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kbo-Heckscher-Klinikum gGmbH, Standort Haar

Max - Isserlin Straße 23
85540 Haar

Phone: 089-9999-0
Mail: ed.obk@hdm-keh.ofni ed.obk@hdm-keh.ofni ed.obk@hdm-keh.ofni

https://kbo-heckscher-klinikum.de/

Basic information

Number of beds: 20
Number of specialist departments: 1

Number of inpatient cases: 25
Number of partial inpatient cases: 28
Number of outpatient cases: 2.247

Hospital owners: kbo-Heckscher-Klinikum gemeinnützige GmbH im Verbund mit den Kliniken des Bezirks Oberbayern - Kommunalunternehmen (kbo)
Type of provider: freigemeinnützig

Academic teaching hospital

Specialist departments

Kinder- und Jugendpsychiatrie

Services

Quality

Further information

External quality assurance according to state law
No participation

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement
No participation

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

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Kinder und Jugendpsychiatrie

Day shift
Compliance with minimum requirements	no
Level of implementation	140,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	102,49 %
Pflegefachpersonen und Erziehungsdienst	ja	148,9 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen (dazu zählen alle Kinder- und Jugendlichenpsychotherapeutinnen und -psychotherapeuten)	ja	109,57 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	190,42 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	169,21 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	105,51 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	40
Current staffing levels (full-time staff)	11
Number of nights, subject to the minimum requirement	0

quarter Q2

Kinder und Jugendpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	117,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	nein	75,68 %
Pflegefachpersonen und Erziehungsdienst	ja	128,71 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen (dazu zählen alle Kinder- und Jugendlichenpsychotherapeutinnen und -psychotherapeuten)	ja	106,26 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	151,71 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	93,08 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	78,95 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	40
Current staffing levels (full-time staff)	11
Number of nights, subject to the minimum requirement	0

quarter Q3

Kinder und Jugendpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	123,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	122,95 %
Pflegefachpersonen und Erziehungsdienst	ja	135,17 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen (dazu zählen alle Kinder- und Jugendlichenpsychotherapeutinnen und -psychotherapeuten)	ja	119,89 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	95,47 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	124,88 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	57,62 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	40
Current staffing levels (full-time staff)	12
Number of nights, subject to the minimum requirement	0

quarter Q4

Kinder und Jugendpsychiatrie

Day shift
Compliance with minimum requirements	no
Level of implementation	142,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	113,31 %
Pflegefachpersonen und Erziehungsdienst	ja	136,98 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen (dazu zählen alle Kinder- und Jugendlichenpsychotherapeutinnen und -psychotherapeuten)	ja	192,56 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	159,41 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	160,98 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	143,39 %
Night shift
Compliance with minimum requirements	yes
Minimum requirement (full-time staff)	40
Current staffing levels (full-time staff)	19
Number of nights, subject to the minimum requirement	0

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

Number	Group
16	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*
3	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
3	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
  
  Age-appropriate complaint options
  
  Code of conduct with rules for treating children and young people with respect
- Intervention
  
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence

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

Name of the working group: AG Arzneimitteltherapiesicherheit

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

Use of standardised forms for drug medical history

Enthalten im standardisierten Anamnesebogen

02.12.2024

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)

Für das kbo-Heckscher-Klinikum existiert ein umfangreiches QM-Handbuch mit Verlinkung zu weiterführenden Unterlagen wie Leitlinien, Betriebsvereinbarungen und -Anweisungen, sowie die Prozesse unterstützende Formulare / Dokumente, inklusive der RM-Politik und Prozessbeschreibung.

02.12.2024

SOP on good prescription practices

02.12.2024

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Measures to minimise medication errors

Vier-Augen-Prinzip; regelmäßige Schulungen; Sensibilisierung

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.

Research & teaching