Overall result forecast presentation:	no
Quantity performed reporting year:	5
Quantity forecast year:	7
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	50
Quantity forecast year:	49
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:	233
Quantity forecast year:	249
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:	185
Quantity forecast year:	186
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
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
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: no

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

Number	Group
153	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*
96	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
96	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
  
  Training of employees
  
  Information gathering on the topic

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

Functional areas: Zur regelmäßigen Pflege und Fortentwicklung des QM-Systems werden die Oberste Leitung (Geschäftsführung) und die beiden QMBs durch weitere Mitarbeiter unterstützt, die über besondere Kenntnisse und Fähigkeiten verfügen.
Conference frequency: bei Bedarf

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

DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff

31.10.2020

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)

DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff

31.10.2020

SOP on good prescription practices

DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff

31.10.2020

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

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)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)

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

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

FL04 - Project-related cooperation with colleges and universities

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

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

Explanation

Training

Training in other healing professions

HB12 - Medical technical laboratory assistant (MTLA) (m/f)

Comment

Für die theoretische Ausbildung unserer MTL-AZUBIS koop. wir mit der MTL Schule in Bayreuth sowie mit der Ludwig Fresenius Schule in Zwickau.

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

Für die theoretische Ausbildung unserer MTR-AZUBIS arbeiten wir in Koop. mit der BmH in Gera zusammen. Die Schule befindet sich in der Hainstraße 21, 07545 Gera. Weitere Info erhalten Sie per E-Mail an info(at)bmh-gesundheits-und-sozialberufe-gera.de.

HB15 - Anaesthesia technical assistant (m/f)

Comment

Für die theoretische Ausbildung unserer ATA-AZUBIS koop. wir mit der Bamberger Akademie für Gesundheitsberufe gemeinnützige GmbH in Bamberg. Die Akademie befindet sich in der Buger Straße 80, 96049 Bamberg. Weitere Informationen sind per E-Mail an info(at)bamberger-akademie.de erhältlich.

HB07 - Surgical technical assistant (m/f)

Comment

Für die theoretische Ausbildung unserer OTA-AZUBIS koop. wir mit der Bamberger Akademie für Gesundheitsberufe gemeinnützige GmbH in Bamberg. Die Akademie befindet sich in der Buger Straße 80, 96049 Bamberg. Weitere Informationen sind per E-Mail an info(at)bamberger-akademie.de erhältlich.

HB10 - Midwife (m/f)

Comment

Für das Studium Hebammenwissenschaft B.Sc. stehen wir zukünftigen Hebammen und Entbindungspflegern als Kooperationspartner folgender Hochschulen zur Verfügung: der Hochschule Coburg und der OTH Regensburg.

HB19 - Nursing professionals

Comment

Bewerbungsanschrift: Berufsfachschule für Pflege am Klinikum Kulmbach der Schwesternschaft Nürnberg v. BRK e. V. Doris Pösch Albert-Schweitzer-Straße 12-14 95326 Kulmbach Email: krankenpﬂegeschule-kulmbach@t-online.de

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 3
- Additional staff: 5
- Nursing staff regulation

Service contact persons

Patient advocates

Elke Zettler

QM-Beauftragte der Pflege

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-4701
Mail: ed.hcabmluk-mukinilk@relttez.ekle

Customer feedback management

Brigitte Angermann

Geschäftsführerin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-5001
Mail: ed.hcabmluk-mukinilk@gnurheufstfeahcseg

Quality management

Dr. Susanne Luber

Qualitätsmanagementbeauftragte

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-5009
Mail: ed.hcabmluk-mukinilk@rebuL.ennasuS

Hygiene officer

Dr. Dr. med. Thomas Banse,Dr. med. Sven Schimanski und PD Dr. med. habil. Andreas Schwarzkopf

Vorstände Hygienekommission

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1803
Mail: ed.hcabmluk-mukinilk@esnaB.samohT

Accessibility Officer

Sonja Eckert

Gerontopsychiatrische Fachkraft

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-7046
Mail: ed.hcabmluk-mukinilk@trekcE.ajnoS

Company

General contact details of the hospital

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221-98-0
Fax: 09221-98-5094
Mail: ed.hcabmluk-mukinilk@gnurheufstfeahcseg

Nursing service management

Sebastian Ditschek

Pflegedienstleiter

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-4701
Mail: ed.hcabmluk-mukinilk@gnutieltsneidegelfp

Head of administration

Brigitte Angermann

Geschäftsführerin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-5001
Mail: ed.hcabmluk-mukinilk@gnurheufstfeahcseg

Responsible for the quality report in the hospital management

Dr. med. Susanne Luber

Qualitätsmanagementbeauftragte - Sachgebietsleitung Medizin-Controlling

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-5009
Mail: ed.hcabmluk-mukinilk@rebuL.ennasuS

Medical management

Dr. med. Sabine Leins

Ltd. Ärztin Zentrale Notaufnahme

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1060
Mail: ed.hcabmluk-mukinilk@sniel.enibas

Dr. med. Achim Ehrt, DESA, MBA

Ltd. Arzt Klinik für Anästhesiologie und operative Intensivmedizin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-7405
Mail: ed.hcabmluk-mukinilk@trhE.mihcA

Dr. med. Marian Maier

Ltd. Arzt Klinik für Plastische und Handchirurgie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1781
Mail: ed.hcabmluk-mukinilk@reiaM.nairaM

Dr. med. Arkadiusz Kosmala

Ltd. Arzt Klinik für Neuro- und Wirbelsäulenchirurgie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-7161
Mail: ed.hcabmluk-mukinilk@eigrurihcnelueaslebriw

Dr. med. Andreas Brugger

Ltd. Arzt Medizinische Klinik I - Kardiologie und internistische Intensivmedizin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1851
Mail: ed.hcabmluk-mukinilk@reggurB.saerdnA

Doktor der Medizin (Uni. Damaskus) Joseph Alhanna

Ltd. Arzt Medizinische Klinik I - Pneumologie, Beatmungs- und Schlafmedizin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1851
Mail: ed.hcabmluk-mukinilk@annahlA.hpesoJ

Markus Hirschmann

Leitender Arzt Medizinische Klinik II - Gastroenterologie und Palliativmedizin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1803
Mail: ed.hcabmluk-mukinilk@nnamhcsriH.sukraM

Dr. med. Harald Biersack

Ltd. Arzt Medizinische Klinik II - Hämatologie und Onkologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1851
Mail: ed.hcabmluk-mukinilk@kcasreiB.dlaraH

Dr. med. Thomas Banse

Ltd. Arzt Medizinische Klinik III - Nephrologie und Dialyse

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1803
Mail: ed.hcabmluk-mukinilk@esnaB.samohT

Dr. med. Benno Lex

Ltd. Arzt Frauenklinik

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1901
Mail: ed.hcabmluk-mukinilk@ofni-hg

Dr. med. Detlef Thomschke

Ltd. Arzt Klinik für Allgemein- und Visceralchirurgie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1701
Mail: ed.hcabmluk-mukinilk@ekhcsmohT.felteD

Dres. med. Gerald Hahn und Ingo Maatz

Ltd. Ärzte Klinik für Gefäßchirurgie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1721
Mail: ed.hcabmluk-mukinilk@reilK.niraK

Prof. Dr. med. Thomas Bohrer

Ltd. Arzt Klinik für Thoraxchirurgie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1721
Mail: ed.hcabmluk-mukinilk@rerhoB.samohT

Dr. med. Gerhard Finkenzeller

Ltd. Arzt Klinik für Unfallchirurgie und Orthopädie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1751
Mail: ed.hcabmluk-mukinilk@relleznekniF.drahreG

Dr. med. Christian Konhäuser

Ltd. Arzt Klinik für Neurologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-1834
Mail: ed.hcabmluk-mukinilk@eigoloruen

Dr. med. Jordan Todorov

Ltd. Arzt Klinik für Urologie und Kinderurologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-7341
Mail: ed.hcabmluk-mukinilk@eigoloru

Dr. med. Thomas Hüttner und Prof. Dr. med. Gernot Schulte-Altedorneburg

Ltd. Ärzte Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-7386
Mail: ed.hcabmluk-mukinilk@lehceulB.enitsirhC

Dr. med. Sven Schimanski

Ltd. Arzt Institut für Laboratoriumsmedizin und Mikrobiologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-2710
Mail: ed.hcabmluk-mukinilk@iksnamihcS.nevS

Dr. med. Michael Neininger

Ltd. Arzt Institut für Nuklearmedizin

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-2751
Mail: ed.hcabmluk-mukinilk@regninieN.leahciM

Prof. Dr. med. Andreas Gschwendtner

Ltd. Arzt Institut für Pathologie

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-2801
Mail: ed.hcabmluk-mukinilk@eigolohtap

Regional care obligation for psychiatry?

IK number

IK: 260940449

Location number

Location number: 771090000

Certified centers

Alterstraumazentrum

Certified until: 08.2021

Endoprothetikzentrum

Certified until: 07.2023

Traumazentrum

Certified until: 03.2021

Hospital portrait for download