St. Josef Krankenhaus GmbH Moers - Betriebsstätte St. Josef Krankenhaus Moers

Quality results

Treatment sector: Pressure ulcer (decubitus): prevention through nursing measures (DEK) Explanation

Information about this treatment area (documentation)

Designation	Dekubitusprophylaxe
Shortcut	DEK
Number of cases	264
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: 264

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 actual to the previously expected number of patients who developed a pressure ulcer (moderate to very severe, grade 2 - 4) in hospital

Hospital: 1,16

Target area: at most 2,68

Quality objective achieved

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So few patients developed moderate pressure ulcers (grade 2) in hospital

Hospital: 0,30 %

as rarely as possible

Evaluation is not available

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So few patients developed severe pressure ulcers (grade 3) in hospital

Hospital: 0,06 %

as rarely as possible

Evaluation is not available

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So rarely did patients develop pressure ulcers of unknown severity in hospital

Hospital: Data protection

No information due to data protection

as rarely as possible

Evaluation is not available

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So rarely did a very severe pressure ulcer (grade 4) develop during the hospital stay

Hospital: Data protection

No information due to data protection

Sentinel Event

Quality objective achieved
Why?

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Code ID	52009
Result	1,16
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	15388
Events observed	59
Anticipated events	50,96
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,18
Target range (reference range)	<= 2,68 (95. Perzentil)
Confidence interval nationwide	1,17 - 1,19
Hospital confidence interval	0,90 - 1,49
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	52326
Result (%)	0,30
Evaluation through structured dialogue
Population	15388
Events observed	46
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,36
Target range (reference range)
Confidence interval nationwide (%)	0,36 - 0,37
Hospital confidence interval (%)	0,22 - 0,40
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 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	521801
Result (%)	0,06
Evaluation through structured dialogue
Population	15388
Events observed	10
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,07
Target range (reference range)
Confidence interval nationwide (%)	0,06 - 0,07
Hospital confidence interval (%)	0,04 - 0,12
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 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	521800
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 (%)	0,01
Target range (reference range)
Confidence interval nationwide (%)	0,01 - 0,01
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 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 information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept. According to current knowledge, the classification of a pressure ulcer can be done according to the WHO (DIMDI) as well as according to NPUP/EPUAP. The classification according to EPUAP/NPUAP describes the categories Cannot be assigned to a category/stage: depth unknown and Suspected deep tissue damage: Depth unknown. Therefore, suspected deep tissue damage may have been documented as pressure ulcer, stage unspecified.

Code ID	52010
Result (%)	Data protection
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to be achieved, since the deviation can be traced back to isolated documentation problems after examination by specialist committees. There are no indications of defects (U63)
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 (%)	0,01
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,01 - 0,01
Hospital confidence interval (%)	0,00 - 0,00
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 It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the disease severity or concomitant diseases of the patients have an influence on the result. 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.