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Universitätsklinikum Frankfurt

Theodor-Stern-Kai 7
60590 Frankfurt am Main

Phone: 069-6301-0
Fax: 069-6301-7474
Mail: ed.ugk@ofni

http://www.kgu.de

Basic information

Number of beds: 1.306
Number of specialist departments: 42

Number of inpatient cases: 42.786
Number of partial inpatient cases: 1.904
Number of outpatient cases: 445.859

Hospital owners: Land Hessen
Type of provider: öffentlich

University Hospital
Academic teaching hospital

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	does not apply
Bezeichnung
Teilnahme externe Qualitätssicherung	yes

External quality assurance according to the DMP

Brustkrebs

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Liver transplant

Quantity performed	31
Exception?	No exception

Kidney transplantation

Quantity performed	46
Exception?	No exception

Complex operations on the esophageal organ system

Quantity performed	14
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	58
Exception?	No exception

Stem cell transplant

Quantity performed	194
Exception?	No exception

Care of premature and newborn babies (with a birth weight of less than 1250g) at a hospital with proven level 1

Quantity performed	45
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	121
Exception?	No exception

Minimum quantities forecast

Liver transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	31
Quantity forecast year:	22
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Kidney transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	46
Quantity forecast year:	46
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	121
Quantity forecast year:	119
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex operations on the esophageal organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	14
Quantity forecast year:	8
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	58
Quantity forecast year:	54
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	194
Quantity forecast year:	170
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Care of premature and newborn babies (with a birth weight of less than 1250g) at a hospital with proven level 1

Overall result forecast presentation:	yes
Quantity performed reporting year:	45
Quantity forecast year:	33
Examination by state associations?	yes
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.	Explanation
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ18	Measures for quality assurance of positron emission tomography in patients with Hodgkin lymphoma and aggressive non-Hodgkin lymphoma for interim staging after chemotherapy to decide on the continuation of therapy
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ23	Measures for quality assurance of allogeneic stem cell transplantation with in vitro preparation of the transplant for acute lymphatic leukaemia and acute myeloid leukaemia in adults
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ24	Quality assurance measures for allogeneic stem cell transplantation in multiple myeloma
CQ26	Decision on measures for quality assurance of targeted lung denervation by catheter ablation in chronic obstructive pulmonary disease
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)

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
467	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*
37	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
37	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

Drug therapy safety

Steering committee

Name of the working group: Arbeitsgruppe AMTS

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)

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

Hausweites Dokumentenlenkungsprogramm

14.10.2021

SOP on good prescription practices

Hausweites Dokumentenlenkungsprogramm

14.10.2021

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

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 von Patienteninformationen zur Umsetzung von Therapieempfehlungen
Aushändigung des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten