Overall result forecast presentation:	yes
Quantity performed reporting year:	260
Quantity forecast year:	327
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 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

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

Number	Group
12	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*
11	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
7	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

Drug commission

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

AA Arzneimittelanamnese

14.10.2021

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)

VA Umgang mit Arzneimitteln

26.10.2018

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
umfassendes IT-Laborsystem (standardisierte Herstellungsvorschrift, Herstellungsporotokoll, Therapieprotokolle, elektronische Dokumentation)

Electronic support for the supply of patients with drugs

ePA: Recom-GRIPS, Zenzy

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)
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
Vermittlung und Kontaktaufnahmen (Arztpraxen, Angehörige)

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

FL03 - Student training (clinical traineeship / internship year)

Explanation

Famulatur (in der Klinik für Innere Medizin, Chirurgie); PJ (in der Klinik für Chirurgie, EndoProthetikZentrum); Apotheke (auf Nachfrage)

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

Theoretische Ausbildung: in der Akademie für Gesundheit NEW LIFE in Neustadt/WN; Praktische Ausbildung: in den chirurgischen Fachabteilungen der Kliniken Nordoberpfalz AG sowie Kooperationspartnern an den Standorten

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

Comment

Theoretische Ausbildung: in der Akademie für Gesundheit NEW LIFE in Neustadt/WN; Praktische Ausbildung: an allen Standorten der Klinik AG; (bis 2022)

HB19 - Nursing professionals

Comment

Ab 01.09.2020 - Theoretische Ausbildung: in der Akademie für Gesundheit NEW LIFE in Neustadt/WN; Praktische Ausbildung: an allen Standorten der Klinik AG und weiteren Kooperationspartnern

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 8
- Additional staff: 6
- Nursing staff regulation

Service contact persons

Patient advocates

Roswitha Kuriczak

Patientenfürsprecherin

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71309
Mail: ga.zlafprebodron-nekinilk@ofnimek

Customer feedback management

Alexander Vetter

Assistenz der Krankenhausleitung

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09631 -87-30262
Mail: ga.zlafprebodron-nekinilk@rettev.rednaxela

Quality management

Kerstin Schwarz

Abteilungsleitung Qualitätsmanagement

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12400
Mail: ga.zlafprebodron-neknilk@zrawhcs.nitsrek

Hygiene officer

Michaela Hutzler

Medizinische Direktorin

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-2101
Mail: ga.zlafprebodron-nekinilk@relztuh.aleahcim

Prof. Dr. Christian Paetzel

Ärztlicher Direktor

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-13401
Mail: ga.onk@lezteap.naitsirhc

Responsible for drug therapy

Dr. Werner Speckner

Apothekenleiter

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-13601
Mail: ga.zlafprebodron-nekinilk@ekehtopA

Accessibility Officer

Roswitha Kuriczak

Patientenfürsprecherin

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71309
Mail: ga.zlafprebodron-nekinilk@ofnimek

Company

General contact details of the hospital

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642-706-70000
Fax: 09642-706-1111
Mail: ga.onk@ofnimek

Nursing service management

Thomas Baldauf (bis 31.01.2020)

Pflegedirektor der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-15002
Mail: ga.zlafprebodron-nekinilk@fuadlab.samoht

Renate Lindgens

Pflegedienstleitung

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71310
Mail: ga.zlafprebodron-nekinilk@snegdnil.etaner

Michaela Hutzler (ab 01.02.2020)

Medizinische Direktorin der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12100
Mail: ga.zlafprebodron-nekinilk@relztuh.aleahcim

Michaela Hutzler (bis 30.06.2022)

Medizinische Direktorin der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12100
Mail: ga.zlafprebodron-nekinilk@relztuh.aleahcim

Angela Dzyck (seit 01.04.2023)

Pflegedirektorin

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-15002
Mail: ga.onk@kcyzd.alegna

Head of administration

Christian Stadler (bis 30.04.2020)

Krankenhausleiter

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71109
Mail: ga.zlafprebodron-nekinilk@reldats.naitsirhc

Timo Sonntag (ab 01.06.2020)

Krankenhausleiter der Region Nord, West und Süd

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71109
Mail: ga.zlafprebodron-nekinilk@gatnnos.omit

Dr. med. Thomas Egginger (ab 01.01.2020)

Vorstand der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.zlafprebodron-nekinilk@dnatsrov

Michael Hoffmann (ab 01.11.2021)

Vorstand der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.zlafprebodron-nekinilk@dnatsrov

Dr. med. Thomas Egginger (bis 31.10.2021)

Vorstand der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.zlafprebodron-nekinilk@dnatsrov

Michael Hoffmann

Vorstand der Kliniken Nordoberpfalz AG

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.onk@dnatsrov

Stephan Schumacher (ab 01.07.2023)

Klinikdirektor

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09631 -87-30120
Mail: ga.onk@rehcamuhcs.nahpets

Timo Sonntag (bis 30.06.2023)

Krankenhausleiter der Region Nord, West und Süd

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09642 -706-71109
Mail: ga.onk@gatnnos.omit

Responsible for the quality report in the hospital management

Dr. med. Thomas Egginger

Vorstand

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.zlafprebodron-nekinilk@ofni

Michael Hoffmann

Vorstand

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 0961 -303-12000
Mail: ga.zlafprebodron-nekinilk@ofni

Medical management

Elisabeth Eißner (ab 01.02.2020 bis 30.09.2021)

Ärztliche Direktorin der Region Nord und West

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09631 -87-37140
Mail: ga.zlafprebodron-nekinilk@renssie.htebasile

Prof. Dr. Edgar Pscheidl (ab 01.10.2021)

Ärztlicher Direktor der Region Nord und West

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09631 -87-30931
Mail: ga.zlafprebodron-nekinilk@ldiehcsp.ragde

Prof. Dr. Edgar Pscheidl

Ärztlicher Direktor der Region Nord und West

Werner-von-Siemens-Straße 7
95478 Kemnath

Phone: 09631 -87-30931
Mail: ga.onk@ldiehcsp.ragde

Regional care obligation for psychiatry?

IK number

IK: 260930517

Location number

Location number: 771934000

Old location number: 771934000

Hospital portrait for download