Overall result forecast presentation:	yes
Quantity performed reporting year:	62
Quantity forecast year:	56
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

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
46	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*
36	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
23	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
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  30.06.2023 16:29:04
  Age-appropriate complaint options
  
  Special requirements for the selection of persons
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  30.06.2023 16:29:04
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  30.06.2023 16:29:04

Eine Risikoanalyse/Gefährdungsanalyse wurde durchgeführt. Innerhalb des Schutzkonzeptes ist der Umgang in einem Verhaltenskodex zum Umgang mit minderjährigen PatientInnen und MitarbeiterInnen formuliert, sowie eine Handlungsempfehlung zur Intervention und Aufarbeitung von Kinderschutzfällen bei (sexualisierter) Gewalt festgeschrieben.

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

Intranet

02.05.2022

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)

Intranet

02.05.2022

SOP on good prescription practices

Intranet

02.05.2022

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

Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
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)

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Measures to ensure seamless drug therapy after discharge

Aushändigung des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Zu verschiedenen medizinischen Fachbereichen an folgenden Hochschulen: - Westfälische Wilhelms Universität Münster - Universität Witten/Herdecke - Universitätsklinik Essen - Universität Bonn Medizinische Fakultät Universität Witten/Herdecke - Lehrstuhl für Psychiatrie und Psychotherapie

FL03 - Student training (clinical traineeship / internship year)

Explanation

Absolvierung aller Tertiale in den Pflichtbereichen - Chirurgie in 3 operativen Kliniken - Innere Medizin in 3 medizinischen Kliniken Wahlbereich - Neurologie - Orthopädisch-Traumatologische Zentrum - Anästhesiologie - Institut für Diagnostische und Interventionelle Radiologie

FL09 - Doctoral supervision

Explanation

Betreuung medizinischer Dissertationen in den jeweiligen Fachbereichen.

FL04 - Project-related cooperation with colleges and universities

Explanation

Zu den verschiedensten Themen in Medizin, Pflege und Wirtschaftswissenschaften

FL08 - Editors of scientific journals/textbooks

Explanation

Training

Training in other healing professions

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

Comment

Es werden 105 Ausbildungsplätze für Gesundheits- und Krankenpfleger angeboten. Die praktische Ausbildung erfolgt am St. Marien-Hospital Hamm. Die theoretische Ausbildung wird am Canisius Campus Dortmund gGmbH durchgeführt.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Es stehen Praktikantenplätze zur Verfügung.

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

Comment

Es stehen Praktikantenplätze zur Verfügung.

HB07 - Surgical technical assistant (m/f)

Comment

2 Ausbildungsplätze in Kooperation mit einer anerkannten Ausbildungsstätte.

HB17 - Auxiliary nurse (m/f)

Comment

10 Ausbildungsplätze im 1-jährigen Ausbildungszweig "Gesundheits- und Krankenpflegeassistenz" in Kooperation mit dem Canisius Campus Dortmund gGmbH

HB11 - Podiatrist (m/f)

Comment

Es stehen Praktikantenplätze zur Verfügung.

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 1
- Explanations: Zentral-Apotheke des St.-Johannes-Hospital Dortmund gGmbH Stationsapothekerin
- Nursing staff regulation

Service contact persons

Patient advocates

Herr Herrmann Kampmann

Patientenfürsprecher

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1715
Mail: ed.mmah-latipsohneiram@rehcerpsreufnetneitap

Herr Attila Pap

Patientenfürsprecher

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1715
Mail: ed.mmah-latipsohneiram@rehcerpsreufnetneitap

Customer feedback management

Frau Michaela Schulz

Abteilung Qualitätsmanagement

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-71030
Mail: ed.mmah-latipsohneiram@zluhcS.aleahcim

Frau Martina Poppe

Sekretariat Geschäftsführung

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1001
Mail: ed.mmah-latipsohneiram@eppoP.anitraM

Frau Michaela Schulz

Abteilung Qualitätsmanagement

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-71030
Mail: ed.mmah-latipsohneiram@zluhcS.aleahcim

Frau Martina Poppe

Sekretariat Geschäftsführung

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1001
Mail: ed.mmah-latipsohneiram@eppoP.anitraM

Quality management

Frau Michaela Schulz

Leitung Abteilung Qualitätsmanagement

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-71030
Mail: ed.mmah-latipsohneiram@zluhcs.aleahcim

Frau Michaela Schulz

Abteilung Qualitätsmanagement

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-71030
Mail: ed.mmah-latipsohneiram@zluhcs.aleahcim

Hygiene officer

Dr. Frank Marquardt

Leitender Arzt für Krankenhaushygiene

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-3870
Mail: ed.mmah-latipsohneiram@tdrauqram.knarf

Dr. Frank Marquardt

Leitender Arzt für Krankenhaushygiene

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-3870
Mail: ed.mmah-latipsohneiram@tdrauqram.knarf

Responsible for drug therapy

Herr Ulrich Sommer

Leitung Zentral-Apotheke Dortmund

Nassauerstraße 13-19
59065 Hamm

Phone: 0231 -1843-31710
Mail: ed.dnumtrod-ohoj@remmos.hcirlu

Accessibility Officer

Herr Andreas Kämper

Vertrauensmann für Schwerbehinderte

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-71095
Mail: ed.mmah-latipsohneiram@repmeak.saerdna

Company

General contact details of the hospital

Nassauerstraße 13-19
59065 Hamm

Phone: 02381-18-0
Fax: 02381-18-1006
Mail: ed.mmah-latipsohneiram@ofni

Nursing service management

Herr Jörg Beschorner

Pflegedirektor

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1007
Mail: ed.mmah-latipsohneiram@renrohcseb.greoj

Head of administration

Herr Hauke Schild

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1000
Mail: ed.mmah-latipsohneiram@dlihcs.ekuah

Herr Thomas Tiemann

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1000
Mail: ed.mmah-latipsohneiram@nnameit.samoht

Herr Klaus Bathen

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 0231 -1843-31000
Mail: ed.dnumtrod-ohoj@nehtab.sualk

Herr Thomas Tiemann

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1000
Mail: ed.mmah-latipsohneiram@nnameit.samoht

Herr Klaus Bathen

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 0231 -1843-31000
Mail: ed.dnumtrod-ohoj@nehtab.sualk

Responsible for the quality report in the hospital management

Herr Thomas Tiemann

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1000
Mail: ed.mmah-latipsohneiram@nnameit.samoht

Herr Thomas Tiemann

Geschäftsführer

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-1000
Mail: ed.mmah-latipsohneiram@nnameit.samoht

Medical management

Prof. Dr. Dirk Böcker

Ärztlicher Direktor

Nassauerstraße 13-19
59065 Hamm

Phone: 02381 -18-2300
Mail: ed.mmah.latipsohneiram@rekceob.krid

Regional care obligation for psychiatry?

IK number

IK: 260590388

More IK: 260590388

Location number

Location number: 772120000

Old location number: 772120000