28
1 THE JACIE ACCREDITATION PROCESS

THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

  • Upload
    others

  • View
    0

  • Download
    0

Embed Size (px)

Citation preview

Page 1: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

1

THE JACIE

ACCREDITATION

PROCESS

Page 2: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Inspection to

accreditation

2

Page 3: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

InvitationInspection

Evidence

of corrections (EC)

Assessment EC

Accreditation

Inspector Center JACIE Office

Teleconference

PRE-INSPECTION INSPECTION

Summary

Report and

Checklist

JACIE

Accreditation

Committee

Pre-Inspection

DocumentationInspection

Report

YOU

ARE

HERE

NOW

POST-INSPECTION

Accreditation Process

Page 4: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

4

1. Distribution of the standards

2. The inspection

3. The post-inspection procedure

4. Accreditation

Contents

Page 5: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Distribution of the

standards

Page 6: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

CLINICAL ADULT & PAEDCOLLECTION PROCESSING

Part B

Med-A

Donors part B

Part CM

Part C

Donors part C

Collection labels

Part CM

Part D

Processing labels

Shipping labels

Part B/CM/C/D 4 QM excluding:

• Outcome analysis

• Tracking & traceability/labeling requirements

• Qualification

• Validation

Parts B/CM/C/D 5 Polices & Procedures

QM

Distribution of the Standards

Page 7: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

The inspection

Page 8: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

1st Half Day – Day 1

Opening meeting

Review documentation

2nd Half Day – Day 1

Tour of facilities

Interviews key personnel each unit

Observation of procedures

3rd Half Day – Day 2

Continue tour, interviews and document review

Exit Meeting with Programme Director

Closing Meeting

Inspection agenda

Page 9: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

9

APPLICANT TEAM LEADER

Opening meeting

Programme

InspectorsRoles &

responsibilities

ConfidentialityAgenda

Scope

Page 10: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

• Verification of the applicant’s completed checklist

• Examination of all aspects of the programme

The on-site inspection

Page 11: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Inspection Team Meeting

Discuss & compare findings within team

Agree in grading

Exit Meeting with Programme Director

Brief on any sensitive / important issues

Private meeting

Closing Meeting

Inspectors present main findings

Congratulate on positive things

Inspection outcome will be made by JACIE Accreditation

Committee

Q&A

The closing meeting

Page 12: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Applicants and inspectors feedback helps us to improve the

accreditation process.

The online post inspection survey

Online survey

CentreInspectionfeedback

Inspectors

Strengths

Areas forimprovement

Page 13: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

The post inspection

procedure

Page 14: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

INSPECTORS

2 weeks

TEAM

LEADER

JACIE

OFFICE

Summary

ReportChecklist

Inspection report and Inspection

checklist preparation

Page 15: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

JACIE

OFFICE

JACIE REPORT

ASSESSORS

JACIE

ACCREDITATION

COMMITTEE CENTER

The inspection report path

Page 16: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections
Page 17: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Click to add title

17

Page 18: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Evidence of

corrections

Page 19: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

InvitationInspection

Evidence

of corrections (EC)

Assessment EC

Accreditation

Inspector Center JACIE Office

Teleconference

PRE-INSPECTION INSPECTION

Summary

Report and

Checklist

JACIE

Accreditation

Committee

Pre-Inspection

DocumentationInspection

Report

YOU

ARE

HERE

NOW

POST-INSPECTION

Accreditation Process

Page 20: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Evidence of corrections

JAC ASSESSMENT OF THE INSPECTION

REPORT

All standards

compliant

Minor

deficiencies

Major

deficiencies

NO

CORRECTIONSCORRECTIONS

CORRECTIONS

+

RE-INSPECTION

ACCREDITATION

Page 21: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

• 99,99% of inspections reveal deficiencies

• In very rare occasions a re-inspection is required

• Around 8% of standards present non/partial

compliances

Page 22: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

APPLICANT PROVIDE

• Checklist

• Supporting doucmentation

INSPECTORS ASSESSMENT

(same inspection team)

• All standards are compliant

• Further evidence of

corrections needed

• Re-visit if:

- Extensive QMS failures

- New facility

Evidence of corrections

Page 23: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Accreditation

Page 24: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Accreditation Awarded

✓Inspectors confirm all points are resolved

✓JACIE Accreditation Committee do not have further

comments

✓Applicants receive Certificate and letter of accreditation

✓Listing at JACIE’s web site

Page 25: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Accreditation conditions

• If a centre takes more than 9 months to resolve the deficiencies, JACIE may award the accreditation from the date of the inspection

Accreditation awarded for 4 years

• Summary of activity and changes

Annual report

• End of year 2 of Accreditation: focused QM review, based on standards, may result in on-site visit

Interim Audit (50% centres)

Page 26: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Inspector’s time and timing

JAICE Inspector time

Pre-Audit

documentation

11,5h

Teleconference

0,5-1h

Inspection

1,5 days

Inspection

report

Evidence of

corrections

Interim audit Annual

reports

Page 27: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

InvitationInspection

Evidence

of corrections (EC)

Assessment EC

Accreditation

Inspector Center JACIE Office

Teleconference

PRE-INSPECTION INSPECTION

Summary

Report and

Checklist

JACIE

Accreditation

Committee

Pre-Inspection

DocumentationInspection

Report

YOU

ARE

HERE

NOW

POST-INSPECTION

Accreditation Process

Page 28: THE JACIE ACCREDITATION PROCESS - EBMT · 2021. 5. 27. · The inspection report path. Click to add title 17. Evidence of corrections. Invitation Inspection Evidence of corrections

Questions?