No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM05	Pain management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM06	Fall prophylaxis QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM08	Regulated handling of custodial measures QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM09	Regulated handling of occurring malfunctions of devices QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel Interdisziplinäre Hauttumor- und Kopf-Hals-Tumorkonferenzen Dermatopathologiebesprechungen standortübergreifende/interdisziplinäre Besprechungen im Rahmen der Münsteraner Allianz gegen Krebs (MAgKs)
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 QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM15	Preoperative, complete presentation of necessary findings QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM16	Procedure to avoid procedural and patient mix-ups QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM17	Standards for recovery and postoperative care QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)
RM18	Discharge management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Risikobewertung der Prozesse vor dem Hintergrund der APS Never-Event-Liste, Optimierung der Arzneimitteltherapiesicherheit, regelmäßige ABS Visiten

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.08.2022
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 jährlich

No.

Explanation

IF01

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

As of: 01.08.2022

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 jährlich

Across all institutions

Conference committee

Conference frequency: jährlich

No.	Explanation
EF03	KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)
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)