Caritas-Krankenhaus St. Lukas GmbH

Quality results

Treatment sector: Gynecological operations: operations on the female genital organs (excluding operations to remove the uterus) (GYN-OP)

Information about this treatment area (documentation)

Designation	Gynäkologische Operationen
Shortcut	15/1
Number of cases	165
Documentation rate	100 %

Summary result:

In 7 of 7 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 165

Quality objective achieved
Quality objective not achieved

The results in detail

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Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

One of the two ovaries or fallopian tubes was removed. However, the tissue examination after the operation showed no pathological result

National result: 7,61 %
Hospital: Data protection

No information due to data protection

Target area: at most 20,00 %

Quality objective achieved

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After surgery on one of the two ovaries, no examination of the removed tissue was performed

National result: 0,95 %
Hospital: 0,00 %

Target area: at most 5,00 %

Quality objective achieved

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This is how rarely patients 45 years or younger were found to have no diseased tissue or compromised cyst after removal of an ovary or fallopian tube

National result: 11,16 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how rarely patients aged 46 to 55 years were found to have no diseased tissue or compromising cyst after removal of an ovary or fallopian tube

National result: 13,49 %
Hospital: 0,00 %

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of female patients in whom at least one of the surrounding organs was injured during an operation on the female reproductive organs (individual risks of the patients were taken into account). The operation was performed by means of laparoscopy

National result: 1,05
Hospital: 0,93

Target area: at most 4,18

Quality objective achieved

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Patients had a bladder catheter for more than 24 hours

National result: 3,15 %
Hospital: Data protection

No information due to data protection

Target area: at most 6,59 %

Quality objective achieved

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Both ovaries were removed in patients aged 45 years and younger who underwent surgery on the ovaries and/or fallopian tubes. However, the tissue examination after the operation showed no pathological or a benign result

National result: 0,74 %
Hospital: 0,00 %

Sentinel Event

Quality objective achieved

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Both ovaries were removed in patients who were 46 to 55 years old who underwent surgery on the ovaries and/or fallopian tubes. However, the tissue examination after the operation showed no pathological or a benign result

National result: 19,31 %
Hospital: Data protection

No information due to data protection

Target area: at most 42,35 %

Quality objective achieved

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The ovaries were not removed during surgery in patients 45 years of age and younger. The tissue examination after the operation showed no pathological or a benign result

National result: 88,74 %
Hospital: 86,11 %

Target area: at least 74,46 %

Quality objective achieved

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Code ID	10211
Result (%)	Data protection
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	unverändert
National result (%)	7,61
Target range (reference range)	<= 20,00 %
Confidence interval nationwide (%)	7,20 - 8,05
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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 indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link: https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. 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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	12874
Result (%)	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	40
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	0,95
Target range (reference range)	<= 5,00 %
Confidence interval nationwide (%)	0,85 - 1,05
Hospital confidence interval (%)	0,00 - 8,76
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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 indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link: https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. 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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	172000_10211
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 (%)	11,16
Target range (reference range)
Confidence interval nationwide (%)	9,90 - 12,55
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	10211
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	172001_10211
Result (%)	0,00
Evaluation through structured dialogue
Population	4
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	13,49
Target range (reference range)
Confidence interval nationwide (%)	12,39 - 14,67
Hospital confidence interval (%)	0,00 - 48,99
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	10211
Sorting	2
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	51906
Result	0,93
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	unverändert
National result	1,05
Target range (reference range)	<= 4,18
Confidence interval nationwide	0,99 - 1,11
Hospital confidence interval	0,16 - 5,09
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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 indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link: https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. 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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	52283
Result (%)	Data protection
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	unverändert
National result (%)	3,15
Target range (reference range)	<= 6,59 % (90. Perzentil)
Confidence interval nationwide (%)	3,05 - 3,27
Hospital confidence interval (%)	0,00 - 0,00
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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	60685
Result (%)	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	42
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	0,74
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,66 - 0,83
Hospital confidence interval (%)	0,00 - 8,38
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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	60686
Result (%)	Data protection
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	unverändert
National result (%)	19,31
Target range (reference range)	<= 42,35 % (95. Perzentil)
Confidence interval nationwide (%)	18,56 - 20,07
Hospital confidence interval (%)	0,00 - 0,00
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 This indicator is a planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link: https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. 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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	612
Result (%)	86,11
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	36
Events observed	31
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	88,74
Target range (reference range)	>= 74,46 % (5. Perzentil)
Confidence interval nationwide (%)	88,41 - 89,07
Hospital confidence interval (%)	71,34 - 93,92
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 noticeable in terms of calculation, 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.