Immanuel Klinikum Bernau Herzzentrum Brandenburg

Quality results

Treatment sector: Operation on the mitral valve (valve between the left atrium and the left ventricle) with the chest open (KCHK-MK-CHIR)

Information about this treatment area (documentation)

Designation	Zählleistungsbereich Offen-chirurgische Mitralklappeneingriffe
Shortcut	HCH_MK_CHIR
Counts to the treatment area	HCH
Number of cases	83
Documentation rate	97.59 %

Summary result:

In 2 of 3 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 83

Quality objective achieved
Quality objective not achieved

The results in detail

Hide national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

This is how rarely serious complications occurred during the hospital stay due to the operation

National result: 12,20 %
Hospital: 15,91 %

Target area: at most 23,77 %

Quality objective achieved

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This is how often the planned result of the intervention was achieved

National result: 97,18 %
Hospital: 97,73 %

Target area: at least 89,14 %

Quality objective achieved

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How rarely patients died in hospital as a result of urgently planned mitral valve surgery

National result: 3,12 %
Hospital: 20,51 %

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of patients who died in hospital

National result: 0,94
Hospital: 3,93

Target area: at most 2,69

Quality objective not achieved

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Code ID	402002
Result (%)	15,91
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	44
Events observed	7
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result (%)	12,20
Target range (reference range)	<= 23,77 % (95. Perzentil)
Confidence interval nationwide (%)	11,34 - 13,12
Hospital confidence interval (%)	7,93 - 29,37
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 establishes a benchmark for the evaluation 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 incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	402006
Result (%)	97,73
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	44
Events observed	43
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	verbessert
National result (%)	97,18
Target range (reference range)	>= 89,14 % (5. Perzentil)
Confidence interval nationwide (%)	96,70 - 97,60
Hospital confidence interval (%)	88,19 - 99,60
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 establishes a benchmark for the evaluation 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 incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	402010
Result (%)	20,51
Evaluation through structured dialogue
Population	39
Events observed	8
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	3,12
Target range (reference range)
Confidence interval nationwide (%)	2,67 - 3,64
Hospital confidence interval (%)	10,78 - 35,53
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 Although key figures represent quality, their results do not enable a direct assessment of the quality of care (due to the lack of a reference range) and they are also not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the results of which are supplemented by the key figures (imputed and supplementary key figures). They therefore contribute to increasing the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for presenting the quality of care. Further information on key figures can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept/. Due to adjustments to the calculation rule or inclusion/exclusion criteria for the cases to be documented in the QA procedure, the quality result is only comparable with the previous year's results to a limited extent. Further information on the adjustments made can be found in the description of the quality indicators and key figures at the following link: https://iqtig.org/qs-verfahren/.

Code ID	402011
Result	3,93
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	44
Events observed	10
Anticipated events	2,55
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	unverändert
National result	0,94
Target range (reference range)	<= 2,69 (95. Perzentil)
Confidence interval nationwide	0,82 - 1,07
Hospital confidence interval	2,22 - 6,39
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 Risk adjustment aims to compensate for the different patient structure in different facilities. Ideally, this leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome, without it being possible to attribute responsibility for e.g. resulting more frequent complications to one facility. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution with many low-risk cases. More information on risk adjustment can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen. 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 establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. 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 incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.