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Universitätsklinikum Mannheim GmbH

Theodor-Kutzer-Ufer 1-3
68167 Mannheim

Phone: 0621-383-0
Fax: 0621-383-2185
Mail: ed.mmu@ofni

https://www.umm.de/start/

Basic information

Number of beds: 1.352
Number of specialist departments: 27

Number of inpatient cases: 44.176
Number of partial inpatient cases: 5.489
Number of outpatient cases: 318.097

Hospital owners: Universitätsklinikum Mannheim GmbH
Type of provider: öffentlich

University Hospital
Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes

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

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Complex interventions on the organ system esophagus for adults

Quantity performed	52
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	70
Exception?	No exception

Kidney transplant (including living donation)

Quantity performed	27
Exception?	No exception

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	50
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	93
Exception?	No exception

Liver transplantation (including partial liver donation)

Quantity performed	41
Exception?	No exception

Minimum quantities forecast

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	93
Quantity forecast year:	74
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:	70
Quantity forecast year:	71
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:	0
Quantity forecast year:	19
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	41
Quantity forecast year:	44
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:	0
Quantity forecast year:	188
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Overall result forecast presentation:	yes
Quantity performed reporting year:	0
Quantity forecast year:	49
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Kidney transplantation (including living donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	27
Quantity forecast year:	32
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:	52
Quantity forecast year:	49
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
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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
CQ30	Quality assurance guideline for interstitial LDR brachytherapy for low-risk localized prostate cancer (effective January 8, 2021).
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm

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: yes

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

Number	Group
522	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*
344	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
344	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
  Flyer zur Gewaltprävention auf den Stationen.
  Training of employees
  Note on the measure
  Regelmäßige Seminare, Fallvorstellungen, interdisziplinäre Konferenzen zum Kinderschutz.
  Special requirements for the selection of persons
  Note on the measure
  Personal, ÄD: Im Vorstellungsgespräch werden regelmäßig Verhaltensmuster und Persönlichkeitsstruktur der Kandidat*innen in Bezug auf die Betreuung von Kindern und Jugendlichen und deren Familien abgefragt und herausgearbeitet.
  Age-appropriate complaint options
  Note on the measure
  Derzeit in Planung.
  Education
  Note on the measure
  Regelmäßige Seminare, Fallvorstellungen, interdisziplinäre Konferenzen zum Kinderschutz.
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Derzeit in Planung.
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  KIND_PA_Kinderschutz; Kinderschutzteam, standardisiertes Vorgehen.
  
  Last review of the measure
  07.11.2022 19:12:12
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Kinderschutzteam für externe Fälle, Konzept für interne Vorfälle wird erarbeitet.

Flyer zur Gewaltprävention auf den Stationen.

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

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)

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

Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Zentrale Herstellung von Zytostatikazubereitungen durch die Apotheke; Herstellung von Lösungen für die parenterale Ernährung (Neonatologie) durch die Apotheke; Herstellung von Schmerzmittelkassetten zur i.v. Applikation durch die Apotheke; Prozessanweisung "Vorbereitung und Applikation von i.v. Injektionen und Infusionen.

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)
Sonstige elektronische Unterstützung (bei z.B. Bestellung, Herstellung, Abgabe): Zenzy Programm für die Zentrale Zytostatikazubereitung

Measures to minimise medication errors

Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
AMK_DA_Medikationsprozess

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

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

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehre in den Studiengängen Medizintechnik und Medizinische Informatik an der Hochschule Mannheim.

FL08 - Editors of scientific journals/textbooks

Explanation

J. d. D. Dermatologischen Gesellschaft; Sportverletzung Sportschaden; Clin. a. Exp. Metastasis; Europ. J. of Pain; Int. J. of Cancer; Nature Scientific Rep.; Intraoperative Radiotherapy; Orthopädie und Unfallchirurgie; Atlas der MR-Angiographie.

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

Explanation

ACO/ARO/AIO 18.1, ENEST Freedom, BODO, DASFree, OPTIC, ENDURE, DAStop2, PONS, CLLRUmbrella1, Citadel-203

FL09 - Doctoral supervision

Explanation

Gemeinsame Doktorandenbetreuung mit ZI (Mannheim), Hochschule Mannheim, KIT (Karlsruhe), DKFZ (Heidelberg), Harvard University und anderen Fakultäten der Universität Heidelberg

FL03 - Student training (clinical traineeship / internship year)

Explanation

Akad. LehrKH: TKH MA, Diak. KH MA, Diak. SP, St. Marien KH LU, Klin. DA, Westpfalz-Klin. KL, KliLU, St. Josef KH HD, Hosp. R. Schumann LUX; Klin. Crailsheim; Akad. Lehrpraxen: PJ-Quartal "Amb. Med." u. "Allg.Med"; Famulatur: Med. Uni Ufa; Uni Potosí; Uni. del Rosario; Gulf Med. Uni. Dubai.

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

Explanation

GISG-06, CTCL, MINDED, NAUT, INTRABEAM, INTRAGO

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

Explanation

AIO-KRK-0214, PETRARCA, RAMSES, DANTE

FL04 - Project-related cooperation with colleges and universities

Explanation

MWK-geförderte Studie zum Einfluss beruflich-praktischer Vorqualifikationen auf den Studienerfolg im Verbd. „Studierendenauswahl in der Medizin BW“; Aufbau Modellregion Ärztl. Ausbildung: Digitale Plattform zur Vernetzung mit Akad. LehrKH und Lehrpraxen BW, Teaching Cloud Medizin BW (TeaCM-BW).

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Gemeinsame Vorlesungen an der Universität Heidelberg zwischen Med. Fakultät Mannheim (MSc Biomedical Engineering ) und den Fakultäten Physik, Astronomie, Mathematik und Informatik.

Training