Overall result forecast presentation:	yes
Quantity performed reporting year:	169
Quantity forecast year:	156
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:	yes
Quantity performed reporting year:	86
Quantity forecast year:	94
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)
No participation

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: no

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

Number	Group
35	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*
33	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
29	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
  Information gathering on the topic
  Note on the measure
  Risikoanalyse lt. Checkliste für die Einrichtung besteht als Anhang Nr. 1 des Rahmenkonzeptes Prävention (sexualisierter) Gewalt.
  Training of employees
  Note on the measure
  Institutionelles Schulungskonzept/ Präventionsordnung, Pflichtfortbildung für alle Mitarbeiter:innen
  Education
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Rahmenkonzept Prävention (sexualisierter) Gewalt
  
  Last review of the measure
  27.03.2023 16:06:29
  Age-appropriate complaint options
  
  Special requirements for the selection of persons
  Other aspects of prevention
  Note on the measure
  erweitertes Führungszeugnis, Selbstverpflichtungserklärung zur Einhaltung der Präventionsordnung.
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Rahmenkonzept Prävention (sexualisierter) Gewalt: S. 16
  
  Last review of the measure
  27.03.2023 16:06:29
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Handlungsleitfaden als Anhang Nr. 2 zum bestehendem Rahmenkonzept Prävention (sexualisierter) Gewalt.
  
  Last review of the measure
  27.03.2023 16:06:29

Handlungsleitfaden als Anhang Nr. 2 zum bestehendem Rahmenkonzept Prävention (sexualisierter) Gewalt.

Commentary on the protection concept

Gemäß § 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 § 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

Name of the working group: Gremium zur Arzneimitteltherapiesicherheit

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

Anamnesebogen für alle Abteilungen

04.07.2023

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)

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)

Measures to minimise medication errors

Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
tägliche Medikations-Kurvenvisite in der Chirurgie

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

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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Universität Münster: - Priv.-Doz. Dr. med. H. Wedekind (Kardiologie) - Prof. Dr. med. F. Schmäl (Zentrum HNO Münster/Greven) - Priv.-Doz. Dr. med. C. Kösters (Orthopädie und Unfallchirurgie) Uniklinik Köln: - Priv.-Doz. Dr. med. C. Eichler (Klinik für Brusterkrankung)

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Pflegedirektion: Hr. Apken übt eine Lehrtätigkeit im Bereich Pflegemanagement an der FH Münster aus.

FL03 - Student training (clinical traineeship / internship year)

Explanation

- Anästhesiologie und Intensivmedizin; Innere Medizin, Kardiologie - Zentrum für HNO Greven (Belegarztpraxis) - Viszeralchirurgie, Unfallchirurgie

FL04 - Project-related cooperation with colleges and universities

Explanation

- Zentrum für HNO Münster/Greven (Belegarztpraxis) - Kardiologie PD Dr. med. Wedekind: Klinikum Rheine (Versorgung von Patienten mit pulmonaler Hypertonie) - Unfallchirurgie PD Dr. med. Kösters: Uniklinikum Münster (klinische und biomechanische Studien)

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

Explanation

Die Klinik für Orthopädie und Unfallchirurgie nimmt an klinischen Multicenterstudien (z.B. Meniskus-Allografttransplantation) teil und hat mehrere klinische Studien initiiert.

FL08 - Editors of scientific journals/textbooks

Explanation

FL09 - Doctoral supervision

Explanation

- Kardiologie: Doktorandenbetreuung und Dissertationvergaben in Zusammenarbeit mit dem Universitätsklinikum Münster - Unfallchirurgie /Orthopädie: Doktorandenbetreuung

Training

Training in other healing professions

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

Comment

Generalistische Pflegeausbildung -Pflegefachfrau/Pflegefachmann in der stationären/ambulanten Akutpflege (Setting: Krankenhaus; 10 Ausbildungsplätze pro Jahr) -Pflegefachfrau/Pflegefachmann in der ambulanten Langzeitpflege (Setting: Ambulanter Pflegedienst, 1-2 Ausbildungsplätze pro Jahr)

HB07 - Surgical technical assistant (m/f)

Comment

Wir bieten 2 Ausbildungsplätze pro Jahr in Kooperation mit dem IBiG (= Institut für Bildung im Gesundheitswesen) in Hamm.

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

Im Rahmen der 3-jährigen Ausbildung bietet das Maria-Josef-Hospital die Möglichkeit für die praktischen Ausbildungsinhalte. Bewerbungsmöglichkeit ist ganzjährig gegeben.

HB19 - Nursing professionals

Comment

HB20 - Nursing professional B. Sc.

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

Wir bieten Ausbildungsplätze pro Jahr in Kooperation mit dem Institut für Bildung im Gesundheitswesen in Hamm und Niels-Stensen-Kliniken in Osnabrück an. Bewerbungsmöglichkeit ist ganzjährig gegeben. Die Ausbildung in Osnabrück umfasst die Bereiche OTA und ATA.

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 16
- Additional staff: 8
- Explanations: Das Maria-Josef-Hospital Greven wird durch das Medical Order Center als zentrale Apotheke in Ahlen versorgt. Betreuung und Ansprechpartner bei Fragen sind 24 Stunden / 7 Tage die Woche vorhanden. Regelmäßige, protokollierte Begehungen vor Ort erfolgt durch eine Apothekerin mindestens 2 x jährlich.
- Nursing staff regulation