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Klinikum Traunstein

Cuno-Niggl-Str. 3
83278 Traunstein

Phone: 0861-705-0
Mail: ed.bos-nekinilk@st.ofni ed.bos-nekinilk@st.ofni ed.bos-nekinilk@st.ofni

http://www.kliniken-suedostbayern.de/de/leistungss...

Basic information

Number of beds: 548
Number of specialist departments: 24

Number of inpatient cases: 26.565
Number of partial inpatient cases: 2.589
Number of outpatient cases: 42.328

Hospital owners: Landkreis Traunstein
Type of provider: öffentlich

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

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

Liver transplantation (including partial liver donation)

Quantity performed	28
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	29
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	243
Exception?	No exception

Thoracic surgical treatment of lung cancer in adults

Quantity performed	50
Exception?	No exception

Minimum quantities forecast

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	28
Quantity forecast year:	23
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:	243
Quantity forecast year:	248
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:	29
Quantity forecast year:	37
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
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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

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
223	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*
162	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
148	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
  Age-appropriate complaint options
  Note on the measure
  Telefon, E-Mail, Lob und Beschwerderückmeldung über Briefkästen auf jeder Station
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Verfahrensanweisung zu den Schutzkonzepten für Kinder und Jugendliche KSOB mit Präventionskonzept
  
  Last review of the measure
  17.03.2023 20:24:07
  Special requirements for the selection of persons
  Note on the measure
  Führungszeugnis von allen Mitarbeitern, die Kontakt zu Kinder und Jugendlichen haben
- Intervention
  Other aspects of intervention
  Note on the measure
  Meldeverfahren über Meldebögen in Abstimmung mit den Jugendämtern der Landkreise BGL und TS
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Interventionsplan lt. Kinderschutz-Leitlinie unter Einbindung der Kinderschutzgruppe KSOB
  
  Last review of the measure
  17.03.2023 20:24:07
- Review
  Other information on recognition
  Note on the measure
  Kinderschutzgruppe KSOB / Qualitätszirkel Schutzkonzepte KSOB
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Handlungsempfehlungen in der Verfahrensanweisung Schutzkonzepte und den mitgeltenden Unterlagen enthalten
  
  Last review of the measure
  24.04.2023 21:24:07

Meldeverfahren über Meldebögen in Abstimmung mit den Jugendämtern der Landkreise BGL und TS

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

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)

VA OP-Checkliste Team Time Out CIRS (PaSIS) Patientenarmband präoperative Checkliste M&M-Konferenzen Fallkonferenzen Risikoaudits

05.06.2025

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

Rezepturanweisung für Standardtherapien (z.B. Antibiotika) in Karteikästen hinterlegt.

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

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

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL09 - Doctoral supervision

Explanation

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

Explanation

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

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

Explanation

Training

Training in other healing professions

HB10 - Midwife (m/f)

Comment

Praktische Ausbildung u. Praktika im Hebammen-Studium

HB19 - Nursing professionals

Comment

am Bildungszentrum für Gesundheitsberufe der Kliniken Südostbayern AG in Traunstein, Vertiefung Pädiatrie möglich

HB17 - Auxiliary nurse (m/f)

Comment

am Bildungszentrum für Gesundheitsberufe der Kliniken Südostbayern AG in Traunstein

HB15 - Anaesthesia technical assistant (m/f)

Comment

am Bildungszentrum für Gesundheitsberufe der Kliniken Südostbayern AG in Traunstein

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

Praktika

HB07 - Surgical technical assistant (m/f)

Comment

am Bildungszentrum für Gesundheitsberufe der Kliniken Südostbayern AG in Traunstein

HB20 - Nursing professional B. Sc.

Comment

am Bildungszentrum für Gesundheitsberufe der Kliniken Südostbayern AG in Traunstein

HB02 - Health and paediatric nurse (m/f)

Comment

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

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Praktika vor Ort in Kooperation mit Schulen für Physiotherapie

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 7
- Additional staff: 10
- Explanations: Mit dem angegebenen pharmazeutischen Personal wird die Versorgung der trägereigenen Kliniken (ca. 1.300 Betten) und weitere Fremdversorgung gewährleistet. Das in Teilzeit arbeitende Personal wurde in Vollkräfte umgerechnet und dabei leicht auf- bzw. abgerundet
- Nursing staff regulation