Overall result forecast presentation:	yes
Quantity performed reporting year:	233
Quantity forecast year:	253
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 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

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

Number	Group
17	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*
15	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
15	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
  
  Education
  Other aspects of prevention
  Note on the measure
  Meldebogen Jugendamt bei Verdacht und Schweigepflichtsentbindung
  Information gathering on the topic
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  19.12.2022 16:07:57

Meldebogen Jugendamt bei Verdacht und Schweigepflichtsentbindung

Commentary on the protection concept

Gemäß § 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 § 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

Use of standardised forms for drug medical history

Geregelt in der QM-Dokumentation

08.09.2022

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)

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Möglichkeit der Teilnahme am einrichtungsinternen Fehlermeldesystem

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

Research & teaching

Job

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

Training

Training in other healing professions

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

Comment

nur praktischer Teil

HB19 - Nursing professionals

Comment

HB17 - Auxiliary nurse (m/f)

Comment

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

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

HB07 - Surgical technical assistant (m/f)

Comment

HB13 - Medical technical assistant for functional diagnostics (MTAF) (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Explanations: Es besteht ein Vertrag mit einer externen Apotheke. Die Mitarbeiterzuordnung zum Auftragsvolumen wird in Verantwortung seitens der Apotheke geregelt.
- Nursing staff regulation

Service contact persons

Patient advocates

Brigitte Bauer

Patientenfürsprecherin / Stationssekretärin

Laurentiusweg 1
84048 Mainburg

Phone: 08751 -78-1085
Mail: moc.znaillakinilk@rehcerpsnetneitap.bm

Customer feedback management

Renate Emmer

Beschwerdemanagement

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-2150
Mail: moc.znaillakinilk@nedrewhcseb.kti

Renate Emmer und ab 01.03.2023 Denise Dompert

Beschwerdemanagement

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -78-1001
Mail: moc.znaillakinilk@nedrewhcseb.kti

Quality management

Dr. Michael Wagner

Zentralbereichsleitung Medizincontrolling / Qualitätsmanagement

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1056
Mail: moc.znaillakinilk@rengaw.leahcim

Monika Nowacka

Leitung Qualitätsmanagement

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1076
Mail: moc.znaillakinilk@akcawon.akinom

Hygiene officer

Dr. med. Hansjörg Aust

Ärztlicher Direktor / Chefarzt Anästhesie

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1801
Mail: moc.znaillakinilk@eisehtseana.tairaterkes.fp

Peter Jezek

Ärztlicher Direktor / Chefarzt Gynäkologie

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-2311
Mail: moc.znaillakinilk@kezej.retep

Responsible for drug therapy

Dr. med. Hansjörg Aust

Ärztlicher Direktor / Chefarzt Anästhesie

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1801
Mail: moc.znaillakinilk@eisehtseana.tairaterkes.fp

Dr. med. Joachim Reisner

stellv. ärztliche Leitung Intensiv

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1846
Mail: moc.znaillakinilk@rensier.mihcaoj

Accessibility Officer

Karin Post

Gesundheits- und KrankenpflegerIn

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1850
Mail: moc.znaillakinilk@tsop.nirak

Company

General contact details of the hospital

Laurentiusweg 1
84048 Mainburg

Phone: 08441-79-0
Mail: moc.znaillakinilk@tairaterkes.fp

Nursing service management

Margarete Reiter

Pflegedirektorin

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1079
Mail: moc.znaillakinilk@retieR.eteragraM

ab 01.07.2022 Sandra Bär

Pflegedirektorin

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1004
Mail: moc.znaillakinilk@reab.ardnas

Head of administration

Janine Kau

Verwaltungsleitung

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1001
Mail: moc.znaillakinilk@uak.eninaj

Responsible for the quality report in the hospital management

ab 10.11.2021 Peter Lenz (Geschäftsführer Doppelspitze) Ingo Goldammer

Geschäftsführer

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1001
Mail: moc.znaillakinilk@tairaterkes.fp

Christian Degen

Geschäftsführer

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1001
Mail: moc.znaillakinilk@tairaterkes.fp

Medical management

Dr. med. Hansjörg Aust

Ärztlicher Direktor / Chefarzt Anästhesie

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-1801
Mail: moc.znaillakinilk@eisehtseana.tairaterkes.fp

ab 01.07.2022 Peter Jezek

Ärztlicher Direktor /Chefarzt Gynäkologie und Geburtshilfe

Laurentiusweg 1
84048 Mainburg

Phone: 08441 -79-2336
Mail: moc.znaillakinilk@kinilkneuarf.fp

Dr. med. Otto Dietl

Co-Chefarzt Chirurgie- und Viszeralchirurgie / stellv. Ärztlicher Direktor

Laurentiusweg 1
84048 Mainburg

Phone: 08751 -78-1180
Mail: moc.znaillakinilk@lteid.otto

Regional care obligation for psychiatry?

IK number

IK: 260913117

Location number

Location number: 772984000

Old location number: 772984000