No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM02	Regular further education and training measures
RM04	Clinical emergency management Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM05	Pain management Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM06	Fall prophylaxis Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM08	Regulated handling of custodial measures Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM14	Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM15	Preoperative, complete presentation of necessary findings Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM16	Procedure to avoid procedural and patient mix-ups Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM17	Standards for recovery and postoperative care Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)
RM18	Discharge management Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

strukturiertes Fehlermanagement nach den Vorgaben der DIN EN ISO 9001:2015 etabliert

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 21.02.2023
IF02	Internal evaluation of the received reports taken monatlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 21.02.2023

IF02

Internal evaluation of the received reports

taken monatlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
	Other
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)

No.

Explanation

Other

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)