Overall result forecast presentation:	yes
Quantity performed reporting year:	590
Quantity forecast year:	723
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:	28
Quantity forecast year:	34
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:	20
Quantity forecast year:	26
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
66	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*
8	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
8	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
No care for children and young people

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

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

Qualitätsmanagementhandbuch im Intranet der Gruppe

13.07.2023

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)

Qualitätsmanagementhandbuch im Intranet der Gruppe

13.07.2023

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)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

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
Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen
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

FL03 - Student training (clinical traineeship / internship year)

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

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

Explanation

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

FL09 - Doctoral supervision

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Training

Training in other healing professions

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

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Die St. Elisabeth Gruppe verfügt über eine gruppeneigene Akademie der Physiotherapie und Ergotherapie.

HB06 - Occupational therapist (m/f)

Comment

Die St. Elisabeth Gruppe verfügt über eine gruppeneigene Akademie der Physiotherapie und Ergotherapie.

HB07 - Surgical technical assistant (m/f)

Comment

HB10 - Midwife (m/f)

Comment

HB09 - Speech therapist (m/f)

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

HB19 - Nursing professionals

Comment

HB02 - Health and paediatric nurse (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

HB21 - Geriatric nurse (m/f)

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 8
- Additional staff: 9
- Nursing staff regulation

Service contact persons

Patient advocates

Frau Hedi Schmiedners

Patientenfürsprecherin

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-0
Mail: ed.latipsohanna@rehcerpsreufnetneitap

Customer feedback management

Frau Sarah Heintze

Assistentin zentrale Pflegedienstleitung

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2380
Mail: ed.eppurghtebasile@eztnieh.haras

Quality management

Frau Cordula Schütze

Qualitätsmanagement St. Anna Hospital

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2313
Mail: ed.eppurghtebasile@ezteuhcs.aludroc

Frau Cordula Schütze

Qualitätsmanagement St. Anna Hospital

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2313
Mail: ed.eppurghtebasile@ezteuhcs.aludroc

Hygiene officer

Dr. med. Martin Komp

Oberarzt Orthopädie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-5001
Mail: ed.eppurghtebasile@pmok.nitram

Responsible for drug therapy

Dr. Frank Seifert

Apothekenleiter

Hospitalstr. 19
44649 Herne

Phone: 02325 -592-801
Mail: ed.eppurghtebasile@trefieS.knarF

Accessibility Officer

Elke Untersberger

Schwerbehindertenvertretung

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-5476
Mail: ed.eppurghtebasile@regrebsretnU.eklE

Company

General contact details of the hospital

Hospitalstr. 19
44649 Herne

Phone: 02325-986-0
Fax: 02325-986-2649
Mail: ed.latipsohanna@ofni

Nursing service management

Marion Schmitz

Gesamtpflegedienstleitung St. Elisabeth Gruppe

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2380
Mail: ed.eppurghtebasile@1ztimhcs.noiram

Andreas Kowalski

Pflegerische Leitung St. Anna Hospital

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2360
Mail: ed.eppurghtebasile@ikslawok.saerdna

Head of administration

Dr. jur. Sabine Edlinger

Geschäftsführerin St. Elisabeth Gruppe

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@gnurheufstfeahcseg

Simone Lauer

Geschäftsführerin St. Elisabeth Gruppe

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@gnurheufstfeahcseg

Dr. jur. Sabine Edlinger

Geschäftsführerin St. Elisabeth Gruppe

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@gnurheufstfeahcseg

Simone Lauer

Geschäftsführerin St. Elisabeth Gruppe

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@gnurheufstfeahcseg

Daniel Matosin

Kaufmännischer Leiter (seit 01/2023)

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@nisotam.leinad

Responsible for the quality report in the hospital management

Dr. jur. Sabine Edlinger

Geschäftsführerin St. Elisabeth Gruppe GmbH

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2610
Mail: ed.eppurghtebasile@gnurheufstfeahcseg

Medical management

Prof. Dr. med. Klaus Kisters

Chefarzt Medizinische Klinik I - Allgemeine Innere Medizin (bis 12/2022)

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2101
Mail: ed.latipsohanna@1kinilkdem

Dr. med. Roderich Heikenfeld

Chefarzt Zentrum für Orthopädie und Unfallchirurgie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2020
Mail: ed.eppurghtebasile@uoz

Dr. med. Oliver Meyer

Chefarzt Zentrum für Orthopädie und Unfallchirurgie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2020
Mail: ed.eppurghtebasile@uoz

PD Dr. med. Sebastian Rütten

Chefarzt Zentrum für Orthopädie und Unfallchirurgie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2020
Mail: ed.eppurghtebasile@uoz

Dr. med. Nurettin Albayrak

Chefarzt Klinik für Allgemein- und Viszeralchirurgie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2051
Mail: ed.latipsohanna@eigrurihc

Prof. Dr. med. Klaus Kisters

Chefarzt Medizinische Klinik I - Allgemeine Innere Medizin (bis 12/2022)

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2101
Mail: ed.latipsohanna@1kinilkdem

Dr. med. Viktor Rempel

Chefarzt Medizinische Klinik 2 - Schwerpunkt Gastroenterologie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2151
Mail: ed.latipsohanna@eigoloretneortsag

Valentin Menke

Chefarzt Klinik für Frauenheilkunde und Geburtshilfe / Klinik für Brustchirurgie

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2301
Mail: ed.latipsohanna@eigolokeanyg

Dr. med. Kornelius Bott

Chefarzt Klinik für Anästhesie und Intensivmedizin

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-5308
Mail: ed.latipsohanna@eisehtseana

Dr. med. Panagiota Zgoura

Chefärztin Medizinische Klinik I - Allgemeine Innere Medizin (seit 01/2023)

Hospitalstr. 19
44649 Herne

Phone: 02325 -986-2101
Mail: ed.latipsohanna@1kinilkdem

Regional care obligation for psychiatry?

IK number

IK: 260590468

Location number

Location number: 772418000

Old location number: 772418000