • Research
        • Data Collection& Analysis
        • Support Services
        • Screening
        • Outreach
        • Prevention/Risk assessment
        • Assessment Area
        • Case Planning
        • Physician engagement
        • Treatment Team integration
        • Integration of Care Co-ordinators
        • Infrastructure
        • Clinical Trials
        • Quality Improvement
        • Medical Records
        • Performance Indicator
        • Specialist Team
        • Waiting Times
        • Practice
        • Outcomes and Recovery
        • Patient Experience
        • Audit
        • Research
      • Palliative Care Assessment Tool
      • Psychosocial Care Assessment Tool
    4. Pathway to Accreditation
      The Pathway to The Accreditation process is simple and straight forward for all prospective clients… It starts with a basic question. The following guide indicates the sequential steps along the Pathway to Accreditation, and the support which will be provided:

      • Is accreditation appropriate for us? Accreditation within the health and social care sector provides reassurance to patients, commissioners and the health and social care providers that the service that is being provided has been independently evaluated against recognised standards. It seeks to validate and recognise success, as well as drive up the quality and consistency of service by aspiring towards excellence and the sharing of good practice with quality patient outcomes at its core.
      • Where do we start? Identify what you want to be accredited. Is it a specific unit, a department, a hospital? … Inspect the standards contained within the CCC assessment/accreditation documentation online. At any time, contact CCC for guidance or advice.
      • How to apply: To apply for accreditation, please complete the Online Application Form. Upon receipt of the application, you will be allocated an Assessment Manager as your case manager and point of contact with CCC. The Assessment Manager will review the documentation and guide you through the process of gaining accreditation. They will also discuss the composition of a proposed assessment team with you, that will be best placed to technically assess your organisation. At any time, contact CCC for guidance or advice.
      • Pre-assessment visit: Your Assessment Manager will guide you through the process and agree timescales for key milestones. A pre-assessment is an informal visit to determine how ready you are for accreditation (can be a physical or virtual visit).  A pre-assessment visit (physical) is optional, but it can be a valuable step in the process to reduce delays in gaining accreditation. This visit addresses the scope of accreditation requested and will normally involve between 1 and 4 man-days work. It is designed to confirm your organisation’s readiness for full assessment.
      • Initial assessment visit: Once you have addressed any issues raised during the pre-assessment process, the initial assessment is the first formal assessment. This will be conducted by a Lead Assessor (normally your Assessment Manager) supported, as necessary, by technical assessors with the expertise to cover your scope of application.  The length of the visit will depend upon the scope of application requested. In advance of the visit, you will receive a visit confirmation followed by a visit plan, which provides a proposed timetable for the work to be assessed.
        • An opening meeting will take place to agree the arrangements.
        • The assessment will involve a detailed review of pertinent documentation.
        • Interviews will take place with staff and managers, as well as witnessing of key activities.
        • A full vertical and horizontal audit will take place.
        • A de-brief of the visit and any findings will be discussed at a closing meeting.
        • CCC will provide a full report following the assessment visit.
      • Post assessment: Should you have any findings, you will have approximately 12 weeks (this may vary but will be agreed with your Assessment Manager) to provide suitable evidence to your Assessment Manager that they have been addressed. You will be notified of your award for accreditation in writing. You will also receive a certificate and a schedule of accreditation will be made publicly available on the CCC website.
      • Maintaining accreditation: Your accreditation will be confirmed on an annual basis by monitoring visits, with a full re-assessment every fourth year ( an organisation can request a full re-assessment after 24months of the initial assessment/accreditation). The first surveillance visit takes place 6 months after the Grant of Accreditation.
    5. Attaining Accreditation
      Once assessed, if your organisation meets the required standards, you will be awarded an appropriate level of accreditation. The Cancer Care Commission will present a certificate and an inscribed commemorative plaque at one of the following levels:

      • Bronze : Safe service delivery and clinical practices. Good foundation and base for development.
      • Silver: Enhanced service delivery with good clinical outcomes. Developed Improvement Plan for targeted areas.
      • Gold: Professional (clinical) service excellence with outstanding personal service. Continually striving for quality improvement , including exceptional patient satisfaction, in all areas.
    6. Maximising  your  Accreditation
      Maximise your marketing strategy and emphasise your organisational credibility, by utilising the CCC branded accreditation logo and symbols in your promotional publications and materials.