Klinikum Bayreuth

Preuschwitzer Straße 101
95445 Bayreuth

Phone: 0921-400-0
Mail: ed.htueryab-mukinilk@elletstsop poststelle@klinikum-bayreuth.d... ed.htueryab-mukinilk@elletstsop

http://www.klinikum-bayreuth.de

Basic information

Number of beds: 662
Number of specialist departments: 24

Number of inpatient cases: 25.575
Number of partial inpatient cases: 350
Number of outpatient cases: 32.702

Hospital owners: Klinikum Bayreuth GmbH
Type of provider: öffentlich

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

External quality assurance according to the DMP

Diabetes mellitus Typ 2

Implementation of the minimum quantity agreement

Treatment area

Complex interventions on the organ system esophagus for adults

Quantity performed	7
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	167
Exception?	No exception

Thoracic surgical treatment of lung cancer in adults

Quantity performed	22
Exception?	No exception

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

Quantity performed	25
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	40
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	2
Exception?	No exception

Minimum quantities forecast

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	167
Quantity forecast year:	155
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:	40
Quantity forecast year:	43
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:	no
Quantity performed reporting year:	7
Quantity forecast year:	5
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	no
Quantity performed reporting year:	22
Quantity forecast year:	8
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
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:	36
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:	no
Quantity performed reporting year:	2
Quantity forecast year:	3
Examination by state associations?	no
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
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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

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

Management of quality assurance for proximal femoral fracturet (QSFFx)

Full record of compliance maintained

Number of days shown	366
Days of non-performance	0
Number of minimum requirements not met	0

Specific minimum requirements

Minimum requirement	Days of non-performance
Doctor on duty	0
Supervision by a medical specialist	0
Geriatric expertise	0
Operating room equipment	0
Post-operative physiotherapy	0
Independent organisational unit	0

Minimum requirements for process quality

Minimum requirement	Days of non-performance
SOP: Surgical procedures	0
SOP: Perioperative Planning	0
SOP: Capacity to consent	0
Standard Operating Procedure for the Management of Anticoagulants	0
SOP: Ortho-geriatric Care	0
SOP: Physiotherapy Measures	0
SOP: Patient-centred blood management	0

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

Number	Group
195	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*
131	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
122	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
  Other aspects of prevention
  Note on the measure
  Die Kinderschutzgruppe am Klinikum Bayreuth (ärztliche und pflegerische Mitarbeiter*innen) trifft sich 1x im Quartal zum "Runden-Tisch Kinderschutz" mit Fachkräften der Jugendämter im Umkreis.
  Education
  Note on the measure
  Bei internen Multiplikationen werden die Inhalte in den interdisziplinären Teams kommuniziert; Eltern und Bezugspersonen werden durch die psychosoziale Beratung und Begleitung zu den Themen sensibilisiert und entsprechende Hilfestellungen, Kontakte, Vernetzungen oder Unterstützungen vermittelt
  Information gathering on the topic
  Note on the measure
  In den Räumlichkeiten der Kinderklinik sowie der Geburtshilfe wird auf die möglichen Unterstützungs- und Hilfsangebote Frühe Hilfen und Kinderschutz hingewiesen; Flyer und Termine liegen aus, sind verfügbar.
  Training of employees
  Note on the measure
  Besuch der Runden Tische zu Vernetzung; Austausch und Kenntniserweiterung; Infos werden im Team multipliziert; Besuch von Treffen zum Thema Kinderschutz und Prävention im überregionalen Kontext; Modulares E-Learning wird auf diversen Plattformen vorangebracht
  Special requirements for the selection of persons
  Note on the measure
  Ein erweitertes polizeiliches Führungszeugnis wird erwartet; bei den Einstellungen im Sozialdienst Kinderklinik werden erweiterte Kenntnisse zu den Themen Kinderschutz und Prävention sowie Umgang bei Gefährdung vorausgesetzt
  Age-appropriate complaint options
  Note on the measure
  Die Kinderschutzgruppe im Haus ist telefonisch erreichbar;
  Externe Kontakte bestehen zu Jugendamt, Beratungsstellen, Avalon und Kinderschutzbund;
  Meldung bei Kindeswohlgefährdung;
  Die Erzieherin auf der Kinderstation ist für Kinder ansprechbar.
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Interdisziplinäres Team geht Anhaltspunkte durch; Einbeziehung der Sorgeberechtigten; Zusammenarbeit mit dem Jugendamt; Dokumentation in der Patientenakte; Hilfeangebot für Sorgeberechtigten wird angeboten/vermittelt; Sichernde Hinzuziehung von Maßnahmen im Bedarfsfall
  Other aspects of intervention
  Note on the measure
  Nutzung anonymisierter Fälle für einen fortlaufenden Verbesserungsprozess; Austauschtermine der Kinderschutzgruppe; Vorbereitung einer Kooperationsvereinbarung mit den Jugendämtern, Regelung/Inhalt zur Festlegung der Runden zum Austausch der Klinikmitarbeiter mit den FK des Jugendamtes
- Review
  Other information on recognition
  Note on the measure
  Im Patientendatensystem sind die für die Kinderschutzfälle notwendigen Dokumente verfügbar. Sie können im Bedarfsfall als Handlungsleitfaden von allen Professionen genutzt werden.

Die Kinderschutzgruppe am Klinikum Bayreuth (ärztliche und pflegerische Mitarbeiter*innen) trifft sich 1x im Quartal zum "Runden-Tisch Kinderschutz" mit Fachkräften der Jugendämter im Umkreis.

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

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)

QM-Handbuch

15.10.2025

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

CATO als Closed-Loop-System

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

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

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

FL09 - Doctoral supervision

Explanation

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

Explanation

Training

Training in other healing professions

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

in Kooperation mit dem BSZG Erlangen (Staatliches Berufliches Schulzentrum für Gesundheitsberufe Erlangen)

HB15 - Anaesthesia technical assistant (m/f)

Comment

in Kooperation mit Sozialstiftung Bamberg

HB01 - Nurse and health care worker (m/f)

Comment

Generalistischen Ausbildung zum Pflegefachmann/- frau im Bereich Akutpflege und mit pädiatrischer Vertiefung

HB07 - Surgical technical assistant (m/f)

Comment

in Kooperation mit der Sozialstiftung Bamberg und dem Klinikum Weiden

HB17 - Auxiliary nurse (m/f)

Comment

KPH Schule ist Zertifiziert, Ausbildung auch über Berufsförderprogramme der Bundesagentur für Arbeit möglich

HB19 - Nursing professionals

Comment

Generalistischen Ausbildung zum Pflegefachmann/- frau im Bereich Akutpflege und mit pädiatrischer Vertiefung

HB12 - Medical technical laboratory assistant (MTLA) (m/f)

Comment

HB10 - Midwife (m/f)

Comment

in Kooperation mit der EAH Jena und Universiätat Erlangen

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 6
- Additional staff: 14
- Explanations: Die Apotheke hat Ihren Sitz an der Betriebsstätte Klinikum. Zugeordnet ist das Personal beiden Standorten der Klinikum Bayreuth GmbH.
- Nursing staff regulation