ELBLANDKLINIKEN Stiftung & Co. KG, ELBLANDKLINIKUM Radebeul

Overall result forecast presentation:	yes
Quantity performed reporting year:	311
Quantity forecast year:	342
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:	320
Quantity forecast year:	361
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
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	113,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	139,11 %
Pflegefachpersonen	ja	107,52 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	161,25 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	94,14 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	107,19 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	110,75 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	66
Current staffing levels (full-time staff)	86
Number of nights, subject to the minimum requirement	91

quarter Q2

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	95,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	105,8 %
Pflegefachpersonen	nein	92,83 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	122,35 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	84,65 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	106,17 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	97,63 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	66
Current staffing levels (full-time staff)	86
Number of nights, subject to the minimum requirement	91

quarter Q3

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	100,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	116,37 %
Pflegefachpersonen	ja	97,15 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	124,24 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	85,98 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	101,11 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	97,17 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	66
Current staffing levels (full-time staff)	83
Number of nights, subject to the minimum requirement	92

quarter Q4

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	no
Level of implementation	95,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	117,39 %
Pflegefachpersonen	ja	91,1 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	109,02 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	93,43 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	100,47 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	92,56 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	66
Current staffing levels (full-time staff)	84
Number of nights, subject to the minimum requirement	92

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

General minimum requirements

Minimum requirement	Days of non-performance
Trauma room	0
Availability	0
Computed tomography (CT)	0
Intensive care beds	0
Department of Surgery	0
Forwarding by air	0
Department of Internal Medicine	0
Intensive care beds with ventilator facilities	0
Emergency care training courses	0
Treatment prioritisation system (triage)	0
Responsibility for emergency care	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
89	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*
72	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
68	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
  
  Special requirements for the selection of persons
  
  Training of employees
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Kinderschutzkonzept
  
  Last review of the measure
  13.07.2023 22:03:02
  Education
  
  Information gathering on the topic
  
  Age-appropriate complaint options
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Kinderschutzkonzept
  
  Last review of the measure
  13.07.2023 22:03:02
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Kinderschutzkonzept
  
  Last review of the measure
  13.07.2023 22:03:02

Kinderschutzkonzept

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

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

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)

Qualitätsmanagementhandbuch der ELBLANDKLINIKEN

25.08.2025

SOP on good prescription practices

Qualitätsmanagementhandbuch der ELBLANDKLINIKEN

25.08.2025

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
u.a. Zenzy II

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)
Modulsystem für Bestellung über KIS; Zenzy II

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)
Risikomanagement & CIRS

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

in Kooperation mit der Carus Akademie Dresden

HB11 - Podiatrist (m/f)

Comment

Praxispartner

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 6
- Additional staff: 6
- Explanations: Das Personal gehört zur zentralen Klinikapotheke der ELBLANDKLINIKEN. Die zentrale Klinikapotheke betreut alle Standorte der ELBLANDKLINIKEN.
- Nursing staff regulation