Overall result forecast presentation:	yes
Quantity performed reporting year:	536
Quantity forecast year:	616
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
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

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

Number	Group
51	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*
51	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
51	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
  Special requirements for the selection of persons
  Note on the measure
  Ein erweitertes Führungszeugnis wird von allen neuen Mitarbeitenden jeglicher Berufsgruppen und Dienstarten eingefordert.
  Other aspects of prevention
  Note on the measure
  Es befinden sich Aushänge mit Notfalltelefonkontakten in den sanitären Räumlichkeiten für Frauen. Wir verfügen ferner in unserm Haus über eine kollegiale Beratung für berufliche Extremsituationen in Form der betrieblichen Ansprechpartner (BAP), die jederzeit erreichbar sind.
  Training of employees
  Note on the measure
  Die Mitarbeitenden haben über die Innerbetriebliche Fort- und Weiterbildung die Möglichkeit an Schulungen zum Thema teilzunehmen.
  Information gathering on the topic
  Note on the measure
  Im Intranet der KLW wird Informationsmaterial zur Thematik veröffentlicht und Veranstaltungen des BAP (Betriebliche Ansprechpartner) beworben.
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Es liegt ein Schutzkonzept vor.
  
  Last review of the measure
  15.08.2024 20:00:37
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Es liegt eine Dienstvereinbarung vor.
  
  Last review of the measure
  08.04.2013 20:00:37
  Other information on recognition
  Note on the measure
  Sowohl im Rahmen der Prävention als auch Intervention besteht eine enge Zusammenarbeit mit den LWL Kliniken und externen Beratungsstellen.

Ein erweitertes Führungszeugnis wird von allen neuen Mitarbeitenden jeglicher Berufsgruppen und Dienstarten eingefordert.

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

Verfahrensanweisung

27.02.2024

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)

Website zum Qualitäts- und Risikomanagement im Intranet (SharePoint) mit allen dokumentierten Verfahren für alle Mitarbeitenden des Hauses einsehbar (z.B. QM-Handbücher, Leitlinien, Standards, Checklisten, Arbeits- und Verfahrensanweisungen sowie aktuelle Mitarbeiterinformationen).

09.10.2025

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

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)

Measures to minimise medication errors

Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)

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

Wir bieten im klinischen Bereich die Möglichkeit einer Promotion an. Bei Interesse wenden Sie sich bitte an die jeweilige Chefärztin, den jeweiligen Chefarzt oder den Fachbereichsleiter.

FL08 - Editors of scientific journals/textbooks

Explanation

Chefärzte und Oberärzte publizieren in diversen Fachzeitschriften.

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Für den Fachbereich spezielle Wirbelsäulen- und Neurochirurgie.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Allgemeinchirurgie; Anästhesiologie; Gastroenterologie; Geriatrie; Kardiologie; Neurochirurgie; Notfall- u. Intensivmedizin; Orthopädie und Unfallchirurgie; Pneumologie; Schmerzmedizin

Training

Training in other healing professions

HB19 - Nursing professionals

Comment

Die Canisius Campus Dortmund gGmbH ist eine staatlich anerkannte Pflegeschule und gehört ebenfalls zur Kath. St. Paulus GmbH. Sie bildet für die Krankenhäuser der Kath. St. Paulus Gesellschaft, dazu gehört auch das St. Christophorus Krankenhaus, Fachpersonal in der Pflege aus.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Ausbildung von Physiotherapeuten in Kooperation mit der FHS "Gesundheit" in Bochum; Kooperation mit der"ganzheitlichorientierte Physiotherapieschule Bergkamen GmbH"(GPS).

HB07 - Surgical technical assistant (m/f)