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Theresienkrankenhaus und St. Hedwig-Klinik gGmbH

Bassermannstraße 1
68165 Mannheim

Phone: 0621-424-0
Fax: 0621-424-4218
Mail: ed.suahneknarkneisereht@ofni

http://www.theresienkrankenhaus.de

Basic information

Number of beds: 530
Number of specialist departments: 12

Number of inpatient cases: 15.561
Number of outpatient cases: 25.179

Hospital owners: Theresienkrankenhaus und St. Hedwig-Klinik gGmbH Mannheim
Type of provider: freigemeinnützig

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	does not apply

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	213
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	4
Exception?	No exception
Durch die Verschmelzung zweier Häuser und die damit einhergehende Verlagerung von Versorgungsstrukturen wurde die Mindesmenge am Standort TKH nicht erbracht. Allerdings operierte Prof. Dr. Kienle sowohl am Standort TKH als auch am Diako in Mannheim. Daher wurden komplexe Eingriffe am Organsystem Pankreas für Erwachsene Mengenmäßig überwiegend am Standort Diako durchgeführt.

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	213
Quantity forecast year:	229
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V

Compliance with staffing requirements

Clarifying chat completed: no
Clarifying chat not completed: no
No participation in clarifying chat: no
Notification of non-fulfilment of nursing care not made: no

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
87	Medical specialists (m/f) , psychological psychotherapists (m/f) and child and adolescent psychotherapists (m/f) who are subject to the obligation to undergo further training*
87	Number of medical specialists (m/f) from no. 1 who have completed a five-year period of further training and are therefore subject to the obligation to provide evidence
86	Number of those persons from no. 2 who have provided proof of further training according to Article 3 of the G-BA regulations

* according to the “Provisions of the Joint Federal Committee for the Further Training of Medical Specialists (m/f), Psychological Psychotherapists (m/f) and Child and Adolescent Psychotherapists (m/f) in Hospitals”

General information

Protection concept against (sexual) violence against children and young people

Advice on prevention and intervention in cases of violence and abuse

According to Section 4 (2) of the Quality Management Guideline, facilities must provide for the prevention of and intervention in cases of violence and abuse as part of their internal quality management. The aim is to prevent, recognise and respond appropriately to abuse and violence, particularly against vulnerable patient groups such as children and adolescents or people in need of help, and also to prevent it within the facility. The respective procedure is aligned with the size of the facility, the range of services and the patients in order to define customised solutions for sensitising the teams as well as other suitable preventative and interventional measures. These may include information materials, contact addresses, training/education, codes of conduct, recommendations for action/intervention plans or comprehensive protection concepts.

Is a protection concept in place? Yes

Commentary on the protection concept

Gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie haben sich Einrichtungen, die Kinder und Jugendliche versorgen, gezielt mit der Prävention von und Intervention bei (sexueller) Gewalt und Missbrauch bei Kindern und Jugendlichen zu befassen (Risiko- und Gefährdungsanalyse) und – der Größe und Organisationsform der Einrichtung entsprechend – konkrete Schritte und Maßnahmen abzuleiten (Schutzkonzept). In diesem Abschnitt geben Krankenhäuser, die Kinder und Jugendliche versorgen, an, ob sie gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie ein Schutzkonzept gegen (sexuelle) Gewalt bei Kindern und Jugendlichen aufweisen.

Drug therapy safety

Steering committee

No working group set up

Use of standardised forms for drug medical history

Dokumentenmanagementsystem

29.09.2020

Electronic support for the admission and anamnesis process (e.g. import of patient master data or medication plans, use of a drug knowledge database, input screen for drugs or anamnesis information)

Possibility of electronic prescription i.e. structured entry of active substances (or name of the preparation), form, dose, dose frequency (e.g. in the HIS, in prescription software)

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Concepts for ensuring the error-free preparation of medications

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Standards für die Zubereitung auf Stationen
Qualitätsmanagementsystem in der Apotheke

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Standards zur Verordnung und Bereitstellung von Medikamenten
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Measures to ensure seamless drug therapy after discharge

Aushändigung des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten

Instruments and measures

The instruments and measures to promote drug therapy safety are presented with a focus on the typical procedures of the medication process in inpatient patient care. A special feature of the medication process in the inpatient environment is the transition management during admission and discharge. The instruments and measures listed below address structural elements, e.g. special IT equipment and work materials, as well as process aspects, such as work descriptions for particularly risky process steps or concepts for securing typical risk situations . In addition, proven measures to avoid or learn from medication errors can be specified. The hospital presents here which aspects it has already dealt with and which measures it has specifically implemented. The following aspects can be presented, if necessary using free text fields:
- Admission to hospital, including anamnesis
; Instruments and measures are presented for determining the old medication (drug history), the subsequent clinical assessment and the switch to the medication available in the hospital (house list), as well as for documenting both the patient's original medication and that for hospital treatment adapted medication.
- Medication process in the hospital
In this context, the following sub-processes are assumed as examples: drug history - prescription - patient information - drug delivery - drug use - documentation - therapy monitoring - result assessment. Instruments and measures for safe medication prescription can be presented, e.g. B. in terms of readability, clarity and completeness of the documentation, but also in terms of area of application, effectiveness, benefit-risk ratio, tolerability (including potential contraindications, interactions, etc.) and resource considerations. Information can also be provided to support reliable medication ordering, delivery and use or administration.
- Discharge
In particular, the measures taken by hospitals can be presented to ensure that information on drug therapy is structured and passed on to doctors and physicians providing further treatment, as well as the appropriate provision of patients with drug information, medication plans and medications. Drug prescriptions are made.

AMTS is the totality of measures to ensure an optimal medication process with the aim of reducing medication errors and thus avoidable risks for patients during drug therapy. A prerequisite for the successful implementation of these measures is that AMTS is practised as an integral part of daily routine in an interdisciplinary and multi-professional approach.

Special instrument-based equipment

Research & teaching

Job

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Unsere Proffeseoren und Privatdozenten sind u.a. an der Rheinischen Friedrich-Wilhelms-Universität Bonn, der Ruhr-Universität Bochum, der Universität Heidelberg, der Goethe Universität Frankfurt und Visiting Professor of Azerbaijan Medical University (Prof. Keese) tätig.

FL03 - Student training (clinical traineeship / internship year)

Explanation

In allen Fachabteilungen werden Famulanten und PJler in ihrer praktischen Ausbildung eingesetzt. Sie werden von erfahrenen Ärzten gecoacht und angeleitet. Eine strukturierte Unterrichtsreihe vertieft die praktische Ausbildung.

FL04 - Project-related cooperation with colleges and universities

Explanation

Prof. Dr. Kienle Studie über Pankreaszysten / Pankreastumore mit dem Pathologischen Institut der Universitätsklinik Heidelberg. Prof. Dr. Keese Industrieforschung mit Urgo (Frankreich) und Forschungskooperation mit dem Bioquant Insititut Heidelberg.

FL05 - Participation in multi-centre Phase I/II studies

Explanation

Unfallchirurgie: Multicenter Study of Assess the Efficacy and Safty of Allogenic Osteoblastic Cells (ALLOB®) Single Implantation in Tibial Fracture.

FL06 - Participation in multi-centre phase III/IV studies

Explanation

Prof. Dr. Rudi: FIRE-4 ; CIRCULATE (beide Interventionell). Prof. Dr. Kienle: Inspire / Alofisel 5003 und die OB 10 Probiotika von Allergosan.

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

Unfallchirurgie: NISANIK und JUNOVO (NOVOCART® 3D); FLAG SCS , Advisory Board der ARENA-Studie. Prof. Dr. Rudi: ColoPredict 2.0; EDIUM; NLS Kolonsegment; PEARL-Studie; Musiktherapie vs. Entspannungsübungen in der Onkologie Prof. Dr. Kienle: Initiierung/Leitung Kono-S Studie (S391/2019)

FL09 - Doctoral supervision

Explanation

Unfallchirurgie: u.a. Intervention Minced Cartilage; Evaluation Knorpelzelltransplantation, Mortalität und Morbidität der Zystektomie Prof. Dr. Kienle: PouchVision-Trial

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Prof_Dr_Haass_u.a. Mithg. "Kardiologie up2date" Prof_Dr_Köhrmann_u.a. Mithg. "Der Urologe" Prof_Dr_Rudi_Co-Autor Buch "Geriatrische Gastroenterologie" Prof_Dr_Zimmermann_u.a. Co-Autor "Behandlung der Gonarthrose"

Training

Training in other healing professions

HB01 - Nurse and health care worker (m/f)

Comment

Die im Krankenhaus angesiedelte Vinzenz-von-Paul Schule bildet bis zum Herbst 2022 jeweils zum Frühjar und Herbs eines Jahres Gesundheits-und Krankenfleger*innen des Theresienkrankenhauses aus. Dieser Ausbildungsgang endet mit dem Inkrafttreten des Pflegeberufegesetzes zum 31.12.2022.

HB17 - Auxiliary nurse (m/f)

Comment

Die im Krankenhaus angesiedelte Vinzenz-von-Paul Schule bildet zum Frühjahr eines Jahres Krankenpflegeherlfer*in des Theresienkrankenhauses aus.

HB07 - Surgical technical assistant (m/f)

Comment

Es werden regelmäßig OTA (Praxisphase) in unserem Haus ausgebildet.

HB19 - Nursing professionals

Comment

Ebenfalls bildet die Vinzenz-von-Paul Schule auch jeweils zum Frühjahr und Herbst eines Jahres Pflegefachmänner/-frauen aus.

HB20 - Nursing professional B. Sc.

Comment

Des Weiteren bietet die Vinzenz-von-Paul Schule den Schwerpunkt der Pflegefachfrau-/mann B.Sc. an. Dies erfolgt in unterschiedlichen Kooperationsmodellen.

HB21 - Geriatric nurse (m/f)

Comment

Ferner bildet die Vinzenz-von-Paul Schule bis zum Herbst 2022 auch Altenpfleger*innen. Dieser Ausbildungsgang endet mit dem Inkrafttreten des Pflegeberufegesetzes zum 31.12.2022. Fortgesetzt wird die Ausbildung zum/zur Altenpflegehelfer*innen.