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Universitätsklinikum Magdeburg A. ö. R. - Standort Leipziger Straße

Leipziger Straße 44 44
39120 Magdeburg

Phone: 0391-67-01
Mail: ed.ugvo.dem@dea ed.ugvo.dem@dea ed.ugvo.dem@dea

http://www.med.uni-magdeburg.de/

Basic information

Number of beds: 834
Number of specialist departments: 38

Number of inpatient cases: 32.352
Number of partial inpatient cases: 3.866
Number of outpatient cases: 152.679

Hospital owners: Land Sachsen-Anhalt
Type of provider: öffentlich

University Hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

External quality assurance according to the DMP

Brustkrebs

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	29
Exception?	No exception

Stem cell transplant

Quantity performed	33
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	157
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	49
Exception?	No exception

Liver transplantation (including partial liver donation)

Quantity performed	23
Exception?	No exception

Thoracic surgical treatment of lung cancer in adults

Quantity performed	67
Exception?	No exception

Minimum quantities forecast

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	29
Quantity forecast year:	34
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	33
Quantity forecast year:	31
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:	157
Quantity forecast year:	161
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:	49
Quantity forecast year:	58
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	23
Quantity forecast year:	22
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:	yes
Quantity performed reporting year:	67
Quantity forecast year:	75
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
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
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
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
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)
CQ29	Measures for quality assurance of allogeneic stem cell transplantation with in-vitro processing (T-cell depletion via positive enrichment or negative selection) of the transplant in acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML) in adults
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)
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	no
Level of implementation	113,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	108,33 %
Pflegefachpersonen	ja	113,53 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	116,41 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	116,17 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	130,8 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	115,66 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	43
Current staffing levels (full-time staff)	59
Number of nights, subject to the minimum requirement	90

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	122,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	117,74 %
Pflegefachpersonen	ja	132,74 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	193,61 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	74,12 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	39,7 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	63,89 %

quarter Q2

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	99,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	nein	75,36 %
Pflegefachpersonen	ja	109,06 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	104,92 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	75,53 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	98,59 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	96,88 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	43
Current staffing levels (full-time staff)	56
Number of nights, subject to the minimum requirement	86

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	104,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	118,3 %
Pflegefachpersonen	ja	106,82 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	135,39 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	79,23 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	28,8 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	53,46 %

quarter Q3

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	105,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	nein	76,01 %
Pflegefachpersonen	ja	110,49 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	115,53 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	114,9 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	132,13 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	95,38 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	43
Current staffing levels (full-time staff)	60
Number of nights, subject to the minimum requirement	92

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	116,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	134,89 %
Pflegefachpersonen	ja	98,3 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	172,75 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	116,89 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	67,6 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	66,84 %

quarter Q4

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	105,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	97,75 %
Pflegefachpersonen	ja	110,84 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	70,03 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	122,83 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	90,13 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	86,31 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	43
Current staffing levels (full-time staff)	66
Number of nights, subject to the minimum requirement	92

Psychosomatik

Day shift
Compliance with minimum requirements	no
Level of implementation	116,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	120,78 %
Pflegefachpersonen	ja	102,58 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	183,13 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	106,32 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	93,15 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	93,83 %

Management of quality assurance for proximal femoral fracturet (QSFFx)

Full record of compliance maintained

Number of days shown	366
Days of non-performance	0
Number of minimum requirements not met	0

Specific minimum requirements

Minimum requirement	Days of non-performance
Doctor on duty	0
Supervision by a medical specialist	0
Geriatric expertise	0
Operating room equipment	0
Post-operative physiotherapy	0
Independent organisational unit	0

Minimum requirements for process quality

Minimum requirement	Days of non-performance
SOP: Surgical procedures	0
SOP: Perioperative Planning	0
SOP: Capacity to consent	0
Standard Operating Procedure for the Management of Anticoagulants	0
SOP: Ortho-geriatric Care	0
SOP: Physiotherapy Measures	0
SOP: Patient-centred blood management	0

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

Number	Group
351	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*
255	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
249	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
  
  Information gathering on the topic
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  27.03.2023 20:20:32
  Other aspects of prevention
  
  Age-appropriate complaint options
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  20.02.2023 19:20:32
  Other aspects of intervention
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  20.02.2023 19:20:32
  Other information on recognition

Commentary on the protection concept

Gemäß Teil A § 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 Teil A § 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

Use of standardised forms for drug medical history

Qualitätsmanagementhandbuch des Universitätsklinikums Magdeburg

12.07.2017

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)

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

Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung

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)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Maßnahmen zur Vermeidung von Arzneimittelverwechslung

Measures to ensure seamless drug therapy after discharge

bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
Aushändigung des Medikationsplans
Aushändigung von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs

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

FL09 - Doctoral supervision

Explanation

Die Doktorandenbetreuung gehört mit zu den Aufgaben eines Universitätsklinikums.

FL08 - Editors of scientific journals/textbooks

Explanation

Diese Bereiche gehören mit zum Tätigkeitsspektrum der Mitarbeiter eines Universitätsklinikums.

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

Explanation

Die Einrichtung ist ein Universitätsklinikum, Forschung und Lehre sind somit Teil der strukturellen Aufgaben.

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

Explanation

Teilnahme an mehreren multizentrischen Phase-III- und -IV-Studien (Universitätsklinikum).

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

Explanation

Teilnahme an mehreren multizentrischen Phase-I- und -II-Studien (Universitätsklinikum).

FL04 - Project-related cooperation with colleges and universities

Explanation

Da die Einrichtung ein Universitätsklinikum ist, werden universitäre Projekte bearbeitet.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Die Einrichtung ist ein Universitätsklinikum; Forschung und Lehre sind somit Teil der strukturellen Aufgaben. Zusätzlich zu den grundsätzlichen Aufgaben finden Unterricht am Krankenbett (Studium) und Gesundheitspflegepraktika statt.

FL02 - Lectureships / teaching posts at universities of applied sciences