No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagement-Konzept (2021-06-10) Konzept Klinisches Risikomanagement (10.06.2021)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Verfahrensanweisung Medizinisches Notfallmanagement (04.11.2022)
RM08	Regulated handling of custodial measures Standard Vermeidung, Anwendung und Dokumentation freiheitsentziehender Maßnahmen und Zwangsbehandlung (22.02.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Multidisziplinäre Teambesprechungen
RM18	Discharge management Verfahrensanweisung Entlassmanagement (15.09.2021)

Conference frequency: bei Bedarf

Verbesserte Beschriftung der Sonderkost durch Caterer

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 08.02.2018
IF02	Internal evaluation of the received reports taken bei Bedarf
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 08.02.2018

IF02

Internal evaluation of the received reports

taken bei Bedarf

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Conference frequency: bei Bedarf

No.	Explanation
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)