Kirchfeldstr. 40
40217 Düsseldorf
Phone:0211-9190
Mail:ed.frodlesseud-kve@gnutlawrev
Basic information
- Number of beds: 513
- Number of specialist departments: 15
- Number of inpatient cases: 22.596
- Number of partial inpatient cases: 254
- Number of outpatient cases: 60.788
- Hospital owners: Stiftung Evangelisches Krankenhaus Düsseldorf
- Type of provider: freigemeinnützig
Specialist departments
- Chirurgische Klinik / Klinik für Orthopädie und Unfallchirurgie, Sportmedizin
- Chirurgische Klinik / Klinik für Allgemein-, Viszeral- und Gefäßchirurgie
- Frauenklinik
- Frauenklinik: Geburtshilfe
- Klinik für Kardiologie
- Medizinische Klinik
- Radiologische Klinik
- Kinder- und Jugendpsychiatrie/Tagesklinik (für teilstationäre Pflegesätze)
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerztherapie
- Radiologische Klinik / Strahlentherapie
- Klinik für HNO-Heilkunde und Kopf- und Halschirurgie
- Palliativstation
- Radiologische Klinik / Nuklearmedizin
- Klinik für Kinder- und Jugendmedizin
- Klinik für Dermatologie und Allergologie
Services
- Medical services
- Medical and nursing services
Quality
External comparative quality assurance
Further information
- External quality assurance according to state law
No participation
- Quality of participation in the Disease Management Programme (DMP)
No participation
- Participation in other external comparative quality assurance procedures
Implementation of the minimum quantity agreement
Treatment area
Knee joint total endoprostheses
Quantity performed | 104 |
Exception? | No exception |
Complex interventions on the organ system esophagus for adults
Quantity performed | 30 |
Exception? | No exception |
Complex operations on the pancreatic organ system
Quantity performed | 56 |
Exception? | No exception |
Care of premature and mature infants (with an admission weight < 1250g)
Quantity performed | 17 |
Exception? | No exception |
Minimum quantities forecast
Complex operations on the pancreatic organ system
Overall result forecast presentation: | yes |
Quantity performed reporting year: | 56 |
Quantity forecast year: | 56 |
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: | 30 |
Quantity forecast year: | 35 |
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: | yes |
Quantity performed reporting year: | 17 |
Quantity forecast year: | 19 |
Examination by state associations? | yes |
Exemption? | yes |
Result of the examination by the federal state authorities? | yes |
Transitional arrangement? | no |
Knee joint total endoprostheses
Overall result forecast presentation: | yes |
Quantity performed reporting year: | 104 |
Quantity forecast year: | 131 |
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 |
---|---|
CQ05 | Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1 |
CQ01 | Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm |
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 trainingpursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB
Number | Group |
---|---|
238 | 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* |
72 | 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 |
26 | 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
- Accessibility
- Hygiene
- Quality management and risk management
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
Special requirements for the selection of persons
Information gathering on the topic
Training of employees
- Intervention
Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
- Note on the measure
In Erstellung: Etablierung eines Kinderschutzgremiums
- Note on the measure
- Reprocessing
Recommendations for dealing with/processing cases that have occurred
- Note on the measure
aktuell in Verabschiedung
- Note on the measure
- Prevention
- aktuell in Verabschiedung
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.
- Complaint management
- Participation emergency care
Drug therapy safety
Steering committee
- Drug commission
Training of employees on AMTS related topics
Concepts for ensuring the error-free preparation of medications
- Zubereitung durch pharmazeutisches Personal
Electronic support for the supply of patients with drugs
- Elektronisches Bestellsystem und automatisierte Zusammenstellung, gesicherter Transport
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
Job
FL06 - Participation in multi-centre phase III/IV studies
Explanation
Prof. Dr. med. Horst Neuhaus (Innere Medizin), Fr. Dr. Carolin Nestle-Krämling (Gynäkologie), Fr. Prof. Dr. med Monika Gappa (Kinderklinik), Prof. Dr. Werner Hartwig (Chirurgie), Prof. Dr. Christian Meyer (Kardiologie)
FL03 - Student training (clinical traineeship / internship year)
Explanation
Ausbildung von Famulanten und Studenten im Praktischen Jahr der Heinrich-Heine-Universität-Düsseldorf
FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies
Explanation
Prof. Dr. med. Horst Neuhaus (Innere Medizin) , Prof. Dr. med. Christian Meyer (Kardiologie), Prof. Dr. med. Monika Gappa (Kinderklinik), Prof. Thomas Lauenstein (Radiologie)
FL05 - Participation in multi-centre Phase I/II studies
Explanation
Prof. Dr. med. Werner Hartwig (Chirurgie)
FL08 - Editors of scientific journals/textbooks
Explanation
Prof. Dr. med. Christian Meyer (Kardiologie), Prof. Dr. med. Thomas Lauenstein (Radiologie), Dr. Gregor Wolf (HNO-Klinik), Prof. Dr. med. Monika Gappa (Kinderklinik), Prof. Horst Neuhaus (Innere Medizin), PD Dr. Torsten Beyna (Innere Medizin), PD Dr. Olaf Boehm (Anästhesie)
FL01 - Lectureships / teaching posts at colleges and universities
Explanation
Priv.-Doz. Dr. med. René Chatelain, Prof. Dr. med. Werner Hartwig, Prof. Dr. med. Thomas Lauenstein, Prof. Dr. med. Horst Neuhaus, Prof. Dr. med. Monika Gappa, PD Dr. Olaf Boehm, Prof. Dr. med. Christian Meyer
FL04 - Project-related cooperation with colleges and universities
Explanation
IWF Düsseldorf, Helmholz Institut /Klinik für Kinder-u. Jugendmedizin, Institut für Neuro- u. Sinnesphysiologie, HHU Düsseldorf, Klinik für Kardiologie, Pneumologie u. Angiologie, Universitätsklinikum Düsseldorf, Kooperation mit HNO-Klinik-Universitätsklinikum Düsseldorf
FL09 - Doctoral supervision
Explanation
Training
Training in other healing professions
HB15 - Anaesthesia technical assistant (m/f)
Comment
1 Ausbildungsplatz pro Jahr
HB19 - Nursing professionals
Comment
135 Ausbildungsplätze (Generalistische Ausbildung ab 2022)
HB03 - Physical therapist / physiotherapist (m/f)
Comment
100 Ausbildungsplätze. Zertifizierung und Rezertifizierung nach ISQ.
HB01 - Nurse and health care worker (m/f)
Comment
75 Ausbildungsplätze
HB02 - Health and paediatric nurse (m/f)
Comment
40 Ausbildungsplätze
HB17 - Auxiliary nurse (m/f)
Comment
20 Ausbildungsplätze
HB07 - Surgical technical assistant (m/f)
Comment
3 Ausbildungsplätze pro Jahr
- Hospital staff
- Number of doctors: 189,42
- Total number of nurses: 462,41
- Number of therapeutic staff: 65,50
Pharmaceutical personnel
- Number of pharmacists: 1
- Additional staff: 3
- Explanations: Die Angaben beziehen sich auf Mitarbeiter der Gemeinschaftsapotheke des EVK-Düsseldorf, die im Rahmen der Herstellung individueller parenteralen Zubereitungen (z.B. für onkologische Patienten sowie Früh- und Neugeborene) tätig sind.
- Nursing staff regulation
Service contact persons
Patient advocates
Klaus Wiegand
Patientenfürsprecher
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-0
Mail: ed.frodlesseud-kve@rehcerpsreufnetneitap
Klaus Wiegand
Patientenfürsprecher
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-0
Mail: ed.frodlesseud-kve@rehcerpsreufnetneitap
Customer feedback management
Dieter Gurschke
Leiter Innere Verwaltung
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-2001
Mail: ed.frodlesseud-kve@ekhcsrug.reteid
Quality management
Christiane Koletzki
QMB
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-2140
Mail: ed.frodlesseud-kve@ikztelok.enaitsirhc
Hygiene officer
Prof. Dr. Thomas Lauenstein
Ärztlicher Direktor, Chefarzt der Radiologie
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-1055
Mail: ed.frodlesseud-kve@eigoloidar
Responsible for drug therapy
Drug commission
Accessibility Officer
Renata Plis-Zeligowska
Schwerbehindertenbeauftrage
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-481858
Mail: ed.frodlesseud-kve@akswogileZ-silP.ataneR
Company
General contact details of the hospital
Kirchfeldstr. 40
40217 Düsseldorf
Phone:0211-9190
Mail:ed.frodlesseud-kve@gnutlawrev
Nursing service management
Sandra Cremer
Pflegedirektorin
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-4006
Mail: ed.frodlesseud-kve@ldp
Head of administration
Dipl.-Oec. Klaus Peter Taschner
Vorstand
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-2003
Mail: ed.frodlesseud-kve@gnutlawrev
Responsible for the quality report in the hospital management
Dipl.-Oec. Klaus Peter Taschner
Vorstand
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-2003
Mail: ed.frodlesseud-kve@gnutlawrev
Medical management
Prof. Dr. Thomas Lauenstein
Ärztlicher Direktor, Chefarzt der Radiologie
Kirchfeldstr. 40
40217 Düsseldorf
Phone: 0211 -919-1055
Mail: ed.frodlesseud-kve@eigoloidar
Regional care obligation for psychiatry?
No
IK number
IK: 260510132
Location number
Location number: 773140000
Old location number: 773140000
Related Links
- https://www.evk-duesseldorf.de/krankenhaus/organisation/qualitaetsmanagement.htmlDirekter Link zu den QM Berichten
Hospital portrait for download