Overall result forecast presentation:	yes
Quantity performed reporting year:	186
Quantity forecast year:	215
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:	15
Quantity forecast year:	11
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
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)

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
83	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*
34	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
34	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
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  26.08.2021 17:37:52
  Special requirements for the selection of persons
  Other aspects of prevention
  Note on the measure
  Ein ergänzendes, auf unsere KH-Einrichtung speziell ausgerichtetes Schutzkonzept inkl. eines Verhaltenskodexes befinden sich in Erarbeitung
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  26.08.2021 17:37:52
  Other aspects of intervention
  Note on the measure
  Ein ergänzendes, auf unsere KH-Einrichtung speziell ausgerichtetes Schutzkonzept inkl. eines Verhaltenskodexes befinden sich in Erarbeitung
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  26.08.2021 17:37:52
  Other information on recognition
  Note on the measure
  Ein ergänzendes, auf unsere KH-Einrichtung speziell ausgerichtetes Schutzkonzept inkl. eines Verhaltenskodexes befinden sich in Erarbeitung

Ein ergänzendes, auf unsere KH-Einrichtung speziell ausgerichtetes Schutzkonzept inkl. eines Verhaltenskodexes befinden sich in Erarbeitung

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

Risikomanagementhandbuch

18.07.2016

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)

VA Medikamentenmanagement

17.08.2017

SOP on good prescription practices

VA Medikamentenmanagement

17.08.2017

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
PB_Stellen und Verabreichen von Medikamenten

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)

Measures to ensure seamless drug therapy after discharge

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

Research & teaching

Job

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

Erfassung d. Lebensqualität bei Pat. mit metastasiertem kolorekt. Karzinom u. Zaltrap-Therapie -Random. Random., kontrollierte, multizentr., longitudinale Versorgungsforschungsstudie Onkolotse

Training

Training in other healing professions

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

Comment

Krankenpflegeschule am Haus mit 3 Vollzeitkräften mit direktem Beschäftigungsverhältnis

HB07 - Surgical technical assistant (m/f)

Comment

nur praktische Ausbildung - theoretischer Teil im Verbund mit Uni Leipzig und christliche Akademie Halle

Hospital staff
Pharmaceutical personnel
- Explanations: Zusammenarbeit mit Waisenhaus Apotheke Halle
- Nursing staff regulation

Service contact persons

Patient advocates

Frau Ingrid Hilmers

Patientenfürsprecherin

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -4444-3512
Mail: ed.nocaide@sremlih.dirgni

Customer feedback management

Pfarrer Dr. Michael Kühne

Theologischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Pfarrer Dr. Michael Kühne

Theologischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Pfarrerin Maria Beyer

Theologische Geschäftsführung

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Quality management

B.Sc. Angewandte Gesundheitswissenschaften Therese Al-Kuhaly

Qualitätsmanagementbeauftragte

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-5838
Mail: ed.nocaide@ylahuk-la.esereht

Hygiene officer

Chefarzt Dr. Olaf Richter

Ärztlicher Direktor

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3634
Mail: ed.gizpiel-okaid@ofni

Responsible for drug therapy

Chefarzt Dr. med. Lutz Pomper

Chefarzt im Zentrum für Gefäßmedizin

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-5491
Mail: ed.gizpiel-okaid@ofni

Chefarzt Dr. med. Lutz Pomper

Chefarzt im Zentrum für Gefäßmedizin

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-5491
Mail: ed.gizpiel-okaid@ofni

Accessibility Officer

Diplom-Pflegemanagerin Katrin Völkel-Lutz

Pflegedirektorin

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3664
Mail: ed.gizpiel-okaid@ofni

Company

General contact details of the hospital

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341-444
Fax: 0341-444-3513
Mail: ed.gizpiel-okaid@ofni

Nursing service management

Dipl-Pflegemanagerin Katrin Völkel-Lutz

Pflegedirektorin

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3664
Mail: ed.gizpiel-okaid@ofni

Head of administration

Herr Sebastian Steindorf

Betriebsdirektor

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3511
Mail: ed.gizpiel-okaid@ofni

Pfarrer Dr. Michael Kühne

theologischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Pfarrer Dr. Michael Kühne

theologischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Dipl.-Betriebswirt Dirk Herrmann

kaufmännischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3511
Mail: ed.gizpiel-okaid@ofni

Responsible for the quality report in the hospital management

Dipl.-Betriebswirt Dirk Herrmann

Kaufmännischer Geschäftsführer

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3512
Mail: ed.gizpiel-okaid@ofni

Medical management

Dr. med Ulrich Socha

Chefarzt der Klinik für Unfallchirurgie/ Orthopädie und Traumazentrum

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3601
Mail: ed.gizpiel-okaid@ofni

Dr. med Ulrich Socha

Chefarzt der Klinik für Unfallchirurgie/ Orthopädie und Traumazentrum

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3601
Mail: ed.gizpiel-okaid@ofni

Dr. med. Olaf Richter

Chefarzt der Klinik für Gefäßchirurgie

Gerorg-Schwarz Straße 49
04177 Leipzig

Phone: 0341 -444-3634
Mail: ed.gizpiel-okaid@ofni

Regional care obligation for psychiatry?

IK number

IK: 261401290

Location number

Location number: 772555000

Old location number: 772555000

Certified centers

Darmzentrum am Ev. Diakonissenkrankenhaus Leipzig

Certified until: 04.2020

EndoProthetikZentrum am Ev. Diakonissenkrankenhaus Leipzig

Certified until: 04.2020

Kompetenzzentrum für Hernienchirurgie am Ev. Diakonissenkrankenhaus Leipzig

Certified until: 04.2020

Lungenkrebszentrum Leipzig-Nordwest

Certified until: 04.2020

Zentrum für Fuß- und Sprunggelenkschirurgie der Maximalversorgung am Ev. Diakonissenkrankenhaus Leipzig

Certified until: 04.2020

Trauma-Netzwerk Westsachsen

Certified until: 04.2020

Zertifizierte Notaufnahme

Certified until: 04.2020

Hospital portrait for download Download quality report