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Klinikum Fulda - Hauptstandort

Pacelliallee 4
36043 Fulda

Phone: 0661-84-0
Fax: 0661-84-5013
Mail: ed.adluf-mukinilk@ofni

http://www.klinikum-fulda.de

Basic information

Number of beds: 952
Number of specialist departments: 29

Number of inpatient cases: 34.142
Number of partial inpatient cases: 453
Number of outpatient cases: 48.359

Hospital owners: Klinikum Fulda gemeinnützige Aktiengesellschaft
Type of provider: öffentlich

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

External quality assurance according to the DMP

Koronare Herzkrankheit (KHK)

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Kidney transplantation

Quantity performed	15
Exception?	No exception

Complex operations on the esophageal organ system

Quantity performed	13
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	23
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	27
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	72
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	72
Quantity forecast year:	59
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:	23
Quantity forecast year:	26
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:	13
Quantity forecast year:	14
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Liver transplant

Overall result forecast presentation:	no
Quantity performed reporting year:	0
Quantity forecast year:	0
Examination by state associations?	no
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:	15
Quantity forecast year:	15
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:	no
Quantity performed reporting year:	0
Quantity forecast year:	0
Examination by state associations?	no
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:	27
Quantity forecast year:	16
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
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
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ22	Quality assurance measures for interstitial low-dose-rate brachytherapy for the treatment of localised prostate cancer
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
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

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
232	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*
157	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
152	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

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

Use of standardised forms for drug medical history

Apotheken Handbuch

31.12.2018

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)

Zentrales QM Handbuch

31.12.2019

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
Patientenindividuelle Zubereitung der totalen parenteralen Ernährung und der Antibiotikazubereitung in der Kinderklinik durch die Apotheke

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)
Sonstige Konzepte: DokuPik (Bundesverband Deutscher Krankenhausapotheker)

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

Special instrument-based equipment

Research & teaching

Job

FL04 - Project-related cooperation with colleges and universities

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL05 - Participation in multi-centre Phase I/II studies

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL09 - Doctoral supervision

Explanation

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

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

Universitätsmedizin Marburg - Campus Fulda Universitäre Lehre Humanmedizin: 2. klinischer Abschnitt und Praktisches Jahr (Chirurgie, Innere Medizin, Kinderheilkunde)

FL08 - Editors of scientific journals/textbooks