St. Josefskrankenhaus Heidelberg GmbH

Quality results

Treatment sector: Obstetrics: care of mother and child shortly before, during and shortly after birth (PM-GEBH)

Information about this treatment area (documentation)

Designation	Geburtshilfe
Shortcut	16/1
Number of cases	495
Documentation rate	100 %

Summary result:

In 5 of 6 quality characteristics, the quality objective was achieved.
For 2 quality characteristics, no assessment is possible.

Number of patients treated: 495

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 it took longer than 20 minutes from the decision to have a caesarean section to the birth of the child

National result: 0,21 %
Hospital: Data protection

No information due to data protection

Sentinel Event

Quality objective achieved

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Ratio of actual to expected number of mothers with severe perineal laceration (grade IV)

National result: 0,89
Hospital: 0,00

Target area: at most 3,20

Quality objective achieved

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Ratio of actual to expected number of mothers with severe perineal laceration (grade IV) in spontaneous singleton births (i.e. with labour and in the cranial position)

National result: 0,85
Hospital: 0,00

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of mothers with severe perineal laceration (grade IV) in singleton births with forceps or a vacuum cup

National result: 0,95
Hospital: 0,00

as rarely as possible

Evaluation is not available

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This is how rarely caesarean deliveries of mature singletons and first-time mothers in spontaneous labour in the cranial position have been excecuted.

National result: 18,94 %
Hospital: 22,86 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean deliveries of mature singletons and first-time mothers without spontaneous labour in the cranial position have been excecuted.

National result: 45,90 %
Hospital: 49,44 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean births of mature singletons under spontaneous labour in the cranial position to mothers who had previously given birth to children have been excecuted.

National result: 3,88 %
Hospital: 5,50 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean births of mature singletons to mothers who had previously given birth without spontaneous labour in the cranial position have been excecuted.

National result: 21,45 %
Hospital: 29,63 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean births of mature singletons in cranial position to mothers who had previously had a caesarean section have been Excecuted

National result: 71,72 %
Hospital: 76,12 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean births of singletons to first-time mothers in breech presentation have been excecuted

National result: 93,01 %
Hospital: 100,00 %

as rarely as possible

Evaluation is not available

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This is how rarely caesarean births ofsingletons in breech presentation to mothers who had already given birth previously have been excecuted

National result: 86,60 %
Hospital: 100,00 %

as rarely as possible

Evaluation is not available

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This is how rarely multiples were born with caesarean births

National result: 75,59 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how rarely transverse singletons were born with caesarean births

National result: 100,00 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how rarely premature singletons were born in the cranial position with caesarean births

National result: 44,42 %
Hospital: 50,00 %

as rarely as possible

Evaluation is not available

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This is how rarely children were born in a level 2 perinatal center who should have been born in a higher level of care (level 1 perinatal center)

National result: 0,19 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how rarely children were born in a hospital with a perinatal focus, but who should have been born in a higher level of care (perinatal center level 1 or 2)

National result: 2,95 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how rarely children were born in a maternity clinic who should have been born in a higher level of care (perinatal focus, perinatal center level 1 or 2)

National result: 9,20 %
Hospital: 10,10 %

as rarely as possible

Evaluation is not available

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A paediatrician was present at the birth of the pre-term neonates

National result: 96,85 %
Hospital: Data protection

No information due to data protection

Target area: at least 90,00 %

Assessment not possible

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Acidification of the umbilical cord blood in newborns (premature babies, twin or other multiple births were not included: individual risks of mother and child were not taken into account)

National result: 0,23 %
Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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This is how often the mother was treated with cortisone for a threatened premature birth (hospital admission at least 2 days before birth)

National result: 96,80 %
Hospital: Data protection

No information due to data protection

Target area: at least 95,00 %

Assessment not possible

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To prevent infections, the mother was given antibiotics shortly before or shortly after a caesarean section

National result: 99,01 %
Hospital: 98,33 %

Target area: at least 90,00 %

Quality objective achieved

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Ratio of the actual number to the previously expected number of neonates with hyperacidity of the umbilical cord blood (based on neonates born between the 37th and 41st week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered)

National result: 0,97
Hospital: 1,96

as rarely as possible

Evaluation is not available

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This is how rarely newborns were in a critical state of health or died after birth (excluding premature babies)

National result: 1,01
Hospital: 2,16

Target area: at most 2,32

Quality objective achieved

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Ratio of actual to expected number of children who died at birth

National result: 1,18
Hospital: 0,00

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of newborns in a critical state of health (5 minutes after birth with an Apgar index below 5)

National result: 1,01
Hospital: 3,25

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of newborns of children with insufficient oxygen supply (metabolic acidosis with base excess below -16)

National result: 0,94
Hospital: 1,66

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of newborns of children with insufficient oxygen supply (blood pH below 7)

National result: 1,06
Hospital: 2,05

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of pre-term neonates with hyperacidity of the umbilical cord blood (based on pre-term neonates born between the 24th and 36th week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered) and 36th week of pregnancy inclusive - twin or other multiple births were not included - individual risks of mother and child were considered)

National result: 1,06
Hospital: 0,00

Target area: at most 4,40

Quality objective achieved

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Ratio of the actual number to the previously expected number of caesarean section births (individual risks of the patients were taken into account)

National result: 1,03
Hospital: 1,31

Target area: at most 1,26

Quality objective not achieved

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Code ID	1058
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	unverändert
National result (%)	0,21
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,13 - 0,32
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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	181800
Result	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	314
Events observed	0
Anticipated events	0,36
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	0,89
Target range (reference range)	<= 3,20 (95. Perzentil)
Confidence interval nationwide	0,82 - 0,97
Hospital confidence interval	0,00 - 10,65
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 structures 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 one facility being held responsible for, for example, more frequent complications as a result. With the help of risk adjustment, the quality outcome of, for example, a facility with many high-risk cases can be statistically compared more fairly with the quality outcome of a facility 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 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.

Code ID	181801_181800
Result	0,00
Evaluation through structured dialogue
Population	300
Events observed	0
Anticipated events	0,29
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	0,85
Target range (reference range)
Confidence interval nationwide	0,77 - 0,95
Hospital confidence interval	0,00 - 13,10
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS
Reference to other QA results	181800
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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. More detailed information on ratios can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	181802_181800
Result	0,00
Evaluation through structured dialogue
Population	14
Events observed	0
Anticipated events	0,07
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	0,95
Target range (reference range)
Confidence interval nationwide	0,83 - 1,08
Hospital confidence interval	0,00 - 45,22
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS
Reference to other QA results	181800
Sorting	2
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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. More detailed information on ratios can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182000_52249
Result (%)	22,86
Evaluation through structured dialogue
Population	140
Events observed	32
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	18,94
Target range (reference range)
Confidence interval nationwide (%)	18,76 - 19,12
Hospital confidence interval (%)	16,68 - 30,48
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182001_52249
Result (%)	49,44
Evaluation through structured dialogue
Population	89
Events observed	44
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	45,90
Target range (reference range)
Confidence interval nationwide (%)	45,59 - 46,21
Hospital confidence interval (%)	39,29 - 59,63
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	2
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182002_52249
Result (%)	5,50
Evaluation through structured dialogue
Population	109
Events observed	6
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	3,88
Target range (reference range)
Confidence interval nationwide (%)	3,79 - 3,97
Hospital confidence interval (%)	2,55 - 11,49
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	3
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182003_52249
Result (%)	29,63
Evaluation through structured dialogue
Population	54
Events observed	16
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	21,45
Target range (reference range)
Confidence interval nationwide (%)	21,13 - 21,78
Hospital confidence interval (%)	19,14 - 42,83
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	4
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182004_52249
Result (%)	76,12
Evaluation through structured dialogue
Population	67
Events observed	51
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	71,72
Target range (reference range)
Confidence interval nationwide (%)	71,44 - 71,99
Hospital confidence interval (%)	64,67 - 84,73
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	5
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182005_52249
Result (%)	100,00
Evaluation through structured dialogue
Population	14
Events observed	14
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	93,01
Target range (reference range)
Confidence interval nationwide (%)	92,64 - 93,36
Hospital confidence interval (%)	78,47 - 100,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	6
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182006_52249
Result (%)	100,00
Evaluation through structured dialogue
Population	10
Events observed	10
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	86,60
Target range (reference range)
Confidence interval nationwide (%)	85,95 - 87,21
Hospital confidence interval (%)	72,25 - 100,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	7
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182007_52249
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 (%)	75,59
Target range (reference range)
Confidence interval nationwide (%)	75,06 - 76,11
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	8
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182008_52249
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 (%)	100,00
Target range (reference range)
Confidence interval nationwide (%)	99,86 - 100,00
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	9
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182009_52249
Result (%)	50,00
Evaluation through structured dialogue
Population	10
Events observed	5
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	44,42
Target range (reference range)
Confidence interval nationwide (%)	43,91 - 44,93
Hospital confidence interval (%)	23,66 - 76,34
Reference infection	No
Type of value	EKez
Relation to the procedure	DeQS
Reference to other QA results	52249
Sorting	10
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	182010
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 (%)	0,19
Target range (reference range)
Confidence interval nationwide (%)	0,17 - 0,23
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 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	51803
Result	2,16
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	483
Events observed	7
Anticipated events	3,23
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,01
Target range (reference range)	<= 2,32
Confidence interval nationwide	0,98 - 1,03
Hospital confidence interval	1,10 - 3,89
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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 In diesem Qualitätsindex werden wesentliche Ergebnisparameter kombiniert, um den Zustand des Kindes einzuschätzen. Bei diesem Indikator handelt es sich um einen planungsrelevanten Qualitätsindikator. Standorte, bei denen sich eine statistische Auffälligkeit ergibt, werden vom IQTIG zur Abgabe einer Stellungnahme aufgefordert. Im Rahmen dieses Stellungnahmeverfahrens soll geklärt werden, ob es Gründe gibt, die darauf schließen lassen, dass trotz statistischer Auffälligkeit bei den Qualitätsergebnissen keine unzureichende Qualität vorliegt. Die Bewertung der Qualität im Rahmen der anschließenden fachlichen Klärung erfolgt mit der Unterstützung von Fachkommissionen durch das IQTIG. Die Ergebnisse zu diesem Indikator und die Bewertung der Qualität werden an die für die Krankenhausplanung zuständigen Landesbehörden, an die Landesverbände der Krankenkassen und die Ersatzkassen weitergeleitet. Nähere Informationen zu den planungsrelevanten Qualitätsindikatoren sind unter folgendem Link zu finden: https://www.iqtig.org/qs-instrumente/planungsrelevante-qualitaetsindikatoren/. Bei diesem Indikator handelt es sich um einen risikoadjustierten Indikator. Eine Risikoadjustierung gleicht die unterschiedliche Zusammensetzung der Patientenkollektive verschiedener Einrichtungen aus. Dies führt zu einem faireren Vergleich, da es patientenbezogene Risikofaktoren gibt (wie zum Beispiel Begleiterkrankungen), die das Indikatorergebnis systematisch beeinflussen, ohne dass einer Einrichtung die Verantwortung für z.B. daraus folgende häufigere Komplikationen zugeschrieben werden kann. Beispielsweise kann so das Indikatorergebnis einer Einrichtung mit vielen Hochrisikofällen fairer mit dem Ergebnis einer Einrichtung mit vielen Niedrigrisikofällen statistisch verglichen werden. Die Risikofaktoren werden aus Patienteneigenschaften zusammengestellt, die im Rahmen der Qualitätsindikatorenentwicklung als risikorelevant eingestuft wurden und die praktikabel dokumentiert werden können. 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 im QS-Filter 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	182011
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 (%)	2,95
Target range (reference range)
Confidence interval nationwide (%)	2,83 - 3,06
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 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	182014
Result (%)	10,10
Evaluation through structured dialogue
Population	495
Events observed	50
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	9,20
Target range (reference range)
Confidence interval nationwide (%)	9,08 - 9,32
Hospital confidence interval (%)	7,75 - 13,07
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	50045
Result (%)	98,33
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	180
Events observed	177
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	99,01
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	98,97 - 99,05
Hospital confidence interval (%)	96,07 - 99,44
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS, QS-Planung
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 planning-relevant quality indicator. Locations where there is a statistical abnormality are requested by the IQTIG to submit a statement. The purpose of this opinion process is to clarify whether there are reasons that suggest that, despite statistical abnormalities in the quality results, there is no insufficient quality. The quality is assessed as part of the subsequent technical clarification with the support of specialist commissions from the IQTIG. The results of this indicator and the evaluation of the quality are forwarded to the state authorities responsible for hospital planning, to the state associations of health insurance companies and to the replacement funds. Further information on the planning-relevant quality indicators can be found under the following link: https://www.iqtig.org/qs-instrument/planungsrelevante-qualitaetsindikatoren/. 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. Due to adjustments to the QS filter, the results of this quality indicator can only be compared to 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 at the following link: https://iqtig.org/qs-verfahren/.

Code ID	51397
Result	1,96
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	0,97
Target range (reference range)
Confidence interval nationwide	0,92 - 1,02
Hospital confidence interval	0,54 - 7,07
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 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 poor quality of the facility. The deviation can also be traced back to incorrect documentation or to individual cases in which, for example, there was a well-founded deviation from medical standards. 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	51808_51803
Result	0,00
Evaluation through structured dialogue
Population	483
Events observed	0
Anticipated events	0,13
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	1,18
Target range (reference range)
Confidence interval nationwide	1,03 - 1,36
Hospital confidence interval	0,00 - 17,78
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS, QS-Planung
Reference to other QA results	51803
Sorting	1
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	51813_51803
Result	3,25
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	1,01
Target range (reference range)
Confidence interval nationwide	0,96 - 1,07
Hospital confidence interval	1,09 - 7,75
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS, QS-Planung
Reference to other QA results	51803
Sorting	2
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	51818_51803
Result	1,66
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	0,89 - 0,98
Hospital confidence interval	0,40 - 4,72
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS, QS-Planung
Reference to other QA results	51803
Sorting	3
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	51823_51803
Result	2,05
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	1,06
Target range (reference range)
Confidence interval nationwide	1,01 - 1,11
Hospital confidence interval	0,50 - 5,84
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS, QS-Planung
Reference to other QA results	51803
Sorting	4
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are 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 result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in 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 the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	51831
Result	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	10
Events observed	0
Anticipated events	0,03
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,06
Target range (reference range)	<= 4,40 (95. Perzentil)
Confidence interval nationwide	0,95 - 1,18
Hospital confidence interval	0,00 - 96,85
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 structures 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 one facility being held responsible for, for example, more frequent complications as a result. With the help of risk adjustment, the quality outcome of, for example, a facility with many high-risk cases can be statistically compared more fairly with the quality outcome of a facility 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 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.