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Klinikum Herford AöR

Schwarzenmoorstraße 70
32049 Herford

Phone: 05221-94-0
Fax: 05221-94-2649
Mail: ed.drofreh-mukinilk@dnatsrov.kes

http://www.klinikum-herford.de

Basic information

Number of beds: 755
Number of specialist departments: 15

Number of inpatient cases: 26.245
Number of outpatient cases: 48.846

Hospital owners: Klinikum Herford -Anstalt des öffentlichen Rechts-
Type of provider: öffentlich

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

Quality of participation in the Disease Management Programme (DMP)
No participation

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Complex interventions on the organ system esophagus for adults

Quantity performed	26
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	25
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	88
Exception?	No exception

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

Quantity performed	18
Exception?	No exception

Minimum quantities forecast

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	26
Quantity forecast year:	27
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:	25
Quantity forecast year:	25
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:	88
Quantity forecast year:	94
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

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

Overall result forecast presentation:	yes
Quantity performed reporting year:	18
Quantity forecast year:	18
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:	99
Quantity forecast year:	59
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:	no
Quantity performed reporting year:	30
Quantity forecast year:	25
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
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ30	Quality assurance guideline for interstitial LDR brachytherapy for low-risk localized prostate cancer (effective January 8, 2021).
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

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
149	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
66	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
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Geregelt in der hausinternen Richtlinie "Vorgehen bei Verdacht auf Kindeswohlgefährdung (Gewalt, Vernachlässigung, Missbrauch)"
  
  Last review of the measure
  30.06.2023 16:25:46
  Other aspects of intervention
- Reprocessing
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Geregelt in der hausinternen Richtlinie "Vorgehen bei Verdacht auf Kindeswohlgefährdung (Gewalt, Vernachlässigung, Missbrauch)"
  
  Last review of the measure
  30.06.2023 16:25:46

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

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

Manual zur einheitlichen Verordnung und Dokumentation von Medikamenten am Klinikum Herford

06.12.2021

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)

Manual zur einheitlichen Verordnung und Dokumentation von Medikamenten am Klinikum Herford

06.12.2021

SOP on good prescription practices

Manual zur einheitlichen Verordnung und Dokumentation von Medikamenten am Klinikum Herford

06.12.2021

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

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)
Sonstige elektronische Unterstützung (bei z.B. Bestellung, Herstellung, Abgabe): CGM-Muse als intranetbasierte Arzneimittelbestellplattform

Measures to minimise medication errors

Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Nutzung eines einrichtungsinternen Fehlermeldesystems (Critical Incident Reporting System - CIRS)

Measures to ensure seamless drug therapy after discharge

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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Es sind 3 Universitätskliniken der RUB mit den Fachvertretern (Anästhesie, Chirurgie, Urologie, W-3 analoge Univ.-Professuren) lokalisiert. Lehrtätigkeiten an versch. Universitäten (Westfälische Wilhelms-Universität Münster, Medizinische Hochschule Hannover (MHH), Universitätsklinikum Hamburg-Epp.).

FL03 - Student training (clinical traineeship / internship year)

Explanation

Am Klinikum Herford findet die klinisch-universitäre Ausbildung für Medizinstudenten der RUB ab dem 7. Semester bis inklusive des Praktischen Jahres und dem letzten Teil des Staatsexamens statt. Zusätzlich wird der Bachelor-Studiengang "Pflege" in Kooperation mit der FHDD Bielefeld angeboten.

FL04 - Project-related cooperation with colleges and universities

Explanation

Das Klinikum Herford beteiligt sich an projektbezogenen Fragestellungen kooperierender Hochschulen (z.B. Hypothermie nach Reanimation, Multicenterstudien zur patientenbezogenen Entscheidungsfindung uro-onkologischer Operationen) und dem Fraunhofer Institut für angewandte Polymerforschung.

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

Explanation

Beteiligung an der Studie "RECOVER, Clinical Trial Code SARS-CoV-2CP-HD-001" zur Behandlung von COVID-19.

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

Explanation

Beteiligung an der "PROCYS"-Studie zum Einsatz von Cytosorb beim Septischen Schock.

FL08 - Editors of scientific journals/textbooks

Explanation

Im Rahmen von Lehr- und Forschungstätigkeiten der Chefärzte finden wissenschaftliche Beiträge regelmäßig Eingang in Lehrbücher und Fachmagazine. Darüber hinaus bestehen Beteiligungen als Mitherausgeber einschlägiger Journale

FL09 - Doctoral supervision

Explanation

Die Fachvertreter der universitären Fächer (Anästhesie, Chirurgie, Urologie) betreuen Studierende der RUB bei Promotionen. Darüber hinaus findet die Betreuung weiterer Promovenden statt.

Training

Training in other healing professions

HB15 - Anaesthesia technical assistant (m/f)

Comment

ATA-Ausbildung und Anä-Fachweiterbildung erfolgen in Kooperation mit der "Zentralen Akademie für Berufe im Gesundheitswesen GmbH" (ZAB).

HB10 - Midwife (m/f)

Comment

Vereinbarung als 2. Externat mit der Universität Bochum im Hebammenstudium. Seit dem 01.10.2020 findet in Kooperation mit der Fachhochschule des Mittelstands (FHM) Bielefeld das Hebammenstudium statt.

HB06 - Occupational therapist (m/f)

Comment

Das Klinikum Herford ermöglicht Berufspraktika für angehende Ergotherapeuten in Kooperation mit den externen Schulen.

HB01 - Nurse and health care worker (m/f)

Comment

Am Standort Herford der "Schulen für Pflegeberufe Herford/Lippe GmbH" stehen 126 Ausbildungsplätze in der Gesundheits- und Krankenpflege zur Verfügung.

HB19 - Nursing professionals

Comment

Zusammenführung der Ausbildungsberufe Gesundheits- und Krankenpflege/ Gesundheits- und Kinderkrankenpflege und Altenpflege seit dem 01.01.2020 (Standort Herford der "Schulen für Pflegeberufe"). Angeboten werden 39 Plätze mit der Vertiefung Pädiatrie und 126 Plätze mit der Vertiefung Akutpflege.

HB02 - Health and paediatric nurse (m/f)

Comment

Am Standort Herford der "Schulen für Pflegeberufe Herford/Lippe GmbH" stehen 39 Ausbildungsplätze in der Gesundheits- und Kinderkrankenpflege zur Verfügung.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Das Klinikum Herford ermöglicht Berufspraktika für angehende Physiotherapeuten in Kooperation mit den externen Schulen.

HB17 - Auxiliary nurse (m/f)

Comment

Am Standort Herford der "Schulen für Pflegeberufe Herford/Lippe GmbH" stehen seit dem 01.11.2020 25 Ausbildungsplätze in der Gesundheits- und Krankenpflegeassistenz zur Verfügung.

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

Comment

Das Klinikum Herford ermöglicht Berufspraktika für angehende MTRAs in Kooperation mit den externen Schulen.

HB07 - Surgical technical assistant (m/f)

Comment

OTA-Ausbildung und OP-Fachweiterbildung erfolgen in Kooperation mit der „Zentralen Akademie für Berufe im Gesundheitswesen GmbH“ (ZAB) in Gütersloh und den "Mühlenkreiskliniken" in Minden.