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St. Elisabeth-Krankenhaus GmbH

Werthmannstr. 1
50935 Köln

Phone: 0221-4677-0
Mail: ed.dnilnehoh@ofni ed.dnilnehoh@ofni ed.dnilnehoh@ofni

http://www.hohenlind.de

Basic information

Number of beds: 391
Number of specialist departments: 10

Number of inpatient cases: 23.651
Number of outpatient cases: 142.170

Hospital owners: St. Elisabeth-Krankenhaus GmbH. Gesellschafter sind der Diözesan-Caritasverband für das Erzbistum Köln e. V. und die Caritas-Trägergesellschaft West gGmbH, Düren
Type of provider: freigemeinnützig

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

External quality assurance according to the DMP

Brustkrebs

Implementation of the minimum quantity agreement

Treatment area

Complex operations on the pancreatic organ system

Quantity performed	32
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	1.091
Exception?	No exception

Minimum quantities forecast

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	1.091
Quantity forecast year:	1.051
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:	32
Quantity forecast year:	27
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
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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
154	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*
105	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
105	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
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Bestandteil des Institutionellen Schutzkonzeptes
  
  Last review of the measure
  20.01.2025 18:51:44
  Age-appropriate complaint options
  Note on the measure
  Gespräch mit Beteiligten/Ansprechpartnern vor Ort; Ausfüllen eines Papierzettels und Einwurf in einen Briefkasten, digitale Beschwerdemöglichkeiten
  Information gathering on the topic
  Note on the measure
  Informations- und Schulungsmaterial steht im Intranet (Dok. Nr. 42057) zur Verfügung
  Education
  Note on the measure
  Individuelle Schulungsangebote und Kontaktadressen liegen vor
  Training of employees
  Note on the measure
  Verpflichtendes E-learning-Modul zur "Prävention (sexualisierter) Gewalt im Krankenhaus", weitere Schulungsangebote in Präsenz
  Other aspects of prevention
  Note on the measure
  Ständige Sensibilität und Aufmerksamkeit bei allen Beteiligten
  Special requirements for the selection of persons
  Note on the measure
  Einbau diverser Prüfmechanismen
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Institutionelles Schutzkonzept (ISK) Hohenlind mit Handlungsleitfäden
  
  Last review of the measure
  20.01.2025 18:51:44
  Other aspects of intervention
  Note on the measure
  Flyer "Prävention (sexualisierter) Gewalt" mit Ansprechpartnern in allen Fachbereichen; Präventionsbeauftragte im Haus; Handreichung zur Prävention sex. Übergriffe im KH; Meldebogen zu "Gewalt und Aggression" inkl. laufenden Auswertungen; Arbeitskreis zur Prävention von (sexualisierter) Gewalt;
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Diverse Handlungsleitfäden liegen vor
  
  Last review of the measure
  20.01.2025 18:51:44

Diverse Handlungsleitfäden liegen vor

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

Drug commission

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

Wegen der Gefahr einer fehlerhaften Übertragung bitten wir um den gefaxten Aufnahmebogen. Die Anamnesebögen sollen nicht mehr verwendet werden.

25.08.2025

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)

Schmerzerfassung und Dokumentation bei Pat. mit Demenz (Dok. Nr. 7742)

28.11.2017

SOP on good prescription practices

Pocket Card Antibiotika (Dok.-Nr: 32235) Schmerzschema (Dok.-Nr: 5872) Schlafstandard Hohenlind (Dok.-Nr: 24275)

20.07.2023

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
Berücksichtigung der Leitlinien der Bundesapothekenkammer (BAK)

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)
Software zenzy®

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Auseinzeln von Stoffen, spezielle Ernährungsvisiten

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
Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen
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

FL09 - Doctoral supervision

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Training

Training in other healing professions

HB19 - Nursing professionals

Comment

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

Comment

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

Comment

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

Comment

HB07 - Surgical technical assistant (m/f)

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 5
- Additional staff: 8
- Explanations: 8 Pharmazeutisch technische Assistenten und zusätzlich 2 Pharmaziepraktikanten und zusätzlich 2 Apothekenhelfer-/innen (Helferinnen gelten nicht als pharmazeutisches Personal)
- Nursing staff regulation