GFO Kliniken Südwestfalen – St. Josefs-Hospital Lennestadt

Quality results

Treatment sector: Pacemaker: First use (HSMDEF-HSM-IMPL) Explanation

Information about this treatment area (documentation)

Designation	Herzschrittmacher-Implantation
Shortcut	09/1
Number of cases	41
Documentation rate	100 %
Hospital comment	Die Dokumentationsrate wurde krankenhausbezogen berechnet.

Summary result:

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

Number of patients treated: 41

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

Ratio of the number of problems encountered to the previously expected number (the individual risks of the patients were taken into account). The problems occurred in connection with an operation where a pacemaker was inserted (probe or pocket problems) and led to a new operation within one year

Hospital: 0,00

Target area: at most 2,69

Quality objective achieved

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Ratio of the actual number to the previously expected number of infections or complications that occurred which led to a new operation within one year (individual risks of the patients were taken into account)

Hospital: 43,02

Target area: at most 6,34

Quality objective achieved
Why?

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Code ID	2194
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	6
Events observed	0
Anticipated events	0,23
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,99
Target range (reference range)	<= 2,69 (95. Perzentil)
Confidence interval nationwide	0,96 - 1,03
Hospital confidence interval	0,00 - 16,36
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, 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 to 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/. This quality indicator shows both events that occur before discharge from a hospital and events that occur after discharge but can still be linked to the implantation.

Code ID	2195
Result	43,02
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to have been achieved. For more information, see All information (click here) at the bottom under Comment or Technical note. (H99)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,99
Target range (reference range)	<= 6,34 (95. Perzentil)
Confidence interval nationwide	0,87 - 1,12
Hospital confidence interval	2,45 - 189,22
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level	rechnerisch_auffällig: das Lenkungsgremium folgt der Empfehlung der Fachkommission, kein Stellungnahmeverfahren einzuleiten
Comments/explanations by the hospital
Specialist note IQTIG This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. The results of this quality indicator can only be compared with the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/. This quality indicator shows both events that occur before discharge from a hospital and events that occur after discharge but can still be linked to the implantation.