Overall result forecast presentation:	yes
Quantity performed reporting year:	0
Quantity forecast year:	135
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	58
Quantity forecast year:	66
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	12
Quantity forecast year:	15
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:	43
Quantity forecast year:	38
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
206	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*
128	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
120	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
  Vorlage eines erweiterten Führungszeugnisses (§30a Abs. 2BZRG) vor Arbeitsaufnahme, sofern es sich um kinder- und jugendnahe Tätigkeiten handelt.
  Information gathering on the topic
  Note on the measure
  Kinderschutzkonzept, das das Erkennen und Intervention bei Verdacht auf Kindeswohlgefährdung bei Aufnahme thematisiert vorhanden; Information über Hilfsangebote (Jugendamt, Polizeidienststellen, lokale Hilfsangebote)
  Training of employees
  Note on the measure
  Interne Fortbildung "Kindeswohlgefährdung erkennen und handeln" wird angeboten - die Fortbildung richtet sich an Mitglieder der Kinderschutzgruppe, Pflegende, ärztliche Mitarbeitende und Psycholog*innen, Lehrkräfte an der Schule für Kranke, Kliniksozialarbeiter*innen und Hebammen
  Age-appropriate complaint options
  Note on the measure
  Es existieren verschiedene Beschwerdestellen und -wege: zentrales Beschwerdetelefon, zentales Online-Formular, dezentrale Beschwerdemanager*innen und dezentrale Patientenfürsprecher*innen an allen Standorten, diese in Zusammenarbeit mit dem Gesundheitsladen München e.V.
  Code of conduct with rules for treating children and young people with respect
  Education
  Note on the measure
  Vorstellung Kinderschutzkonzept in der Einarbeitungszeit; Sensibilisierung und Vorgehensweise bei V.a. (sexuelle) Gewalt wird vorgestellt
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Bei Verdacht auf Kindeswohlgefährdung bei Aufnahme: Interventionsplan und Ansprechpartner*innen liegen vor
  
  Last review of the measure
  17.01.2023 16:08:31
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Bei Bedarf kann Supervision erfolgen
  
  Last review of the measure
  17.01.2023 16:08:31

Vorlage eines erweiterten Führungszeugnisses (§30a Abs. 2BZRG) vor Arbeitsaufnahme, sofern es sich um kinder- und jugendnahe Tätigkeiten handelt.

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

Name of the working group: AG Arzneimitteltherapiesicherheit im Risikoausschuss der MüK

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)

DA Umgang mit Arzneimittel

15.02.2018

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
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

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)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)
s. o.

Measures to minimise medication errors

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

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
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

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

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Training

Training in other healing professions

HB17 - Auxiliary nurse (m/f)

Comment

HB20 - Nursing professional B. Sc.

Comment

Theorie an der Hochschule, ein Teil Praxis in der München Klinik

HB19 - Nursing professionals

Comment

HB07 - Surgical technical assistant (m/f)

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 9
- Additional staff: 19
- Explanations: 0,2 VK davon sind überwiegend im Einsatz für das Thema Arzneimittelinformation einschließlich AMTS
- Nursing staff regulation

Service contact persons

Patient advocates

Anni Beck und Walburga Stanglmaier

Patientenfürsprecher

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2663
Mail: ed.kinilk-nehcneum@bk.ehcarpsreufnetneitap

Anni Beck und Friederike Bülter

Patientenfürsprecher

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2663
Mail: ed.kinilk-nehcneum@bk.ehcarpsreufnetneitap

Customer feedback management

Jana Dietzmann

Qualitätsmanagerin

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2609
Mail: ed.kinilk-nehcneum@bk.tnemeganamedrewhcseb

Quality management

Anke Wobbe

Qualitätsmanagement

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2219
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Jana Dietzmann

Qualitätsmanagement

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2219
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Hygiene officer

Dr. med. Benjamin Würstl

Leitender Arzt Klinikhygiene und Infektionsprävention

Englschalkinger Str. 77
81925 München

Phone: --

Dr. med. Benjamin Würstl, seit 07/2022 Dr. Patrick Rämer

Leitender Arzt Klinikhygiene und Infektionsprävention

Englschalkinger Str. 77
81925 München

Phone: --

Dr. med. Patrick Rämer (bis 30.06.2022 Benjamin Würstl)

Leitender Arzt Klinikhygiene und Infektionsprävention

Englschalkinger Str. 77
81925 München

Phone: 089 -3068-2503

Responsible for drug therapy

Dr. Steffen Amann

Chefapotheker

Englschalkinger Str. 77
81925 München

Phone: 089 -3068-2322
Mail: ed.kinilk-nehcneum@ekehtopa

Accessibility Officer

Gisela Bürkmayr

Leitung Sozialdienst

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2417
Mail: ed.kinilk-nehcneum@ryamkreub.alesig

Company

General contact details of the hospital

Englschalkinger Str. 77
81925 München

Phone: 089-9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Nursing service management

Astrid Göttlicher

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Rosa Maria Stahl (ab 01.03.2023 / ab 01.09.2023 gemeinsam mit Astrid Göttlicher)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Head of administration

Dr. med. Tim-Oliver Guderjahn

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Phil Hill (ab 01.02.2023)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Dr. med. Tim-Oliver Guderjahn (bis 31.01.2023)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Responsible for the quality report in the hospital management

Astrid Göttlicher, Dr. med. Tim-Oliver Guderjahn, Dr. med. Christian Unzicker

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Astrid Göttlicher, Rosa Maria Stahl Dr. med. Lydia Hekeler, Phil Hill

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Medical management

Dr. med. Christian Unzicker

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Dr. med. Christian Unzicker (bis 31.03.2023)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Dr. med. Lydia Hekeler (ab. 01.11.2023)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Dr. med. Andreas Schöne (01.05.2023 bis 31.10.2023)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Regional care obligation for psychiatry?

IK number

IK: 260913480

Location number

Location number: 771080000

Old location number: 771080000

Hospital portrait for download