No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement (06.04.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Risikomanagement (06.04.2023)
RM05	Pain management Risikomanagement (06.04.2023)
RM06	Fall prophylaxis Risikomanagement (06.04.2023)
RM08	Regulated handling of custodial measures Risikomanagement (06.04.2023)
RM09	Regulated handling of occurring malfunctions of devices Risikomanagement (06.04.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM18	Discharge management Risikomanagement (06.04.2023)

Conference frequency: quartalsweise

CIRS

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 03.04.2023
IF02	Internal evaluation of the received reports taken halbjährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 03.04.2023

IF02

Internal evaluation of the received reports

taken halbjährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Conference frequency: quartalsweise

No.	Explanation
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea