Overall result forecast presentation:	yes
Quantity performed reporting year:	180
Quantity forecast year:	201
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:	36
Quantity forecast year:	38
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:	202
Quantity forecast year:	189
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
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
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

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
166	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*
45	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
3	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
  
  Special requirements for the selection of persons
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  12.07.2023 20:23:05

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

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

Organisationshandbuch

23.09.2024

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)

Organisationshandbuch

23.09.2024

SOP on good prescription practices

Organisationshandbuch

23.09.2024

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

Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

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

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

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

Dozenturen bestehen an der medizinischen Fakultät der Universitätsklinik Münster, der Universität Osnabrück, der Rheinisch-Westfälischen Technischen Hochschule Aachen, der Universität zu Köln, der Christian Albrechts-Universität zu Kiel sowie dem Universitätsklinikum Schleswig-Holstein, Campus Kiel.

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehrbeauftragungen bestehen u.a. an der Hochschule Osnabrück.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Im Jahre 1971 wurden wir als erstes Lehrkrankenhaus in die ärztliche Ausbildung der Universität Münster eingebunden und verfügen somit als zertifiziertes Krankenhaus der Schwerpunktversorgung über wertvolle Erfahrungen für eine hochqualifizierte medizinische Ausbildung.

FL04 - Project-related cooperation with colleges and universities

Explanation

Mit Universität und der Fachhochschule laufen regelmäßig Zusammenarbeiten

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

Explanation

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

Explanation

Onkologie Neurologie

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

Explanation

Orthopädie und Unfallchirurgie

FL09 - Doctoral supervision

Explanation

In Zusammenarbeit mit der Universität Osnabrück

Training

Training in other healing professions

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

Comment

Die duale Pflegausbildung nach Krankenpflegegesetz wurde 2020 abgelöst durch die Generalistische Pflegeausbildung n. d. Pflegeberufegesetz. 49 Auszubildende absolvieren die Ausbildung n. d. o. g. Vorgaben. Für beide Ausbildungsformen stehen dem Klinikum 350 genehmigte Plätze zur Verfügung.

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

Comment

Es stehen 72 Ausbildungsplätze zur Verfügung. Die Ausbildung beginnt jeweils am 1. August eines jeden Jahres. Seit 2023 bilden wir nach dem neuen MTA-Gesetz aus, auch für den Bereich des Medizinischen Technologen für Radiologe (MTR), der Medizinischen Technologin für Radiologe (MTR)

HB07 - Surgical technical assistant (m/f)

Comment

Seit dem 01.08.22 betreibt das Klinikum eine eigene OTA-Ausbildung. Es stehen 75 Ausbildungsplätze zur Verfügung.

HB10 - Midwife (m/f)

Comment

Die Hebammenschule verfügt über 60 Ausbildungsplätze. Diese Ausbildungsform wird zum 30.09.2024 am Klinikum enden. Zukünftig werden 27 praktische Studienplätze in Kooperation mit der Hochschule Osnabrück im Studiengang Hebammenwissenschaft angeboten.

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

Comment

Es stehen 72 Ausbildungsplätze zur Verfügung. Die Ausbildung beginnt jeweils am 1.8. jeden Jahres. Seit 2023 bilden wir nach dem neuen MTA-Gesetz aus, auch für den Bereich des Medizinischen Technologen für Laboratoriumsanalytik (MTL), der Medizinischen Technologin für Laboratoriumsanalytik (MTL)

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Das Klinikum Osnabrück bietet 75 Ausbildungsplätze für den Bereich der Krankengymnastik/Physiotherapie an.

HB19 - Nursing professionals

Comment

Für die generalistische Ausbildung stehen dem Klinikum 350 genehmigte Plätze zur Verfügung.

HB20 - Nursing professional B. Sc.

Comment

Der Studiengang „Pflege (dual)“ dauert insgesamt 8 Semester und wird in Verbindung mit einer verbundleitenden Fachschule absolviert. Neben dem Bachelor of Science in Pflege erhalten die Absolventen/innen auch einen Berufsabschluss in der Pflege. Es stehen 24 Studienplätze zur Verfügung.

HB15 - Anaesthesia technical assistant (m/f)

Comment

Die theoretische Ausbildung findet an der Akademie für Gesundheitsberufe am Mathias-Spital in Rheine statt. Die praktischen Einsätze werden am Klinikum Osnabrück absolviert. Pro Jahr bildet das Klinikum Osnabrück 2-5 ATA-Auszubildende praktisch aus.

Hospital staff
Pharmaceutical personnel
- Additional staff: 1
- Explanations: Die stationäre pharmazeutische Versorgung der Patienten erfolgt durch die externe Krakenhausapotheke, die auch die halbjährlichen Begehungen der arzneimittelvorhaltenden Bereiche sowie pharmazeutische Visiten durchführt. Apothekenbeauftragte der Pflege mit regelmäßiger Schulung
- Nursing staff regulation