Overall result forecast presentation:	yes
Quantity performed reporting year:	220
Quantity forecast year:	278
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:	yes
Quantity performed reporting year:	22
Quantity forecast year:	25
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:	42
Quantity forecast year:	35
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	393
Quantity forecast year:	415
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	97
Quantity forecast year:	108
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.	Explanation
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
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

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
124	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*
94	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
92	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
  Special requirements for the selection of persons
  Note on the measure
  Einforderung eines erweiterten Führungszeugnisses bei Mitarbeitern, welche in ihrem Arbeitsbereich mit Kindern zu tun haben.
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Der Umgang mit Ereignismeldungen ist geregelt.
  
  Last review of the measure
  22.06.2022 16:03:38

Der Umgang mit Ereignismeldungen ist geregelt.

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

Drug commission

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

Ärztliche Basisanamnese

14.10.2020

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)

SOP Umgang mit Arzneimitteln

21.06.2023

SOP on good prescription practices

SOP zum Umgang mit Arzneimitteln

21.06.2023

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

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

Die Klinikdirektoren des Pius-Hospital haben Professuren an der European Medical School (EMS) inne. Darüber hinaus haben einige Ärztinnen und Ärzte Lehraufträge an anderen Universitäten mit medizinischer Fakultät.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Neben den vergebenen Lehraufträgen an Ärztinnen und Ärzte des Pius-Hospitals werden Vorlesungen und Untersuchungskurse für die Studenten der European Medical School (EMS) durchgeführt. Zudem erfolgt die Gestaltung des EMS-Modellstudienganges und des dazugehörigen Curriculums über das Pius-Hospital.

FL04 - Project-related cooperation with colleges and universities

Explanation

Die Kliniken des Pius-Hospital pflegen die projektbezogene Zusammenarbeit mit verschiedenen Hochschulen und Universitäten.

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

Explanation

Das Pius-Hospital nimmt zur Beantwortung wissenschaftlicher Fragen und Verbesserung der medizinischen Behandlung an klinischen Studien teil. Dazu werden Patientinnen und Patienten für Studien rekrutiert und durch die verantwortlichen Ärzte und die Mitarbeiterinnen des Studiensekretariates betreut.

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

Explanation

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

Explanation

In verschiedenen Kliniken des Pius-Hospital werden wissenschaftliche Studien initiiert und geleitet.

FL08 - Editors of scientific journals/textbooks

Explanation

Die wissenschaftlichen Veröffentlichungen der Ärztinnen und Ärzte des Pius-Hospitals können auf den Internetseiten der Kliniken abgerufen werden.

FL09 - Doctoral supervision

Explanation

Im Pius-Hospital können Doktoranden in den verschiedenen Kliniken betreut werden. In der Universitätsklinik für Gynäkologie und in der Universitätsklinik für Orthopädie und Unfallchirurgie besteht zusätzlich die Möglichkeit der Habilitation.

Training

Training in other healing professions

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

Comment

Dem Pius-Hospital ist die staatlich anerkannte Schule für Pflegefachberufe angeschlossen. Aufgrund der Generalistik in der Ausbildung kooperiert die Ausbildungsstätte mit verschiedenen Pflegeeinrichtungen. Es stehen rund 200 Ausbildungsplätze zur Verfügung.

HB07 - Surgical technical assistant (m/f)

Comment

OTA´s können vielseitig im OP und anderen Funktionsbereichen wie Ambulanz, Endoskopie und Zentralsterilisation arbeiten. Der praktische Teil der Ausbildung erfolgt im Pius-Hospital, die theoretische Ausbildung im Hanseinstitut Oldenburg, dem Bildungszentrum der drei Oldenburger Krankenhäuser.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Das Pius-Hospital stellt den Auszubildenden einer Oldenburger Physiotherapieschule Plätze für ihr klinisches Praktikum zur Verfügung.

HB14 - Orthoptist (m/f)

Comment

Seit September 2022 verfügt das Pius-Hospital über eine eigene Berufsfachschule für Orthoptik, welche zur Universitätsklinik für Augenheilkunde im Pius-Hospital gehört. Es stehen jährlich acht Ausbildungsplätze für die insgesamt dreijährige Ausbildung zur Verfügung.

HB15 - Anaesthesia technical assistant (m/f)