Klinikum Lüdenscheid, Märkische Kliniken GmbH

Quality results

Treatment sector: Carotid artery narrowing: restoration of adequate blood flow through surgery (KAROTIS)

Information about this treatment area (documentation)

Designation	Karotis-Revaskularisation
Shortcut	10/2
Number of cases	33
Documentation rate	100 %

Summary result:

In 7 of 7 quality characteristics, the quality objective was achieved.
No assessment is possible for one quality characteristic

Number of patients treated: 33

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

The operation was appropriate for medical reasons for patients who had a carotid artery narrowed by at least 60% and no complaints

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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The operation was appropriate for medical reasons for patients who had a carotid artery narrowed by at least 50% and complaints

Hospital: 87,50 %

Target area: at least 95,00 %

Quality objective achieved
Why?

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Patients who had a carotid artery narrowed by at least 60% and no complaints suffered a stroke or died during the operation. During the operation the narrowed coronary vessel was bridged at the same time

Hospital: Data protection

No information due to data protection

Sentinel Event

Assessment not possible

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Ratio of the actual number to the previously expected number of patients who suffered a stroke or died during the operation (the individual risks of the patients were taken into account)

Hospital: 2,72

Target area: at most 2,79

Quality objective achieved

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Ratio of the actual number to the previously expected number of patients who suffered a severe stroke or died after the operation (the individual risks of the patients were taken into account)

Hospital: 4,83

as rarely as possible

Evaluation is not available

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Patients who had a carotid artery narrowed by at least 60% and no complaints and who suffered a stroke or died during the operation (patients whose carotid artery on the opposite side of the body was narrowed by more than 75% are not considered)

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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Patients who had a carotid artery narrowed by at least 60% and no complaints and who suffered a stroke or died during the operation and in whom the carotid artery on the opposite side of the body was narrowed by more than 75%

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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Patients who had a carotid artery narrowed by at least 50% and complaints and who suffered a stroke or died during the operation

Hospital: 0,00 %

as rarely as possible

Evaluation is not available

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The intervention was appropriate for medical reasons (related to procedures performed with a tube (catheter)) for patients who had a carotid artery narrowed by at least 50% and no complaints

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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There was a medically appropriate reason for the intervention (related to procedures performed by means of a tube (catheter)) for patients who had a carotid artery narrowed by at least 50% and complaints

Hospital: 100,00 %

Target area: at least 95,00 %

Quality objective achieved

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Ratio of the actual number to the previously expected number of patients who suffered a stroke or died during the procedure (based on procedures performed using a tube (catheter) - individual risks of the patients were taken into account)

Hospital: 2,86

Target area: at most 2,81

Quality objective achieved
Why?

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Ratio of the actual number to the previously expected number of patients who suffered a severe stroke or died in connection with the procedure (related to procedures performed using a tube (catheter) - individual risks of the patients were taken into account)

Hospital: 2,21

as rarely as possible

Evaluation is not available

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Patients who had a carotid artery narrowed by at least 60% and no complaints and who suffered a stroke or died during the procedure (with reference to procedures performed by means of a tube (catheter) - patients in whom the carotid artery on the opposite side of the body was narrowed by more than 75% are not included)

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

Click here

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

Click here

Patients who had a carotid artery narrowed by at least 50% and complaints and who suffered a stroke or died during the operation (related to procedures performed by means of a tube (catheter))

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

Click here

So rarely has no specialist follow-up been carried out on patients with new neurological complaints

Hospital: Data protection

No information due to data protection

Target area: at most 5,00 %

Quality objective achieved

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Code ID	603
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	6
Events observed	6
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 (%)	99,25
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	99,08 - 99,38
Hospital confidence interval (%)	60,97 - 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 noticeable in terms of calculation, 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 with 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	604
Result (%)	87,50
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to have been achieved. For more information, see All information (click here) at the bottom under Comment or Technical note. (H99)
Population	8
Events observed	7
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 (%)	99,69
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	99,55 - 99,79
Hospital confidence interval (%)	52,91 - 97,76
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	rechnerisch_auffällig: das Lenkungsgremium folgt der Empfehlung der Fachkommission, kein Stellungnahmeverfahren einzuleiten
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 noticeable in terms of calculation, 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 with 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	52240
Result (%)	Data protection
Evaluation through structured dialogue	An evaluation is not possible because there were no patients in the hospital to whom this quality criterion could be applied. (N01)
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 (%)	5,07
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	2,48 - 10,10
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 Zu beachten ist, dass dieses rechnerische Ergebnis unter Umständen nicht ausschließlich durch die jeweilige Einrichtung beeinflusst wird. So können z.B. die Erkrankungsschwere oder Begleiterkrankungen der Patientinnen und Patienten einen Einfluss auf das Ergebnis haben. Der Referenzbereich gibt an, in welchem Bereich die Ergebnisse eines Indikators als unauffällig bewertet werden. Eine Einrichtung mit einem Ergebnis außerhalb des Referenzbereichs ist zunächst rechnerisch auffällig, dies zieht üblicherweise eine Analyse im Strukturierten Dialog nach sich. Es ist zu beachten, dass ein Indikatorergebnis außerhalb des Referenzbereichs nicht gleichbedeutend ist mit einer mangelnden Qualität der Einrichtung in dem hier betrachteten Qualitätsaspekt. Die Abweichung kann auch z.B. auf eine fehlerhafte Dokumentation oder auf Einzelfälle zurückführbar sein. Die Bewertung der Qualität wird im Rahmen des Strukturierten Dialogs mit den Einrichtungen vorgenommen. Die Ergebnisse dieses Qualitätsindikators sind aufgrund von Anpassungen der Rechenregel des Indikators nur eingeschränkt mit den Vorjahresergebnissen vergleichbar. Nähere Informationen zu den vorgenommenen Anpassungen können der Beschreibung der Qualitätsindikatoren unter folgendem Link entnommen werden: https://iqtig.org/qs-verfahren/.

Code ID	11704
Result	2,72
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	0,98
Target range (reference range)	<= 2,79 (95. Perzentil)
Confidence interval nationwide	0,90 - 1,07
Hospital confidence interval	0,48 - 11,99
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 This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. 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 noticeable in terms of calculation, 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 with 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	11724
Result	4,83
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	1,05
Target range (reference range)
Confidence interval nationwide	0,94 - 1,16
Hospital confidence interval	0,86 - 21,30
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. This transparency indicator is a risk-adjusted transparency indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, as there are patient-related risk factors (such as comorbidities) that systematically influence the result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the result of the transparency index of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of the transparency indicators and which can be practically documented. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51859
Result (%)	0,00
Evaluation through structured dialogue
Population	8
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	3,13
Target range (reference range)
Confidence interval nationwide (%)	2,78 - 3,53
Hospital confidence interval (%)	0,00 - 32,44
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the severity of illness or concomitant illnesses of the patients have an influence on the result. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51437
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	4
Events observed	4
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 (%)	97,95
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	97,39 - 98,39
Hospital confidence interval (%)	51,01 - 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 noticeable in terms of calculation, 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 with 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	51443
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	9
Events observed	9
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 (%)	99,34
Target range (reference range)	>= 95,00 %
Confidence interval nationwide (%)	98,92 - 99,60
Hospital confidence interval (%)	70,09 - 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 noticeable in terms of calculation, 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 with 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	51873
Result	2,86
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to be achieved, because the deviation can be traced back to one or more well-founded individual cases after examination by specialist committees. (U62)
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	1,01
Target range (reference range)	<= 2,81 (95. Perzentil)
Confidence interval nationwide	0,91 - 1,12
Hospital confidence interval	0,80 - 8,35
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 This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. 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 noticeable in terms of calculation, 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 with 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	51865
Result	2,21
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	0,94
Target range (reference range)
Confidence interval nationwide	0,83 - 1,06
Hospital confidence interval	0,39 - 10,14
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. This transparency indicator is a risk-adjusted transparency indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, as there are patient-related risk factors (such as comorbidities) that systematically influence the result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the result of the transparency index of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of the transparency indicators and which can be practically documented. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51445
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	2,18
Target range (reference range)
Confidence interval nationwide (%)	1,69 - 2,82
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the severity of illness or concomitant illnesses of the patients have an influence on the result. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51448
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	4,14
Target range (reference range)
Confidence interval nationwide (%)	2,72 - 6,25
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the severity of illness or concomitant illnesses of the patients have an influence on the result. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51860
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	4,61
Target range (reference range)
Confidence interval nationwide (%)	3,82 - 5,55
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	TKez
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 This is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the care process and thus increase transparency and the information content. Further information on the key figure concept can be found in the following link: https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the severity of illness or concomitant illnesses of the patients have an influence on the result. The results of this transparency indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule for the transparency indicator. Further information on the adjustments made can be found in the description of the respective transparency key figure at the following link: https://iqtig.org/qs-verfahren/.

Code ID	161800
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 (%)	3,50
Target range (reference range)	<= 5,00 %
Confidence interval nationwide (%)	2,34 - 5,20
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 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.