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St. Martinus Krankenhaus

Klosterstrasse 32
40764 Langenfeld

Phone: 02173-796-0
Mail: ed.dlefnegnal-sunitramts@ofni ed.dlefnegnal-sunitramts@ofni ed.dlefnegnal-sunitramts@ofni

http://www.stmartinus-langenfeld.de

Basic information

Number of beds: 179
Number of specialist departments: 5

Number of inpatient cases: 6.735
Number of outpatient cases: 46.137

Hospital owners: Gemeinnützige Gesellschaft der Franziskanerinnen zu Olpe mbH (GFO)
Type of provider: freigemeinnützig

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

Implementation of the minimum quantity agreement

Treatment area

Surgical treatment of breast cancer (breast surgery)

Quantity performed	47
Exception?	No exception
Übergangslösung für das insolvente St. Josefs Krankenahus in Hilden. Eine Rückverlagerung in die Betriebsstätte des Flächenstandorts der GFO Kliniken Mettmann-Süd, St. Josefs Krankenhaus in Hilden erfolgte im selben Jahr.

Minimum quantities forecast

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	47
Quantity forecast year:	0
Examination by state associations?	no
Exemption?	no
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:	0
Quantity forecast year:	2
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:	0
Quantity forecast year:	14
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 participation

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

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

General minimum requirements

Minimum requirement	Days of non-performance
Trauma room	0
Availability	0
Computed tomography (CT)	0
Intensive care beds	0
Department of Surgery	0
Forwarding by air	0
Department of Internal Medicine	0
Intensive care beds with ventilator facilities	0
Emergency care training courses	0
Treatment prioritisation system (triage)	0
Responsibility for emergency care	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
37	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*
25	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
23	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
  Note on the measure
  - Orientierung an den Vorgabn der NRW-Bistümer und Landesjungendämter
  Training of employees
  Note on the measure
  - Ausbildung von Schulungsreferent:innen und Präventionsfachkräften für alles Einrichtungen
  
  - Alle Mitarbeitende nehmen regelmäßig an verpflichtenden Präventions- sowie Vertiefungsschulungen teil
  Education
  Note on the measure
  - Im Rahmen des Einstellungsprozesses und der sich wiederholenden Schulungen wird über das Schutzkonzept und die Thematik aufgeklärt
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  22.04.2024 19:40:30
  Age-appropriate complaint options
  Special requirements for the selection of persons
  Note on the measure
  - Die Vorlage eines erweiterten polizeilichen Führungszeugnisses wird bei Einstellung und alle 5 Jahre in den Bereichen angefordert, in denen es gesetzlich vorgeschrieben ist.
  
  - Im Rahmen des Einstellungsprozesses und der sich wiederholenden Schulungen wird über das Schutzkonzept und die Haltung der GFO aufgeklärt.
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  08.01.2024 18:40:30
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  -Mitarbeitende inklusive Leitungskräfte sind angehalten, sich an den von der GFO Fachstelle für Prävention und Intervention erstellten Dokumentationsbögen 1-3 zu orientieren.
  
  - Die Fachstelle übernimmt anhand eines erstellten Leitfadens die nachhaltige Aufarbeitung.
  
  Last review of the measure
  20.05.2025 19:40:30

- Orientierung an den Vorgabn der NRW-Bistümer und Landesjungendämter

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

Name of the working group: GFO Fachgruppen

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

im KIS: Medizinische Dokumentation/Anamnse

23.07.2020

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)

s. Kommentar

23.07.2023

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
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)

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
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

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

Pro Jahr werden im September 2 Ausbildungsplätze zur Operationstechnischen Assistentin / Operationstechnischer Assistent (OTA) besetzt, um den hohen Anforderungen im Operationsbereich qualifiziert besetzen zu können. Hierfür besteht eine Kooperation mit der Karl-Borromäus Schule in Bonn.

HB19 - Nursing professionals

Comment

Seit Oktober 2020 werden zweimal im Jahr 60-90 junge Menschen in Kooperation mit dem Katholischen Bildungszentrum Haan ausgebildet.

HB17 - Auxiliary nurse (m/f)

Comment

Seit Juni 2021 werden Krankenpflegehelfer:innen unter einer neuen Berufsbezeichnung (Pflegefachassistent:innen) in den GFO Kliniken Mettmann-Süd (beide Betriebsstätten) ausgebildet. Ab 2022 wird die Ausbildung mit Start im Juni und Oktober angeboten.

HB10 - Midwife (m/f)

Comment

Ausbildungscampus Gesundheit in Bergisch Gladbach-Bensberg in enger Zusammenarbeit mit der Katholische Hochschule Nordrhein-Westfalen. Die GFO Kliniken Mettmann-Süd tragen im Praxisalltag zur entsprechenden Curriculumorientierten Ausbildung bei.

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 14
- Additional staff: 17
- Explanations: Die Leitung der GFO Zentralapotheke informiert und berät das Krankenhauspersonal, insbesondere auch über zweckmäßige und wirtschaftliche Arzneimitteltherapie. Im Notfall ist die Beratung jederzeit unverzüglich möglich. Die Leitung der Zentralapotheke hat den Vorsitz der Arzneimittelkommission.
- Nursing staff regulation