Fachkrankenhaus Kloster Grafschaft GmbH

Quality results

Treatment sector: Pneumonia acquired on an outpatient basis (CAP)

Information about this treatment area (documentation)

Designation	Ambulant erworbene Pneumonie
Shortcut	PNEU
Number of cases	99
Documentation rate	100 %

Summary result:

In 3 of 6 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 99

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

This is how often blood oxygen levels were measured within 8 hours of admission to hospital (all patients)

Hospital: 97,98 %

Target area: at least 95,00 %

Quality objective achieved

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This is how often the blood oxygen level was measured within 8 hours of admission to hospital (all patients, excluding patients from another hospital)

Hospital: 97,70 %

as often as possible

Evaluation is not available

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This is how often the blood oxygen level was measured within 8 hours of admission to hospital (only patients from another hospital)

Hospital: 100,00 %

as often as possible

Evaluation is not available

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This is how often the blood oxygen level was measured within 8 hours of admission to hospital (all patients, excluding COVID-19 patients)

Hospital: 96,97 %

as often as possible

Evaluation is not available

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This is how often the blood oxygen level was measured within 8 hours of admission to hospital (excluding patients from another hospital, excluding COVID-19 patients)

Hospital: 96,83 %

as often as possible

Evaluation is not available

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This is how often the blood oxygen level was measured within 8 hours after admission (only patients from another hospital, without COVID-19 patients)

Hospital: Data protection

No information due to data protection

as often as possible

Evaluation is not available

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This is how often antibiotics were given within 8 hours of admission to hospital (excluding patients from another hospital)

Hospital: 82,14 %

Target area: at least 90,00 %

Quality objective not achieved

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This is how often antibiotics were given within 8 hours of admission to hosptal (excluding patients from another hospital, including COVID-19 patients)

Hospital: 82,14 %

as often as possible

Evaluation is not available

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This is how often patients (with a medium risk of death) were physically activated within 24 hours of admission to hospital

Hospital: 93,18 %

Target area: at least 90,00 %

Quality objective achieved

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This is how often patients (at intermediate risk of death) were physically activated within 24 hours of admission (excluding COVID-19 patients)

Hospital: 100,00 %

as often as possible

Evaluation is not available

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This is how often patients were examined according to defined criteria before being discharged from hospital

Hospital: 70,13 %

Target area: at least 95,00 %

Quality objective not achieved

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This is how often patients were examined according to defined criteria before being discharged from hospital (excluding COVID-19 patients)

Hospital: 67,27 %

as often as possible

Evaluation is not available

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This is how often patients fulfilled certain medical criteria when they were discharged from hospital and were therefore sufficiently healthy.

Hospital: 98,11 %

as often as possible

Evaluation is not available

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This is how often patients met certain medical criteria on discharge from hospital and were thus sufficiently healthy (excluding COVID-19 patients)

Hospital: 97,30 %

as often as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of patients who died during the hospital stay (all patients including Covid 19 patients)

Hospital: 0,25

Target area: at most 1,91

Quality objective achieved

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Ratio of actual to expected number of patients who died during hospitalisation (all patients including Covid 19 patients)

Hospital: 0,19

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of patients who died during hospitalization (COVID-19 patients only)

Hospital: 0,15

as rarely as possible

Evaluation is not available

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How rarely patients with pneumonia died in hospital (excluding Covid 19 patients)

Hospital: 10,61 %

as rarely as possible

Evaluation is not available

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This is how rarely patients died during their hospital stay (all patients including Covid 19 patients)

Hospital: 14,14 %

as rarely as possible

Evaluation is not available

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This is how frequently the number of breaths per minute of patients (respiratory rate) was measured on admission to hospital

Hospital: 91,30 %

Target area: at least 95,00 %

Quality objective not achieved

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This is how frequently the number of breaths per minute of patients (respiratory rate) was measured on admission to hospital (excluding COVID-19 patients)

Hospital: 92,06 %

as often as possible

Evaluation is not available

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Code ID	2005
Result (%)	97,98
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	99
Events observed	97
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	99,02
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	98,98 - 99,06
Hospital confidence interval (%)	92,93 - 99,44
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates in which range the results of an indicator are assessed as inconspicuous. A facility with a result outside the reference range is initially mathematically conspicuous: this usually entails an analysis in the Structured Dialogue. It should be noted that an indicator result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation may also be attributable, for example, to faulty documentation or to individual cases. The assessment of quality is carried out within the framework of the Structured Dialogue with the facilities.

Code ID	2006
Result (%)	97,70
Evaluation through structured dialogue
Population	87
Events observed	85
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	99,05
Target range (reference range)
Confidence interval nationwide (%)	99,02 - 99,09
Hospital confidence interval (%)	92,00 - 99,37
Reference infection	No
Type of value	TKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. More information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf.

Code ID	2007
Result (%)	100,00
Evaluation through structured dialogue
Population	12
Events observed	12
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	98,18
Target range (reference range)
Confidence interval nationwide (%)	97,91 - 98,41
Hospital confidence interval (%)	75,75 - 100,00
Reference infection	No
Type of value	TKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. More information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf.

Code ID	232000_2005
Result (%)	96,97
Evaluation through structured dialogue
Population	66
Events observed	64
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	98,89
Target range (reference range)
Confidence interval nationwide (%)	98,84 - 98,94
Hospital confidence interval (%)	89,61 - 99,17
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	232001_2006
Result (%)	96,83
Evaluation through structured dialogue
Population	63
Events observed	61
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	98,93
Target range (reference range)
Confidence interval nationwide (%)	98,88 - 98,98
Hospital confidence interval (%)	89,14 - 99,13
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf

Code ID	232002_2007
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	97,92
Target range (reference range)
Confidence interval nationwide (%)	97,54 - 98,24
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf

Code ID	2009
Result (%)	82,14
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	56
Events observed	46
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	93,08
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	92,95 - 93,21
Hospital confidence interval (%)	70,16 - 90,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. In pulmonary clinics, antimicrobial therapy started on an outpatient basis can be discontinued on a regular basis upon admission to determine the pathogen. This can lead to computational abnormalities, but does not have to be an expression of a quality problem.

Code ID	232003_2009
Result (%)	82,14
Evaluation through structured dialogue
Population	56
Events observed	46
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	92,65
Target range (reference range)
Confidence interval nationwide (%)	92,52 - 92,78
Hospital confidence interval (%)	70,16 - 90,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/

Code ID	2013
Result (%)	93,18
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	44
Events observed	41
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	92,79
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	92,65 - 92,93
Hospital confidence interval (%)	81,77 - 97,65
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	232004_2013
Result (%)	100,00
Evaluation through structured dialogue
Population	30
Events observed	30
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	93,14
Target range (reference range)
Confidence interval nationwide (%)	92,97 - 93,31
Hospital confidence interval (%)	88,65 - 100,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/ Cases for which COVID-19 was documented were not taken into account in the calculation.

Code ID	2028
Result (%)	70,13
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	77
Events observed	54
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	95,93
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	95,84 - 96,02
Hospital confidence interval (%)	59,15 - 79,20
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	232005_2028
Result (%)	67,27
Evaluation through structured dialogue
Population	55
Events observed	37
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	95,40
Target range (reference range)
Confidence interval nationwide (%)	95,28 - 95,51
Hospital confidence interval (%)	54,10 - 78,19
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/ Cases for which COVID-19 was documented were not taken into account in the calculation.

Code ID	2036
Result (%)	98,11
Evaluation through structured dialogue
Population	53
Events observed	52
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	98,69
Target range (reference range)
Confidence interval nationwide (%)	98,64 - 98,75
Hospital confidence interval (%)	90,06 - 99,67
Reference infection	No
Type of value	TKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	232006_2036
Result (%)	97,30
Evaluation through structured dialogue
Population	37
Events observed	36
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	98,66
Target range (reference range)
Confidence interval nationwide (%)	98,59 - 98,72
Hospital confidence interval (%)	86,18 - 99,52
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/ Cases for which COVID-19 was documented were not taken into account in the calculation.

Code ID	50778
Result	0,25
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,97
Target range (reference range)	<= 1,91 (95. Perzentil)
Confidence interval nationwide	0,96 - 0,99
Hospital confidence interval	0,04 - 1,35
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Risk adjustment compensates for the different patient structure in different facilities. This leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome without one facility being held responsible for, for example, more frequent complications resulting from this. With the help of risk adjustment, the quality outcome of a facility with many high-risk cases can be statistically compared more fairly with the quality outcome of a facility with many low-risk cases. More information on reference ranges can be found at the following link: https://iqtig.org/dateien/dasiqtig/grundlagen/IQTIG_Methodische-Grundlagen-V1.1_barrierefrei_2019-04-15.pdf The reference range indicates the results at which the quality of care of a facility can be assumed to be good, although deviations are possible. The reference range thus sets a benchmark for the assessment of facilities. A facility with a result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of Structured Dialogue. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due to faulty documentation or individual cases, for example. Quality is assessed within the framework of the established procedure in the Structured Dialogue. More detailed information on reference areas can be found under the following link: https://iqtig.org/dateien/dasiqtig/grundlagen/IQTIG_Methodische-Grundlagen-V1.1_barrierefrei_2019-04-15.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/ Cases for which COVID-19 was documented were not taken into account in the calculation.

Code ID	232007_50778
Result	0,19
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	0,82
Target range (reference range)
Confidence interval nationwide	0,81 - 0,83
Hospital confidence interval	0,05 - 0,66
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/

Code ID	232010_50778
Result	0,15
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	0,66
Target range (reference range)
Confidence interval nationwide	0,65 - 0,67
Hospital confidence interval	0,03 - 0,74
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	2
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. Further information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf

Code ID	231900
Result (%)	10,61
Evaluation through structured dialogue
Population	66
Events observed	7
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	16,84
Target range (reference range)
Confidence interval nationwide (%)	16,67 - 17,01
Hospital confidence interval (%)	5,23 - 20,31
Reference infection	No
Type of value	TKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the results of which are supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for presenting the quality of care. More detailed information on ratios can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	232008_231900
Result (%)	14,14
Evaluation through structured dialogue
Population	99
Events observed	14
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	18,28
Target range (reference range)
Confidence interval nationwide (%)	18,14 - 18,43
Hospital confidence interval (%)	8,61 - 22,35
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf. The quality result is only comparable with the previous year's results to a limited extent due to adjustments of the calculation rule or inclusion or exclusion criteria of the cases to be documented in the QA procedure. More detailed information on the adjustments made can be found in the description of the quality indicators under the following link: https://iqtig.org/qs-verfahren/

Code ID	50722
Result (%)	91,30
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	92
Events observed	84
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	96,71
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	96,64 - 96,77
Hospital confidence interval (%)	83,77 - 95,53
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	232009_50722
Result (%)	92,06
Evaluation through structured dialogue
Population	63
Events observed	58
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	96,57
Target range (reference range)
Confidence interval nationwide (%)	96,49 - 96,66
Hospital confidence interval (%)	82,73 - 96,56
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found under the following link: https://iqtig.org/dateien/berichte/2018/2018-03-22_IQTIG_Kez-Umsetzungskonzept.pdf