Quantity performed	22
Exception?	No exception
Die frühgeborenen Intensivstation war jederzeit aufnahmebereit. Auffällig häufig konnte im Vergleich zur Vergangenheit eine drohende Frühgeburt durch die Bemühungen der geburtshilflichen Klinik abgewendet werden.

Knee joint total endoprostheses

Quantity performed	159
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	32
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	137
Exception?	No exception

Minimum quantities forecast

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	22
Quantity forecast year:	25
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	47
Quantity forecast year:	57
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:	137
Quantity forecast year:	134
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:	32
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:	159
Quantity forecast year:	186
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)
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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: yes

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
126	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*
101	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
101	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
  Die BK- Referentin für Präventionsordnung nimmt regelmäßig an Fortbildungen teil.
  Other aspects of prevention
  Note on the measure
  Der Verhaltenskodex ist im Schutzkonzept veröffentlicht und richtet sich an alle Menschen im BK: Mitarbeitende, Lernende, externe Dienstleister, Patient*innen und Besucher*innen.
  Training of employees
  Note on the measure
  Ja.
  Special requirements for the selection of persons
  Note on the measure
  Ja. Es muss ein erweitertes Führungszeugnis vorgelegt werden.
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Ja.

Die BK- Referentin für Präventionsordnung nimmt regelmäßig an Fortbildungen teil.

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

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

VA "Klinisch-pharmazeutische Arzneimittelanamnese" Formblatt "Klinisch-pharmazeutische Arzneimittelanamnese"

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)

Unser Haus führt ein "Unit Dose-Verfahren" durch, welches die Patientensicherheit durch ein elektronisches Verordnungsverfahren deutlich erhöht. Dieses ist abgebildet in der Verfahrensbeschreibung: "Unit Dose - Medikamentenversorgung auf Station"

18.08.2024

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

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Unit Dose

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)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)

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 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

FL03 - Student training (clinical traineeship / internship year)

Explanation

Als Akademisches Lehrkrankenhaus der Universität Göttingen bilden wir Studierende der Medizin im Rahmen von Famulaturen, Blockpraktika, Unterricht am Krankenbett und im Praktischen Jahr aus. Prof. Wilhemi hält Vorlesungen zum Thema der Medizintechnik an der MHH.

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Prof. Dr. Tergau (G.-A.-Uni. Göttingen), Prof. Dr. von Knobelsdorff (Unik. HH), Prof. Dr. Glüer , Prof. Leifeld, Prof. Wilhelmi (MHH), Prof. Dr. Kaiser (Uni Marburg), Priv.-Doz. Dr. Beck (Unik. Rostock), Prof. Dr. Pelz (Unik. Würzburg), Prof. Könecke (MHH)

FL04 - Project-related cooperation with colleges and universities

Explanation

Forschung mit der KCH der MHH, Arbeit in Forschungsprojekten der Unikl. Göttingen mit der Neurologie. Gastroent. Koordinator S3 Leitlinie Divertikulitis. S3 Leitlinie Prost Ca (Prof. Kaiser).

FL09 - Doctoral supervision

Explanation

Es sind Promotionen in einigen Fachrichtungen (u. a. Kinderchirurgie, Anästhesiologie, Hämatoonkologie, ACH) möglich. In der Medizinischen Klinik I, Medizinischen Klinik III, Neurologie und Klinik für Orthopädie und Unfallchirurgie und Labor werden Promotionsarbeiten direkt vergeben und betreut.

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

Explanation

Die Teilnahme an Studien der medizinischen Forschung ist für uns ein wichtiges Instrument, um an der Weiterentwicklung und Verbesserung der Therapien mitzuwirken. Wir sind im Rahmen unseres Onkologischen Zentrums an Studien beteiligt. Auch die Gastroenterologie nimmt an klinischen Studien teil.

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

Explanation

Das multizent. FITT-STEMI-Projekt zur Verbesserung der Herzinfarktversorgung wird durch die medizinische Klinik I durchgeführt. Die Onkologie und Gastroenterologie initiieren und leiten klinisch-wissenschaftliche Studien. Prof. Leifeld ist Leiter der Kommission Qualität DGVS.

FL08 - Editors of scientific journals/textbooks

Explanation

Prof. Tergau ist im wissenschaftl. Beirat des Journals „Clinical Epileptology“ der DGfE. Prof. Wilhelmi ist Associate Editor von intern. Journals. Prof. Pelz ist Vertreter der S3 Leitlinienkommission (DGAV) für das Ovarialkarzinom.

Training

Training in other healing professions

HB19 - Nursing professionals

Comment

300 genehmigte Ausbildungsplätze. 3jährige Ausbildung im Kooperationsverbund. Ausbildungsbegleitende Studiengänge in Kooperation mit 2 Hochschulen möglich. Einsatz von E-Learning-Programm und Laptops im Unterricht, Praxiseinsätze in wechselnden Handlungsfeldern der Pflege.

HB15 - Anaesthesia technical assistant (m/f)