Overall result forecast presentation:	yes
Quantity performed reporting year:	16
Quantity forecast year:	19
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:	62
Quantity forecast year:	55
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	no
Quantity performed reporting year:	3
Quantity forecast year:	3
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
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
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)

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
84	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*
70	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
70	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
  
  Training of employees
  
  Education

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)

Verfahrensanweisung zum richtigen Umgang mit Medikamenten

31.01.2023

SOP on good prescription practices

Risikomanagement-Konzept

10.04.2021

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
Antibiotikaliste mit Angaben zum Lösungsmittel und dessen Menge

Electronic documentation of the administration of drugs

Measures to minimise medication errors

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
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

Allogene Stammzelltransplantation mit der WWU; Klinik Pneumologie: Zusammenarbeit mit der UK Mannheim bzgl. des internat. Studiengangs Public Health; Zusammenarbeit mit der UK Heidelberg bzgl. Projekten der interstitiellen Lungenerkr.; Koop. mit dem CTCR UK Münster; Projekte i.Z.m. der Uni Toronto

FL03 - Student training (clinical traineeship / internship year)

Explanation

Das Klinikum Gütersloh ist Lehrkrankenhaus der med. Fakultät der Uni Münster. Auch Studierende anderer Universitäten können ihr PJ oder eine Famulatur absolvieren, sowohl in der Inneren Med., als auch in der Chirurgie, sowie in der Gynäkologie/Geburtshilfe, Anästhesie/Intensivmedizin und Radiologie

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

Explanation

Frauenklinik: Studien der AGO; Kardiologie:Teilnahme an Multicenterstudien; Innere Medizin II: Multizentrischen Phase-III-Studien zur Behandlung hämatologischer Neoplasien; Pneumologie: Multicenterstudien Phase III/IV; Registerstudien Radiologie: Verschiedenen Multicenterstudien

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Prof. Dr. von Bierbrauer (Universität Marburg);PD Dr. Grau (Uni Münster, Uni Heidelberg);Prof. Dr. Massenkeil (RUB);Prof. Dr. Er (UK Köln; Uni Münster),PD Dr. Kapischke (AMS, Uni Lübeck);Prof. Dr. Buerke (Uni Münster);PD Dr. Horstmann(Universitätsmed. Essen)

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

Explanation

Kardiologie: Prof. Dr. Er; Anästhesiologie: PD Dr. Grau; Prof. Dr. Buerke

FL09 - Doctoral supervision

Explanation

Prof. Dr. A. von Bierbrauer: Betreuung von Doktoranden in Zusammenarbeit mit der Universität Marburg; Kardiologie: Prof. Dr. Er (Uniklinik Köln,Uni Münster);PD Dr. Kapischke (AMS,Uni Lübeck);PD Dr. Grau (Uni Bochum,Uni Münster);Prof. Dr. Buerke (WWU Münster);PD Dr. Horstmann (Universitätsmed. Essen)

FL05 - Participation in multi-centre Phase I/II studies

Explanation

In der Klinik für Allgemein-, Viszeral-, Thorax u. minimalinvasive Chirurgie

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Fliedner Fachhochschule (Dr. Krause-Bergmann und PD. Dr. Horstmann)

Training

Training in other healing professions

HB17 - Auxiliary nurse (m/f)

Comment

Wir bieten eine Ausbildung zum Pflegefachassistenten/-tin. Der theoretische Ausbildungsträger ist die Zentralen Akademie für Berufe im Gesundheitswesen (ZAB-Gütersloh), deren Gesellschafter wir gleichzeitig sind.

HB07 - Surgical technical assistant (m/f)

Comment

Das Klinikum Gütersloh ist Gesellschafter der Zentralen Akademie für Berufe im Gesundheitswesen gGmbH (ZAB). Die Ausbildung zur/ zum Operationstechnischen Assistentin/-ten wird jährlich angeboten. Fachpraktische Einsätze finden in allen Disziplinen im Klinikum statt.

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

Comment

In Kooperation mit dem Studieninstitut Bielefeld, den Johanniter Münster und der Feuerwehr- und Rettungsdienstakademie Bocholt, absolvieren die NotfallsanitäterInnen und -sanitäter einen Teil der praktischen Ausbildung im Klinikum Gütersloh.

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

Comment

In Kooperation mit Bielefeld

HB15 - Anaesthesia technical assistant (m/f)

Comment

ZAB theoretischer Ausbildungsträger

HB19 - Nursing professionals

Comment

Das Klinikum Gütersloh ist Gesellschafter der Zentralen Akademie für Berufe im Gesundheitswesen gGmbH (ZAB). Die generalistische Ausbildung zur/zum Pflegefachfrau/-mann startet 3x im Jahr. Für Einsätze außerhalb einer Akuteinrichtung bestehen Kooperationen.

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 5
- Additional staff: 6
- Explanations: Anzahl Köpfe Apotheker und PTA
- Nursing staff regulation

Service contact persons

Patient advocates

BIGS Bürgerinformation Gesundheit und Selbsthilfekontaktstelle des Kreises Gütersloh

Patientenfürsprecher

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -85-2882
Mail: ed.holsreteug-sierk@sgib

Customer feedback management

Danielle Bohm

Beschwerdemanagement

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -83-29090
Mail: ed.holsreteug-mukinilk@mhob.elleinad

Quality management

Diplompflegewirtin Monika Ossig

Qualitätsmanagement

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -8325116-
Mail: ed.holsreteug-mukinilk@gisso.akinom

Hygiene officer

Prof. Dr. med Axel von Bierbrauer zu Brennstein

Facharzt für Innere Medizin, Pneumologie. Infektiologie, Schlafmedizin, Internistische Intensivmedizin, Notfallmedizin, Angiologie und Labormedizin, Leiter der Hygienekommission

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -83-24702
Mail: ed.holsreteug-mukinilk@reuarbreiBnov.lexA

Responsible for drug therapy

Vera Voigt

Leitung Apotheke

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -83-29210
Mail: ed.holsreteug-mukinilk@tgiov.arev

Accessibility Officer

Bernd Fuchs

Technischer Leiter

Reckenberger Str. 19
33332 Gütersloh

Phone: 05241 -8329230-
Mail: ed.holsreteug-mukinilk@shcuf.dnreb