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Marienhaus Klinikum Hetzelstift

Stiftstraße 10
67434 Neustadt an der Weinstraße

Phone: 06321-859-0
Mail: ed.tfitslezteh@ofni ed.tfitslezteh@ofni ed.tfitslezteh@ofni

https://www.hetzelstift.de/startseite/

Basic information

Number of beds: 362
Number of specialist departments: 11

Number of inpatient cases: 13.130
Number of outpatient cases: 23.452

Hospital owners: Marienhaus Kliniken GmbH
Type of provider: freigemeinnützig

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

External quality assurance according to the DMP

Brustkrebs

Das Marienhaus Klinikum Hetzelstift nimmt im Rahmen des DMP Brustkrebs an den dafür erforderlichen Qualitätssicherungsmaßnahmen teil

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	35
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	18
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	145
Exception?	No exception

Minimum quantities forecast

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	18
Quantity forecast year:	28
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:	35
Quantity forecast year:	40
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:	145
Quantity forecast year:	135
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
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

Management of quality assurance for proximal femoral fracturet (QSFFx)

Full record of compliance maintained

Number of days shown	366
Days of non-performance	0
Number of minimum requirements not met	0

General minimum requirements

Minimum requirement	Days of non-performance
Trauma room	0
Availability	0
Computed tomography (CT)	0
Intensive care beds	0
Department of Surgery	0
Forwarding by air	0
Department of Internal Medicine	0
Intensive care beds with ventilator facilities	0
Emergency care training courses	0
Treatment prioritisation system (triage)	0
Responsibility for emergency care	0

Specific minimum requirements

Minimum requirement	Days of non-performance
Doctor on duty	0
Supervision by a medical specialist	0
Geriatric expertise	0
Operating room equipment	0
Post-operative physiotherapy	0
Independent organisational unit	0

Minimum requirements for process quality

Minimum requirement	Days of non-performance
SOP: Surgical procedures	0
SOP: Perioperative Planning	0
SOP: Capacity to consent	0
Standard Operating Procedure for the Management of Anticoagulants	0
SOP: Ortho-geriatric Care	0
SOP: Physiotherapy Measures	0
SOP: Patient-centred blood management	0

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

Number	Group
67	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*
5	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
5	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
  
  Education
  
  Training of employees
  Special requirements for the selection of persons
  Note on the measure
  Vorlegen eines erweiterten Führungszeugnisses

Vorlegen eines erweiterten Führungszeugnisses

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

Name of the working group: Arzneimittelkommission

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

Nutzung von AiD-Klinik, VA "Medikamentöse Versorgung der Patienten"

27.05.2024

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)

VA "Medikamentöse Versorgung der Patienten"

27.05.2024

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®)

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
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Ruhiges Arbeitsumfeld beim Stellen von Medikamenten

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
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

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

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Universität Regensburg: Gesundheitsökonomie; Universität Rostock: Anästhesiologie u. Intensivmedizin, Notfallmedizin, Palliativmedizin; Forschungsschwerpunkte: Klinische Ökonomie, Qualitätsmanagement. Universität Heidelberg: Unfallchirurgie, Universität Heidelberg Med. Fakultät Mannheim: Urologie

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

Explanation

Brustzentrum: AXSANA Reg.studie, SenTa2 Reg.studie, X-Ray Matrix Studie, ELEANOR NIS, BCP Breast Cancer in Pregnancy, Reg.studie German Breast Group (GBG 29) , OPAL Reg.plattform EBC u. fortgeschr. Mammaca., Mammaca. des Mannes, Reg.studie; Kontinenzzentrum: PMCF-Studie SRS Implantat; Melody Studie

FL04 - Project-related cooperation with colleges and universities

Explanation

Betreuung von Dissertationen und Diplom- bzw. Bachelorarbeiten; Teilnahme an nationalen und internationalen multizentrischen Studien, Kooperationspartner für duale Studiengänge

FL03 - Student training (clinical traineeship / internship year)

Explanation

Hausint. Vorlesungen i. R. d. studentischen Ausbildungen im PJ: FB (Fachbereich) Innere Medizin; FB Anästhesiologie und Intensivmedizin, Notfallmedizin, Schmerztherapie, Palliativmedizin; FB Chirurgie; FB Radiologie, FB Gynäkologie, FB Urologie, Ethikseminar, Famulanten Camp, Simulation

Training

Training in other healing professions

HB15 - Anaesthesia technical assistant (m/f)

Comment

In Kooperation mit der Schule am Klinikum Ludwigshafen finden die Praxiseinsätze in unserem Krankenhaus statt.

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

Comment

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

Comment

In Kooperation mit der MTRA-Schule in Heidelberg finden die Praxiseinsätze in unserem Krankenhaus statt.

HB10 - Midwife (m/f)

Comment

In Kooperation mit der Hebammenschule im Diakonissen-Stiftungs-Krankenhaus in Speyer finden die Praxiseinsätze in unserem Krankenhaus statt.

HB19 - Nursing professionals

Comment

HB17 - Auxiliary nurse (m/f)

Comment

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

In Kooperation mit dem Malteser Rettungsdienst, Bistum Mainz finden die Praxiseinsätze in unserem Krankenhaus statt.

HB07 - Surgical technical assistant (m/f)

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Praktische Ausbildung in Zusammenarbeit mit der Physiotherapie-Schule in Neustadt/Wstr.

Hospital staff
Pharmaceutical personnel
- Explanations: Vertragliche Regelung zur Versorgung mit u. Beratung zu Arzneimitteln mit der Apotheke im Marienhaus Klinikum Mainz. Enge Zusammenarbeit u.a. in der Fortentwicklung der Arzneitherapie u. der Herstellung von Arzneimitteln. Ein entspr. weitergeb. Apotheker ist Teil des Antibiotic Stewardship-Teams.
- Nursing staff regulation