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Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg

Baldingerstraße 01
35043 Marburg

Phone: 06421-58-60
Fax: 06421-58-66370
Mail: ed.mg-ku@rm.fgea

http://www.ukgm.de

Basic information

Number of beds: 944
Number of specialist departments: 25

Number of inpatient cases: 39.088
Number of partial inpatient cases: 973
Number of outpatient cases: 378.663

Hospital owners: Universitätsklinikum Gießen und Marburg GmbH
Type of provider: privat

University Hospital
Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	no

External quality assurance according to the DMP

Brustkrebs

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	39
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	29
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	56
Exception?	No exception

Kidney transplant (including living donation)

Quantity performed	25
Exception?	No exception

Stem cell transplant

Quantity performed	90
Exception?	No exception

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	24
Exception?	No exception

Liver transplantation (including partial liver donation)

Quantity performed	1
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	Pending lawsuit
Quantity performed reporting year:	39
Quantity forecast year:	39
Examination by state associations?	Pending lawsuit
Exemption?	yes
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	29
Quantity forecast year:	32
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:	56
Quantity forecast year:	53
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Kidney transplantation (including living donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	25
Quantity forecast year:	31
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	90
Quantity forecast year:	128
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	Pending lawsuit
Quantity performed reporting year:	24
Quantity forecast year:	22
Examination by state associations?	Pending lawsuit
Exemption?	yes
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	no
Quantity performed reporting year:	1
Quantity forecast year:	0
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	625
Quantity forecast year:	585
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	52
Quantity forecast year:	79
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.	Explanation
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)
CQ30	Quality assurance guideline for interstitial LDR brachytherapy for low-risk localized prostate cancer (effective January 8, 2021).

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: yes

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
363	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*
228	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
225	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
  
  Information gathering on the topic
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  In den Klinischen Strategischen Zielen des UKGM in Marburg wird im Absatz 1 "Patientensicherheit" der Schutz von Minderjährigen explizit festgelegt.
  
  Last review of the measure
  11.02.2022 15:42:35
  Special requirements for the selection of persons
- Intervention
  
  Other aspects of intervention
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  https://insight.rka/fileadmin/100_RKA/199_Microsites/Compliance/Haltungsgrundsaetze/B_Haltungsgrundsaetze_web.pdf
  
  Last review of the measure
  20.02.2022 15:42:35

https://insight.rka/fileadmin/100_RKA/199_Microsites/Compliance/Haltungsgrundsaetze/B_Haltungsgrundsaetze_web.pdf

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

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

Use of standardised forms for drug medical history

Qualitätsmanagement Konzept Rhönklinikum AG. Für alle Standorte des Universitätsklinikums Gießen und Marburg in Marburg sind Vorgabedokumente zu QM-Prozessen und Dokumente für das Risikomanagement jederzeit verfügbar.

09.11.2022

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)

09.11.2022

SOP on good prescription practices

Gute Verordnungspraxis

09.09.2020

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

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

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

Training

Training in other healing professions

HB15 - Anaesthesia technical assistant (m/f)

Comment

HB06 - Occupational therapist (m/f)

Comment

die praktische Ausbildung findet auch am Klinikum statt.

HB02 - Health and paediatric nurse (m/f)

Comment

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

Comment

HB10 - Midwife (m/f)

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

In Kooperation mit der DRK Schwesternschaft Marburg wird eine Krankenpflegehilfeausbildung angeboten. Die Ausbildung ist AZAV zertifiziert.

HB09 - Speech therapist (m/f)

Comment

HB13 - Medical technical assistant for functional diagnostics (MTAF) (m/f)

Comment

HB12 - Medical technical laboratory assistant (MTLA) (m/f)

Comment

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

Comment

HB07 - Surgical technical assistant (m/f)

Comment

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

die praktische Ausbildung findet auch am Klinikum statt.

HB19 - Nursing professionals

Comment

HB20 - Nursing professional B. Sc.

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 17
- Additional staff: 32
- Explanations: Angegeben wird beschäftigtes Personal am Stichtag 31.12. Ohne Auszubildende und Praktikant*innen. Das angegeben Personal ist für alle Standorte des UKGM in Marburg tätig.
- Nursing staff regulation