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AGAPLESION EV. KLINIKUM SCHAUMBURG

Zum Schaumburger Klinikum 1
31683 Obernkirchen

Phone: 05724-9580-0
Fax: 05724-9580-881009
Mail: ed.noiselpaga@lsk.gnurheufstfeahcseg

https://www.ev-klinikum-schaumburg.de

Basic information

Number of beds: 437
Number of specialist departments: 18

Number of inpatient cases: 18.725
Number of outpatient cases: 32.680

Hospital owners: AGAPLESION EV. KLINIKUM SCHAUMBURG gemeinnützige GmbH
Type of provider: freigemeinnützig

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

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

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	235
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	14
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	235
Quantity forecast year:	268
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	14
Quantity forecast year:	9
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	263
Quantity forecast year:	266
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

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
88	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*
82	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
70	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
Measures
- Prevention
  Information gathering on the topic
  Note on the measure
  Netzwerkarbeit, AGALernwelt, interne Kommunikation in den verschiedenen Leitungsgremien
  Training of employees
  Note on the measure
  Regelmäßige Fortbildungen
  Education
  Note on the measure
  Regelmäßige Fortbildungen
  Age-appropriate complaint options
  Note on the measure
  Meldwege bzw. Kontaktdaten externer Anlaufstellen sind im Schutzkonzept aufgeführt. Das Meinungsmanagement kann über diverse Kanäle von Kindern und Jugendlichen genutzt werden.
  Special requirements for the selection of persons
  Note on the measure
  Eignungsprüfung, erweitertes Führungszeugnis bei Einstellungen
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Verfahrensanwesiung liegt vor.
  
  Last review of the measure
  28.03.2023 15:50:31
- Reprocessing
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Verfahrensanweisung liegt vor
  
  Last review of the measure
  28.03.2023 15:50:31

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

Functional areas: - Krankenhausleitungssitzung (Lenkungsgremium) - Jour Fixe mit der Geschäftsführung - Gesamtbetriebsleitersitzungen - vierteljährlich AGAPLESION Arbeitsbereich QM (XB PQM) Treffen aller Qualitätsmanagementbeauftragten konzernweit - Vierteljährliches Treffen der QMB im Weserbergland-Cluster
Conference frequency: monatlich

Training of employees on AMTS related topics

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

Electronic documentation of the administration of drugs

Measures to minimise medication errors

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 von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs
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

Dozenturen: Prof. Dr. Bürk hat einen Lehrauftrag am UKSH Universitätsklinikum Schleswig Holstein Prof. Dr. Jagodzinski an der MHH im Rahmen des Exzellenzclusters "Rebirth".

FL03 - Student training (clinical traineeship / internship year)

Explanation

Famulatoren werden angeboten, Mit der Benennung als Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster wird das Praktische Jahr angeboten. (https://www.ev-klinikum-schaumburg.de/karriere/medizinstudierende-pj)

FL04 - Project-related cooperation with colleges and universities

Explanation

Die Frauenklinik kooperiert mit der Medizinischen Hochschule Hannover im Rahmen der Humangenetischen Beratung.

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

Explanation

Teilnahme an multizentrischen Studien in den Fachabteilungen Gynäkologie, Pneumologie,

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

Explanation

Prof. Dr. Jagodzinski ist Leiter einer prospektiven Studie "Arthofibrose" (Doktorand: cand. Med. P. Traud) und Teilnehmer einer multizentrischen Studie „Meniskusnaht bei Rezidivruptur“

FL08 - Editors of scientific journals/textbooks

Explanation

Prof. Dr. Jagodzinski ist Herausgeber des Buches "Das Knie" (gemeinsam mit Dr. Friedrich W. Müller)

FL09 - Doctoral supervision

Explanation

Prof. Dr. Jagodzinski an der Medizinische Hochschule Hannover (MHH), Prof. Dr. Bürk am UKSH Universitätsklinikum Schleswig Holstein.

Training

Training in other healing professions

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

Comment

Dem AGAPLESION EV. KLINIKUM SCHAUMBURG ist eine Schule für Gesundheits- und Krankenpflege, letztztmalig in dieser Schulform mit noch 25 Ausbildungsplätzen bis Ende September 2022, angegliedert (Umstellung zur Berufsfachschule Pflege für Pflegefachfrau/-mann).

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit dem Krankenhaus DIAKOVERE Friederikenstift Hannover wird eine Ausbildung zum:zur OTA angeboten. Die theoretische Ausbildung findet im Friederikenstift Hannover statt und die praktische Ausbildung im AGAPLESION EV. KLINIKUM SCHAUMBURG.

HB19 - Nursing professionals

Comment

Dem AGAPLESION EV. KLINIKUM SCHAUMBURG ist eine Berufsfachschule Pflege mit zunächst 50 Ausbildungsplätzen, ab Oktober 2022 mit 75 Ausbildungsplätzen, angegliedert (generalisierte Ausbildung Pflegefachfrau/-mann).