Evangelisches Krankenhaus Bergisch Gladbach gGmbH

Quality results

Treatment sector: Breast surgery (MC)

Information about this treatment area (documentation)

Designation	Mammachirurgie
Shortcut	18/1
Number of cases	422
Documentation rate	100.47 %

Summary result:

In 11 of 11 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 422

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

This is how often tissue was removed and examined before the operation to confirm the diagnosis

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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This is how often microcalcifications in the breast tissue were marked with a wire before the operation

Hospital: 100,00 %

Target area: at least 80,95 %

Quality objective achieved

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This is how often suspicious breast tissue without microcalcifications was marked with a wire before the operation

Hospital: 98,63 %

Target area: at least 54,43 %

Quality objective achieved

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This is how often the tissue marked with a wire by X-ray and then removed was checked during the operation

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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This is how often the tissue marked by ultrasound with a wire and then removed was checked during the operation

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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This is how rarely the lymph nodes in the armpit were completely removed in patients with early-stage breast cancer

Hospital: 0,00 %

Sentinel Event

Quality objective achieved

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This is how rarely the lymph nodes in the armpit were completely removed in patients with early-stage breast cancer and breast-conserving surgery

Hospital: 0,00 %

Target area: at most 5,00 %

Quality objective achieved

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So often only the sentinel lymph nodes were removed - a subsequent examination confirmed that this was medically justified

Hospital: 99,44 %

Target area: at least 90,00 %

Quality objective achieved

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So rarely have patients been given a reflection period of less than 7 days between diagnosis and surgery

Hospital: Data protection

No information due to data protection

Target area: at most 7,69 %

Quality objective achieved

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So rarely were follow-up operations necessary because the malignant tumours were incompletely removed in the first operation or only removed without a sufficient safety margin

Hospital: 9,26 %

Target area: at most 20,77 %

Quality objective achieved

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This is how often breast cancer treatment was discussed at interdisciplinary tumour conferences and individually planned further

Hospital: 100,00 %

Target area: at least 97,82 %

Quality objective achieved

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Code ID	51846
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	330
Events observed	330
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	98,21
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	98,11 - 98,30
Hospital confidence interval (%)	98,85 - 100,00
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 computationally conspicuous, 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	212000
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	30
Events observed	30
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	95,04
Target range (reference range)	>= 80,95 % (5. Perzentil)
Confidence interval nationwide (%)	94,52 - 95,52
Hospital confidence interval (%)	88,65 - 100,00
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 results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus defines a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually results in an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect under consideration here. The deviation may also be due, for example, to incorrect documentation, special medical features of the patient population or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the statement procedure. Further infor

Code ID	212001
Result (%)	98,63
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	146
Events observed	144
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	85,86
Target range (reference range)	>= 54,43 % (5. Perzentil)
Confidence interval nationwide (%)	85,40 - 86,30
Hospital confidence interval (%)	95,14 - 99,62
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 results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus defines a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually results in an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect under consideration here. The deviation may also be due, for example, to incorrect documentation, special medical features of the patient population or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the statement procedure. Further infor

Code ID	52330
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	163
Events observed	163
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	99,39
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	99,26 - 99,50
Hospital confidence interval (%)	97,70 - 100,00
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 IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons to believe 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 computationally conspicuous, 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	52279
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	65
Events observed	65
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	98,99
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	98,86 - 99,09
Hospital confidence interval (%)	94,42 - 100,00
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 IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons to believe 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 computationally conspicuous, 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	2163
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	35
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	0,04
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,01 - 0,13
Hospital confidence interval (%)	0,00 - 9,89
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 quality indicator relevant to planning. Sites with a statistical anomaly are requested by the IQTIG to submit a statement. The aim of this commenting procedure is to clarify whether there are reasons to conclude that the quality results are not inadequate despite statistical anomalies. The assessment of quality in the context of the subsequent technical clarification is carried out by IQTIG with the support of expert commissions. The results for this indicator and the assessment of quality are forwarded to the Land authorities responsible for hospital planning, to the Land associations of health insurance funds and to the substitute health insurance funds. More detailed information on the quality indicators relevant to planning can be found at the following link, https://www.iqtig.org/qs-instrumente/planungsrelevante-qualitaetsindikatoren/. The reference range indicates in which range the results of an indicator are assessed as inconspicuous. A facility with a result outside the reference range is initially mathematically conspicuous: this usually entails an analysis in the Structured Dialogue. It should be noted that an indicator result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation may also be attributable, for example, to faulty documentation or to individual cases. Quality is assessed within the framework of the structured dialogue with the facilities. The results of this quality indicator are only comparable with the previous year's results to a limited extent due to adjustments in the QA filter. More information on the adjustments made can be found in the description of the quality indicators under the following link, https://iqtig.org/qs-verfahren/.

Code ID	50719
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	31
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	3,35
Target range (reference range)	<= 5,00 %
Confidence interval nationwide (%)	2,90 - 3,87
Hospital confidence interval (%)	0,00 - 11,03
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 computationally conspicuous, 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. The results of this quality indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. 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	51847
Result (%)	99,44
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	178
Events observed	177
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	96,99
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	96,79 - 97,18
Hospital confidence interval (%)	96,89 - 99,90
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 computationally conspicuous, 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	51370
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	eingeschränkt/nicht vergleichbar
National result (%)	1,92
Target range (reference range)	<= 7,69 % (95. Perzentil)
Confidence interval nationwide (%)	1,80 - 2,04
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 If operations are often performed within the first 7 days after diagnosis, this could a. indicate that the possibility of self-information, a second opinion, medical education and the involvement of patients in necessary decisions could not be fully exhausted in time. 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 computationally conspicuous, 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	60659
Result (%)	9,26
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	270
Events observed	25
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	10,66
Target range (reference range)	<= 20,77 % (95. Perzentil)
Confidence interval nationwide (%)	10,41 - 10,91
Hospital confidence interval (%)	6,35 - 13,31
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 results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus sets a benchmark for the assessment of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to faulty documentation, medical specificity of the patient collective or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the comments procedure. More information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	211800
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	293
Events observed	293
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	99,48
Target range (reference range)	>= 97,82 % (5. Perzentil)
Confidence interval nationwide (%)	99,42 - 99,54
Hospital confidence interval (%)	98,71 - 100,00
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 results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.