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St. Anna-Virngrund-Klinik

Dalkinger Straße 8-12
73479 Ellwangen

Phone: 07961-8810
Fax: 07961-881-3003
Mail: ed.blatso-nekinilk@ofni

https://www.klinik-ellwangen.de

Basic information

Number of beds: 242
Number of specialist departments: 9

Number of inpatient cases: 7.274
Number of partial inpatient cases: 87
Number of outpatient cases: 19.331

Hospital owners: Kliniken Ostalb gemeinnützige kAöR Sitz der Kommunalanstalt: 73430 Aalen, Im Kälblesrain 1 Vorsitzender des Verwaltungsrats: Landrat Dr. Joachim Bläse Vorstand: Prof. Dr. Ulrich Solzbach (Vorsitzender), Thomas Schneider, Sylvia Pansow
Type of provider: öffentlich

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes

Quality of participation in the Disease Management Programme (DMP)
No participation

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	167
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	167
Quantity forecast year:	187
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 participation

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
54	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*
42	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
37	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
  Note on the measure
  Informationspakete auf den Stationen über regionale und überregionale Anlaufstellen- / Hilfsangebote. Informationsmaterialien in Form von Flyern und Informationsbroschüren im Schaukasten der Wartebereiche.
  Training of employees
  Note on the measure
  Kinderschutzthemenblock im Rahmen des regelmäßigen, fortlaufenden Fortbildungsprogramms für das gesamte multiprofessionelle Team.
  Themenblöcke zu: 1. Medizinischer Kinderschutz 2. Rechtliche Rahmenbedingungen im Kinderschutz 3. Schulung hausinterner Konzepte
  Education
  Note on the measure
  Wöchentliche Gesprächsgruppen für alle Patienten und Patientinnen im Rahmen des Feedbackmanagements über neutrale Ansprechperson. Sensibilisierung der Teams über über Supervision und Teamreflexionen auch unter Einbezug der Leitung. Niederschwellige Sensibilisierung der Eltern und Bezugspersonen im Rahmen des monatlichen Elterncafes.
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  In aktuell 3. überarbeiteter Version
  
  Last review of the measure
  20.10.2023 16:52:53
  Special requirements for the selection of persons
  Note on the measure
  Erweitertes polizeiliches Führungszeugnis für alle Mitarbeiter und Mitarbeiterinnen in der KJPP bei Einstellung verpflichtend, mit geplanter fortlaufender Überprüfung. Dienstanweisung Kinderschutzkonzept für alle Mitarbeiter und Mitarbeiterinnen mit dokumentierter schriftlicher Verpflichtung der Einhaltung.
  Age-appropriate complaint options
  Note on the measure
  Kummerkasten für Patienten und Patientinnen auf allen Stationen. Fakultativ anonymes Mitteilungsformular für Eltern/ Sorgeberechtigte. Ausgelegter QR- Code für die Nutzung des digitalen zentralen Beschwerde- / Feedbackmanagements (Onlinefragebogen). Externe Anlaufstellen: IBB- Stelle Ostalbkreis www.ibb-ostalb.de, Tel: 07361-99974-99, Beschwerdestelle DGKJP www.dgkjp.de/die-dgkjp/beschwerden/
  Other aspects of prevention
  Note on the measure
  Regelmäßig tagender Kinderschutz- AK (Arbeitskreis) mit Protokollen. Letztes dokumentiertes Treffen 20.10.2023; Teilnahme am SMET im Landratsamt und am AK sexuelle Gewalt (externe Beraterteams).
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  20.10.2023 16:52:53
- Reprocessing
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Aktuell in Überarbeitung
  
  Last review of the measure
  20.10.2023 16:52:53

Informationspakete auf den Stationen über regionale und überregionale Anlaufstellen- / Hilfsangebote. Informationsmaterialien in Form von Flyern und Informationsbroschüren im Schaukasten der Wartebereiche.

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

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

QM-Handbuch

11.07.2022

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
Verfahrensanweisung Arzneimitteltherapiesicherheit

Electronic support for the supply of patients with drugs

in der Apotheke vorhanden: Medical E-Shop (elektronisches Bestellsystem für Arzneimittel); Anforderungs-/Herstellungssoftware Cato: Therapieprotokolle für Zytostasen, von Apothekern evidenzbasiert ang

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

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 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

FL04 - Project-related cooperation with colleges and universities

Explanation

Kooperationspartner Comprehensive Cancer Center Ulm (CCCU)

FL03 - Student training (clinical traineeship / internship year)

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Prof. Dr. Isenmann, Universität Ulm, PD Dr. med. Jung, RWTH Aachen, PD Dr. med. Prengel, Ruhr-Universität Bochum

FL08 - Editors of scientific journals/textbooks

Explanation

Gutachtertätigkeit, Publikationen

FL09 - Doctoral supervision

Explanation

Training

Training in other healing professions

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

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

in Kooperation mit der Bernd-Blindow-Schule Aalen

HB07 - Surgical technical assistant (m/f)

Comment

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

Comment

in Kooperation mit der DRK-Landesschule BW

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

Comment

in Kooperation mit der Universitätsklinik Ulm

HB10 - Midwife (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

HB19 - Nursing professionals

Comment

HB20 - Nursing professional B. Sc.

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 8
- Additional staff: 11
- Explanations: Die Zentralapotheke Kliniken Ostalb ist mit ihrem gesamten pharmazeutischen Personal für alle drei Standorte der Kliniken Ostalb zuständig.
- Nursing staff regulation