Overall result forecast presentation:	yes
Quantity performed reporting year:	400
Quantity forecast year:	456
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	35
Quantity forecast year:	39
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:	45
Quantity forecast year:	42
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	25
Quantity forecast year:	26
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:	317
Quantity forecast year:	309
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	71
Quantity forecast year:	77
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
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1

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

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

Number	Group
166	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*
31	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
31	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
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Zentrales Kinderschutzkonzept
  
  Last review of the measure
  12.10.2023 20:08:17
  Age-appropriate complaint options
  
  Special requirements for the selection of persons
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Zentrales Kinderschutzkonzept
  
  Last review of the measure
  12.10.2023 20:08:17
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Zentrales Kinderschutzkonzept
  
  Last review of the measure
  12.10.2023 20:08:17

Zentrales Kinderschutzkonzept

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

Use of standardised forms for drug medical history

Liegt in digitaler Form vor. Übergreifendes digitales Dokumentenlenkungssystem

07.01.2021

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)

Liegt in digitaler Form vor. Übergreifendes digitales Dokumentenlenkungssystem

07.01.2021

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

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

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

bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
Aushändigung von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs

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

Prof. Weiß: UKE der Uni Hamburg Profs. Dall/Sonntag: Uni Göttingen Profs. Kucharzik/Maaser: Uni Münster Profs. Schniewind/Kramer: UKSH Prof. Frenkel: Uni Bonn Prof. Rodt: MH Hannover Prof. Pfeilschifter: Uni Frankfurt PD Dr. Mühl-Benninghaus: Uniklinikum Saarland Prof Dr. Li: LMU München

FL03 - Student training (clinical traineeship / internship year)

Explanation

wird angeboten

FL04 - Project-related cooperation with colleges and universities

Explanation

Prof. Maaser: Abdominalsonographie im Rahmen der Lehre mit Universität Münster Frau Prof. Pfeilschifter: Teilprojektleiterin TP B08 im SFB 1039

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

Explanation

Gyn: Brust- u. Eierstockkrebs; Kardio: Herzinsuffizienz, Herzrhythmusstörungen, Herzinfarkt Strahl/Uro: Prostatakrebs; Strahl/Gyn: Brustkrebs Gastro: Neue med. Therapieoptionen M. Crohn u. Colitis ulcerosa; Darmsonographie CED Neurologie: Studien:Find AF 2, Librexia; German Stroke Registry

FL08 - Editors of scientific journals/textbooks

Explanation

Prof. Dall: Editorial Board „Breast Care“, Publikation im Journal of Geriatric Oncology Prof. Pfeilschifter: Pflege von Patienten mit Schlaganfall – Von der Stroke Unit bis zur Rehabilitation. Kohlhammer-Verlag, 3.Auflage 2022 Mitherausgeberin DGNeurologie; Zeitschrift der DGN

FL09 - Doctoral supervision

Explanation

Frau Prof. Pfeilschifter

Training

Training in other healing professions

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Standort für den praktischen Teil der Ausbildung in Kooperation mit zwei Ausbildungsstätten (kein direktes Ausbildungsverhältnis)

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit Bildungsakademie Asklepios Hamburg und der Health Academy Hamburg

HB19 - Nursing professionals

Comment

eigene Berufsfachschule: Vertiefungseinsatz akute stationäre Pflege und Vertiefungseinsatz pädiatrische Versorgung Praktischer Einsatzort für Anteile der Ausbildung in der Psychatrischen Klinik sowie weiteren Kooperationspartnern in der Stationäre Langzeitpflege, Amb. Pflege und Rehabilitation

HB15 - Anaesthesia technical assistant (m/f)