St.-Marien-Hospital Marsberg

Quality results

Treatment sector: Knee endoprosthesis supply: first insertion or exchange (KEP)

Information about this treatment area (documentation)

Designation	Knieendoprothesenversorgung
Shortcut	KEP
Number of cases	93
Documentation rate	100 %

Summary result:

In 7 of 7 quality characteristics, the quality objective was achieved.
For 3 quality characteristics, no assessment is possible.

Number of patients treated: 93

Quality objective achieved
Quality objective not achieved

The results in detail

Hide national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

This is how often the decision to insert an artificial knee joint for the first time was made in accordance with the scientific guidelines

National result: 98,12 %
Hospital: 100,00 %

Target area: at least 90,00 %

Quality objective achieved

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This is how often the decision to insert an artificial partial knee joint was made in accordance with the scientific guidelines

National result: 97,42 %
Hospital: 100,00 %

Target area: at least 90,00 %

Quality objective achieved

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This is how often the decision to replace an artificial knee joint (or parts of it) was made in accordance with the scientific guidelines

National result: 92,44 %
Hospital: Data protection

No information due to data protection

Target area: at least 86,00 %

Assessment not possible

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This is how rarely general complications occured (blood clots, pneumonia) due to a planned first-time insertion of an artificial knee joint

National result: 1,02 %
Hospital: 0,00 %

Target area: at most 4,26 %

Quality objective achieved

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This is how rarely general complications (blood clots, pneumonia) occured during operations in which an old artificial knee joint is replaced by a new one or parts are exchanged (replacement operation)

National result: 3,33 %
Hospital: Data protection

No information due to data protection

Target area: at most 11,32 %

Assessment not possible

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This is how rarely specific complications occured (nerve damage, bleeding, implant displacement) due to a planned first-time insertion of an artificial knee joint

National result: 0,88 %
Hospital: Data protection

No information due to data protection

Target area: at most 3,71 %

Quality objective achieved

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This is how rarely specific complications (nerve damage, bleeding, implant displacement) occurred during operations in which an old artificial knee joint is replaced by a new one or parts are exchanged (replacement surgery)

National result: 4,18 %
Hospital: Data protection

No information due to data protection

Target area: at most 14,11 %

Assessment not possible

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Ratio of the actual number to the previously expected number of patients who could not walk 50 metres when discharged from hospital (individual risks of the patients were taken into account)

National result: 1,13
Hospital: 0,00

Target area: at most 5,19

Quality objective achieved

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This is how rarely patients died during their hospital stay after having an artificial knee joint implanted

National result: 0,04 %
Hospital: 0,00 %

Sentinel Event

Quality objective achieved

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This is how often no replacement of the artificial knee joint or individual parts was necessary within 90 days of an initial operation

National result: 99,80 %
Hospital: 100,00 %

Target area: at least 98,81 %

Quality objective achieved

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Code ID	54020
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	87
Events observed	87
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	98,12
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	98,05 - 98,18
Hospital confidence interval (%)	95,77 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 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 computationally conspicuous, 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.

Code ID	54021
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	5
Events observed	5
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	97,42
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	97,22 - 97,61
Hospital confidence interval (%)	56,55 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 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 computationally conspicuous, 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.

Code ID	54022
Result (%)	Data protection
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	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 (%)	92,44
Target range (reference range)	>= 86,00 %
Confidence interval nationwide (%)	91,95 - 92,89
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 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 computationally conspicuous, 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 cannot be compared with the previous year's results. 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	54123
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	93
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	1,02
Target range (reference range)	<= 4,26 % (95. Perzentil)
Confidence interval nationwide (%)	0,98 - 1,07
Hospital confidence interval (%)	0,00 - 3,97
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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.

Code ID	50481
Result (%)	Data protection
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	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 (%)	3,33
Target range (reference range)	<= 11,32 % (95. Perzentil)
Confidence interval nationwide (%)	3,02 - 3,66
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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 cannot be compared with the previous year's results. 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	54124
Result (%)	Data protection
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
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 (%)	0,88
Target range (reference range)	<= 3,71 % (95. Perzentil)
Confidence interval nationwide (%)	0,84 - 0,93
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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.

Code ID	54125
Result (%)	Data protection
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	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 (%)	4,18
Target range (reference range)	<= 14,11 % (95. Perzentil)
Confidence interval nationwide (%)	3,84 - 4,55
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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 cannot be compared with the previous year's results. 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	54028
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	90
Events observed	0
Anticipated events	0,39
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,13
Target range (reference range)	<= 5,19 (95. Perzentil)
Confidence interval nationwide	1,06 - 1,21
Hospital confidence interval	0,00 - 9,55
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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, as there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. the following more frequent complications can be attributed to it. 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 computationally conspicuous, 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. The results of this quality indicator can only be compared to 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	54127
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	82
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	0,04
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,03 - 0,05
Hospital confidence interval (%)	0,00 - 4,48
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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. The results of this quality indicator can only be compared to 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	54128
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	104
Events observed	104
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	99,80
Target range (reference range)	>= 98,81 % (5. Perzentil)
Confidence interval nationwide (%)	99,78 - 99,82
Hospital confidence interval (%)	96,32 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact on the result. 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 computationally conspicuous, 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. This quality indicator represents both events such as Complications that occur before discharge from a hospital, as well as events that occur after discharge but can still be related to the implantation.