Johanniter-Krankenhaus Geesthacht GmbH

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Quality results

Treatment sector: Obstetrics: care of mother and child shortly before, during and shortly after birth (16/1) Explanation

Information about this treatment area (documentation)

Designation	Geburtshilfe
Shortcut	16/1
Number of cases	756
Documentation rate	100.13 %
Hospital comment	Die Dokumentationsrate wurde krankenhausbezogen berechnet.. Hinweis: Für das Berichtsjahr 2020 sind die Dokumentationsraten nur eingeschränkt aussagekräftig, da sich im Erfassungsjahr 2020 Unterschreitungen der Dokumentationsrate in Folge der COVID-19-Pandemie ergeben können, die als unverschuldet zu werten sind.

Summary result:

In 6 of 7 quality characteristics, the quality objective was achieved.
No assessment is possible for one quality characteristic

Number of patients treated: 756

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

In cases of imminent premature birth, the mother was treated with cortisone before birth. For this, the mother had to be admitted to hospital two days before the birth

Hospital:

No patients

Target area: at least 95,00 %

Assessment not possible

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To prevent infections, the mother was given antibiotics shortly before or shortly after a caesarean section

Hospital: 98,86 %

Target area: at least 90,00 %

Quality objective achieved

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Ratio of the actual number to the previously expected number of caesarean section births (individual risks of the patients were taken into account)

Hospital: 0,80

Target area: at most 1,24

Quality objective achieved

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The time between the decision to perform an emergency C-section and the birth of the child was longer than 20 minutes

Hospital: 0,00 %

Sentinel Event

Quality objective achieved

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Acidification of the umbilical cord blood in newborns (premature babies, twin or other multiple births were not included; individual risks of mother and child were not taken into account)

Hospital: 0,00 %

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of neonates with hyperacidity of the umbilical cord blood (based on neonates born between the 37th and 41st week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered)

Hospital: 0,00

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of pre-term neonates with hyperacidity of the umbilical cord blood (based on pre-term neonates born between the 24th and 36th week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered) and 36th week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered)

Hospital: 0,00

Target area: at most 5,32

Quality objective achieved

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A paediatrician was present at the birth of the pre-term neonates

Hospital: Data protection

No information due to data protection

Target area: at least 90,00 %

Quality objective achieved
Why?

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This is how rarely newborns were in a critical state of health or died after birth (excluding premature babies)

Hospital: 2,48

Target area: at most 2,32

Quality objective not achieved

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Hospital: 0,00

Target area: at most 3,23

Quality objective achieved

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Code ID	330
Result (%)
Evaluation through structured dialogue	An evaluation is not possible because there were no patients in the hospital to whom this quality criterion could be applied. (N01)
Population
Events observed
Anticipated events
Result trend compared with the previous reporting year
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	96,57
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	96,13 - 96,97
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH, QS-Planung
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	50045
Result (%)	98,86
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	176
Events observed	174
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	98,98
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	98,94 - 99,02
Hospital confidence interval (%)	95,95 - 99,69
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH, QS-Planung
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "This indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link; https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link; https://iqtig.org/qs-verfahren/."

Code ID	52249
Result	0,80
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	750
Events observed	174
Anticipated events	216,21
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,01
Target range (reference range)	<= 1,24 (90. Perzentil)
Confidence interval nationwide	1,00 - 1,01
Hospital confidence interval	0,70 - 0,91
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "This indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link; https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link; https://iqtig.org/qs-verfahren/."

Code ID	1058
Result (%)	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	7
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	0,31
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,22 - 0,43
Hospital confidence interval (%)	0,00 - 35,43
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH, QS-Planung
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	321
Result (%)	0,00
Evaluation through structured dialogue
Population	716
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,23
Target range (reference range)
Confidence interval nationwide (%)	0,22 - 0,24
Hospital confidence interval (%)	0,00 - 0,51
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "This transparency indicator is part of the index indicator Quality index for the critical outcome in term infants. This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link; https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the severity of illness or concomitant illnesses of the patients have an influence on the result. Due to adjustments in the QS filter, the results of this transparency indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link; https://iqtig.org/qs-verfahren/."

Code ID	51397
Result	0,00
Evaluation through structured dialogue
Population	716
Events observed	0
Anticipated events	1,53
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	1,00
Target range (reference range)
Confidence interval nationwide	0,95 - 1,05
Hospital confidence interval	0,00 - 2,50
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with poor quality of the facility. The deviation can also be traced back to incorrect documentation or to individual cases in which, for example, there was a well-founded deviation from medical standards. Quality is assessed in the context of the structured dialogue with the institutions. The results of this quality indicator can only be compared with the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. Further information on the adjustments made can be found in the description of the quality indicators at the following link; https://iqtig.org/qs-verfahren/."

Code ID	51831
Result	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	24
Events observed	0
Anticipated events	0,08
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,04
Target range (reference range)	<= 5,32 (95. Perzentil)
Confidence interval nationwide	0,93 - 1,16
Hospital confidence interval	0,00 - 40,57
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	318
Result (%)	Data protection
Evaluation through structured dialogue	The result is not in the target area, but the quality target is still considered to be achieved, because the deviation can be attributed to arithmetical reasons after examination by specialist committees. (H20)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	96,92
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	96,69 - 97,13
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH, QS-Planung
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "This indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link; https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link; https://iqtig.org/qs-verfahren/."

Code ID	51803
Result	2,48
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A41)
Population	722
Events observed	12
Anticipated events	4,85
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,06
Target range (reference range)	<= 2,32
Confidence interval nationwide	1,03 - 1,09
Hospital confidence interval	1,42 - 4,30
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH, QS-Planung
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG "In diesem Qualitätsindex werden wesentliche Ergebnisparameter kombiniert, um den Zustand des Kindes einzuschätzen. Bei diesem Indikator handelt es sich um einen planungsrelevanten Qualitätsindikator. Standorte, bei denen sich eine statistische Auffälligkeit ergibt, werden vom IQTIG zur Abgabe einer Stellungnahme aufgefordert. Im Rahmen dieses Stellungnahmeverfahrens soll geklärt werden, ob es Gründe gibt, die darauf schließen lassen, dass trotz statistischer Auffälligkeit bei den Qualitätsergebnissen keine unzureichende Qualität vorliegt. Die Bewertung der Qualität im Rahmen der anschließenden fachlichen Klärung erfolgt mit der Unterstützung von Fachkommissionen durch das IQTIG. Die Ergebnisse zu diesem Indikator und die Bewertung der Qualität werden an die für die Krankenhausplanung zuständigen Landesbehörden, an die Landesverbände der Krankenkassen und die Ersatzkassen weitergeleitet. Nähere Informationen zu den planungsrelevanten Qualitätsindikatoren sind unter folgendem Link zu finden; https://www.iqtig.org/qs-instrumente/planungsrelevante-qualitaetsindikatoren/. Bei diesem Indikator handelt es sich um einen risikoadjustierten Indikator. Eine Risikoadjustierung gleicht die unterschiedliche Zusammensetzung der Patientenkollektive verschiedener Einrichtungen aus. Dies führt zu einem faireren Vergleich, da es patientenbezogene Risikofaktoren gibt (wie zum Beispiel Begleiterkrankungen), die das Indikatorergebnis systematisch beeinflussen, ohne dass einer Einrichtung die Verantwortung für z.B. daraus folgende häufigere Komplikationen zugeschrieben werden kann. Beispielsweise kann so das Indikatorergebnis einer Einrichtung mit vielen Hochrisikofällen fairer mit dem Ergebnis einer Einrichtung mit vielen Niedrigrisikofällen statistisch verglichen werden. Die Risikofaktoren werden aus Patienteneigenschaften zusammengestellt, die im Rahmen der Qualitätsindikatorenentwicklung als risikorelevant eingestuft wurden und die praktikabel dokumentiert werden können. Der Referenzbereich gibt an, in welchem Bereich die Ergebnisse eines Indikators als unauffällig bewertet werden. Eine Einrichtung mit einem Ergebnis außerhalb des Referenzbereichs ist zunächst rechnerisch auffällig, dies zieht üblicherweise eine Analyse im Strukturierten Dialog nach sich. Es ist zu beachten, dass ein Indikatorergebnis außerhalb des Referenzbereichs nicht gleichbedeutend ist mit einer mangelnden Qualität der Einrichtung in dem hier betrachteten Qualitätsaspekt. Die Abweichung kann auch z.B. auf eine fehlerhafte Dokumentation oder auf Einzelfälle zurückführbar sein. Die Bewertung der Qualität wird im Rahmen des Strukturierten Dialogs mit den Einrichtungen vorgenommen. Die Ergebnisse dieses Qualitätsindikators sind aufgrund von Anpassungen im QS-Filter nur eingeschränkt mit den Vorjahresergebnissen vergleichbar. Nähere Informationen zu den vorgenommenen Anpassungen können der Beschreibung der Qualitätsindikatoren unter folgendem Link entnommen werden; https://iqtig.org/qs-verfahren/."

Code ID	181800
Result	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	581
Events observed	0
Anticipated events	0,91
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	0,89
Target range (reference range)	<= 3,23 (95. Perzentil)
Confidence interval nationwide	0,82 - 0,97
Hospital confidence interval	0,00 - 4,18
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG