Overall result forecast presentation:	yes
Quantity performed reporting year:	50
Quantity forecast year:	50
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:	no
Quantity performed reporting year:	7
Quantity forecast year:	4
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)
No participation

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

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	93,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	123,9 %
Pflegefachpersonen	nein	80,89 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	182,93 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	80,08 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	129,59 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	116,27 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	156
Current staffing levels (full-time staff)	137
Number of nights, subject to the minimum requirement	2

quarter Q2

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	95,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	143,49 %
Pflegefachpersonen	nein	86,38 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	163,67 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	65,46 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	105,58 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	73,95 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	156
Current staffing levels (full-time staff)	114
Number of nights, subject to the minimum requirement	0

quarter Q3

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	97,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	135,09 %
Pflegefachpersonen	ja	90,84 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	161,6 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	55,11 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	110,17 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	92,36 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	156
Current staffing levels (full-time staff)	134
Number of nights, subject to the minimum requirement	0

quarter Q4

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	98,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	130,2 %
Pflegefachpersonen	ja	91,61 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	154,57 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	67,17 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	95,73 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	100,49 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	156
Current staffing levels (full-time staff)	125
Number of nights, subject to the minimum requirement	0

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

Number	Group
153	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*
127	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
101	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
  weitreichende Informationen für Mitarbeitende über die Seite Prävention und Intervention der Alexianer GmbH und der Alexianer Krefeld.
  Training of employees
  Note on the measure
  Verpflichtende Fortbildung für alle Mitarbeitenden "Basisprävention sexualisierte Gewalt"
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  01.09.2022 21:13:36
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  01.09.2022 21:13:36

weitreichende Informationen für Mitarbeitende über die Seite Prävention und Intervention der Alexianer GmbH und der Alexianer Krefeld.

Commentary on the protection concept

Gemäß Teil A § 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 Teil A § 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

Drug commission

Training of employees on AMTS related topics

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

Use of standardised forms for drug medical history

sämtliche Verfahrensregelungen sind im elektronischen Handbuch (im Dokumentenlenkungssystem) für alle Mitarbeiter in der aktuellen Version jederzeit verfügbar.

10.10.2025

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)

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

Richten und Verabreichen von Arzneitmittel

18.04.2023

SOP on good prescription practices

ORME Anleitungen

14.03.2025

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
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)

Measures to ensure seamless drug therapy after discharge

Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen
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

z.B. in der Chirurgie Dozenten aus Marburg oder Düsseldorf z.B. Lehrauftrag in der Universität Köln im Bereich Rehawesen

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Z.B. in der Chirurgie Dozenten aus Kaiserswerther Diakonie Z.B. Lehraufträge Ärztekammer Nordrhein und Westfalen-Lippe

FL03 - Student training (clinical traineeship / internship year)

Explanation

z.B. Famulatur von Medizinstudenten, Praktisches Jahr im Rahmen des Lehrkrankenhauses, Praktika von Physician Assistant

FL04 - Project-related cooperation with colleges and universities

Explanation

z.B. in der Chirurgie mit der Universität Tübingen, Wien, Sorbonne Paris im Rahmen von OP Kursen und wissenschaftlichen Projekten (EUROCRINE)

FL09 - Doctoral supervision

Explanation

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Publikationen in Pubmed gelisteten wissenschaftlichen Zeitschriften/ Journals. Buchbeiträge in chirurgischen Fachbüchern. Medikamentöse Suchttherapie erschienen im Kohlhammer Verlag Sep. 2022

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

Explanation

Training

Training in other healing professions

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

Comment

Ausbildung: Akupunktur nach dem NADA-Protokoll

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit der Kaiserswerther Diakonie Düsseldorf

HB17 - Auxiliary nurse (m/f)

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

In Kooperation mit der Kaiserswerther Diakonie Düsseldorf

HB03 - Physical therapist / physiotherapist (m/f)

Comment

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

In Kooperation mit den Maltesern Aachen

HB19 - Nursing professionals

Comment

HB21 - Geriatric nurse (m/f)

Comment

HB20 - Nursing professional B. Sc.

Comment

HB13 - Medical technical assistant for functional diagnostics (MTAF) (m/f)

Comment

Med. Fachangestellte

HB06 - Occupational therapist (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 5
- Additional staff: 2
- Explanations: Weiteres Apothekenpersonal: 2 PKA (davon 1x mit SGB 50) Weiteres pharmazeutisches Personal: 1 PTA und 1 Pharmazeut:in im Praktikum
- Nursing staff regulation