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Die Filderklinik gGmbH

Im Haberschlai 7
70794 Filderstadt

Phone: 0711-7703-0
Mail: ed.kinilkredlif@ofni ed.kinilkredlif@ofni ed.kinilkredlif@ofni

http://www.filderklinik.de/

Basic information

Number of beds: 225
Number of specialist departments: 12

Number of inpatient cases: 13.182
Number of partial inpatient cases: 56
Number of outpatient cases: 29.733

Hospital owners: Die Filderklinik gGmbH
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	yes

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

Surgical treatment of breast cancer (breast surgery)

Quantity performed	154
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	98
Exception?	No exception

Minimum quantities forecast

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	154
Quantity forecast year:	168
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	98
Quantity forecast year:	92
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
CQ06	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 2
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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: yes

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Psychosomatik

Day shift
Compliance with minimum requirements	no
Level of implementation	124,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	132,04 %
Pflegefachpersonen	ja	107,77 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	99,76 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	221,97 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	131,44 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	95,23 %

quarter Q2

Psychosomatik

Day shift
Compliance with minimum requirements	no
Level of implementation	116,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	109,22 %
Pflegefachpersonen	ja	109,91 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	102,94 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	184,11 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	135,77 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	101,12 %

quarter Q3

Psychosomatik

Day shift
Compliance with minimum requirements	no
Level of implementation	119,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	131,44 %
Pflegefachpersonen	ja	105,7 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	90,52 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	177,18 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	154,04 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	106,56 %

quarter Q4

Psychosomatik

Day shift
Compliance with minimum requirements	no
Level of implementation	108,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	117,18 %
Pflegefachpersonen	ja	99,99 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	99,99 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	129,39 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	129,43 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	99,77 %

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*
25	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
23	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
  
  Training of employees
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  14.02.2023 18:44:05
  Special requirements for the selection of persons
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  14.02.2023 18:44:05
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  14.02.2023 18:44:05

SOP Kinderschutz (letzte Aktualisierung: 03.09.2021)

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

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)

SOP on good prescription practices

Regelungen zum QM/RM im Intranet verfügbar

29.04.2022

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

Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal

Electronic support for the supply of patients with drugs

Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
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
Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen

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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Frau Prof. Dr. M. Zdichavsky und Herr Dr. J. Vagedes sind Lehrbeauftragte am Universitätsklinikum Tübingen. Herr Prof. Kühn ist Senior Consultant und apl. Prof. am Universitätsklinikum Ulm. Frau Sperling hat einen Lehrauftrag an der Universität Tübingen im Bereich Hebammenwissenschaften.

FL04 - Project-related cooperation with colleges and universities