Structural and performance data for a KTQ-Certification 1

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1 Structural and performance data for a KTQ-Certification Tongji Hospital affiliated to Tongji Medical college, Huazhong University of Science and Technology This form has to be completed in the scope of a KTQ-Certification by private hospitals having no license, forensic facilities as well as other hospitals outside of Germany, and has to be submitted to the certification agency as a binding precondition for the evaluation of the application. /9/9 Seite von 5

2 Date: [5-4-22] Report period: [//2-3/2/2] Contents General information about the hospital S.3 2 Quality assurance and quality management S. 5 3 Structural and performance data of the organisational units/specialising departments S. 7 Notice: The designation of persons and professions used in this document includes the male and the female gender in equal parts, even if only one gender is mentioned. /9/9 Seite 2 von 5

3 The hospital management, represented by Wang,Liuming is responsible for the completeness and correctness of the information provided in this report. Signature, Place, Date /9/9 Seite 3 von 5

4 General information Name Tongji hospital affiliated to Tongji medical college, Huazhong University of Science and Technology Additional designation Street and no. No.95 Jiefangdadao Ave. ZIP code and City 433,Wuhan, China Phone Facsimile Website/Internet presence Facility identification no. (or respective designation of facility) A Location(no.) (if allocated) Name and type of hospital operator (e.g. non-profit, private, public) Nonprofit Organization yes University teaching hospital University: _Huazhong Univerisity of Sci&Tec no /9/9 Seite 4 von 5

5 Departments and research focuses [Description of the departments and the research focuses] See attachment 2 Organisational structure of the hospital Please give an overview on the departments/disciplines or organisational units/centres in the form of a table or a chart (organisational chart). See attachment For specialized psychiatric hospitals, hospitals with a psychiatric department or hospitals for forensic psychiatry: Is there a regional health care obligation? yes no Total number of hospital beds (Reference date: 3 Dec. of the previous calendar year) Number of departments maintaining hospital beds Type (enumerate) e.g. Department for General Medicine 332 See attachment 2 Hospital case numbers Total number of cases treated during the report year: Outpatient 9446 inpatient Number of inpatient cases: 9446 Number of outpatient cases: Case counting method: Year /9/9 Seite 5 von 5

6 2 Quality assurance and quality management Participation in an external quality assurance* Department Case 2 numbers Documentation rate (%) Comment please enumerate and comment on all departments involved in the external quality assurance, e.g. cholecystectomy, mammary gland surgery) e.g. 5 e.g. 99 % Clinical pathway 42 % 9departments Laboratory Medicine ISO589 certification 35 % Laboratory medicine MOH programme 44 % Laboratory medicine MOH quality programme 7 % Laboratory medicine peer exam 2 % Blood Transfusion MOH programme 5 % Blood Transfusion MOPH programme 3 % Pathology PQCC Programme 4 % Pathology CCP Programme 4 % Pathology Chinese Medical Association Programme Special treatment technology management % 22 % 22 departments Medical official inspection programm 5 % Total 366 % * KTQ-GmbH expects a corresponding proof on the participation in all legally binding and voluntary measures in respect of external quality assurance. 2 here case number is not mean patient number, but the number of quality projects /9/9 Seite 6 von 5

7 Quality assurance with regard to the participation in Disease-Management- Programmes (DMP). According to its performance range, the hospital participates in the following DMPs: DMP Comment/Explanation please list all active DPMs, e.g. type diabetes mellitus, breast cancer, bronchial asthma According to Chinese Policy, these are no DMP yet until now. But our hospital have our own programmes such as all Organ transplantation, Hypertension, Tumor treatment, bronchial asthma, Diabetes, pediatric leukemia and chronic diseases. /9/9 Seite 7 von 5

8 Quality policy (guiding principles) [Please insert guiding principle(s) here] See attachments 3 Quality goals Indicators about mortality of inpatients 2 Indicators about return rate 3 Indicators about hospital infection 4 Indicators about complications of operations 5 Indicators about security of patients 6 Pharmacy management such as reasonable use of antibiotics 7 Indicators about process and performance management Quality management projects 2 3 /9/9 Seite 8 von 5

9 3 Structural and performance data of the organisational units/specialised departments this section has to be completed for each organisational unit/specialising department Name of organisational unit/specialising department Contact data See attachment 4 [Name, Phone no., , Facsimile] Major department Inpatient ward Mixed major department/inpatient ward Healthcare focuses of the organisational unit/specialised department No. Healthcare focuses Comment/Explanation e.g. diagnostics and therapy of oncological diseases e.g. diagnostics and therapy of lung cancer 2 See attachment 4 3 Service offers in terms of medical healthcare and nursing care of the organisation unit/specialising department No. Service offers in terms of medical healthcare, nursing care and therapy Comment/Explanation e.g. acupressure e.g. acupressure treatment in headache 2 e.g. music therapy e.g. in particular diseases 3 See attachment 4 /9/9 Seite 9 von 5

10 /9/9 Seite von 5

11 Non-medical service offers of the organisational unit/specialising department No. Service offer Comment/Explanation e.g. accommodation of accompanying person e.g. free of charge for persons accompanying children, otherwise possible with costs 2 See attachment 5 3 Case numbers of the organisational unit/specialising department Major diagnoses Rank Colloquial designation ICD- number (3 digits) Absolute case number Delivery O Other general examinations for tumor patients 3 Malignant neoplasm of bronchus and lung Z8 974 C Cholelithiasis K Chronic viral hepatitis B8 6 Chronic ischaemic heart disease I Pneumonia J Nephrotic syndrome N Alopecia areata I Malignant neoplasm of liver and C22 94 /9/9 Seite von 5

12 intrahepatic bile ducts /9/9 Seite 2 von 5

13 Outpatient treatment possibilities No. Type of outpatient clinic Services offered All departments have to offer services of outpatient 2 3 Technical equipment No. Existing devices Comment/Explanation e.g. X-ray unit/mrt e.g. C-arm (incl. note: 24h availability in case of emergency is provided/not provided) 2 See attachment 6 3 /9/9 Seite 3 von 5

14 Staff resources of the department see attachment7 Physicians Number Comment/Explanation Specialist knowledge of the department Physicians in total (save attending physicians)... full-time physicians e.g. further education authority e.g. designation of subject, designation of focuses, additional further education of which specialists... full-time physicians Attending physicians... persons Nursing staff Number Comment/Expl anation Nursing staff in total of which examined healthcare and nursing staff or healthcare and nursing staff without specific further education (3 years) of which examined healthcare and nursing staff or healthcare and nursing staff with the respective specific further education (3 years)... full-time staff... full-time staff... full-time staff /9/9 Seite 4 von 5

15 Therapeutic staff of the department No. Occupational title (Therapeutic staff) Number Comment/Explanation e.g. physiotherapists, wound manager, dietary specialists, breast-feeding consultants full-time staff 2 full-time staff 3 /9/9 Seite 5 von 5

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