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Quality Management

Safeguarding, developing and optimising the quality of medical and nursing treatment and care is regarded an important target in all medical and nursing departments. Using a number of different tools and measures, such as the comprehensive training and continuous professional development of employees and the optimisation of all treatment procedures, all processes are directed towards enabling and supporting continuous improvement for patients and employees.


To emphasise these targets the Klinikum Ernst von Bergmann has successfully completed the certification process in accordance with the criteria of the Cooperation for Transparency and Quality in the Health Service (KTQ®) and is now proud holder of the KTQ® certificate. For more information on KTQ [in German], please visit this website under the heading "KTQ® Co-operation for Transparency and Quality in the Health Service".


Staff at our Quality Management Department are happy to answer any question that you may have or to provide additional information; please call them at +49 (0)331/ 241 4052.



Internal quality management

The quality policy of the Klinikum Ernst von Bergmann is guided by the principle of Total Quality Management (TQM). This means the inclusion of all areas of operation into the quality management system. This approach to quality is to be reflected in the structures as well as in the core, support and leadership processes of day-to-day hospital operations. To ensure this, we started in 2006 to develop and introduce a quality management system in the hospital. A cross-department, cross-professional and cross-hierarchical quality management team has been appointed under the direction of a quality manager to work for the communication of quality management principles to all hospital departments and their practical implementation therein.


The aim of all of these measures is to meet the wide range of demands in terms of quality and cost efficiency, but also the requirements and needs of patients, but also of employees and to integrate all of them into day-to-day working practice.



External quality management

Mandatory external quality assurance in accordance with § 137 SGB V involves the recording of set, measurable and comparable date (quality indicators) nationwide in all hospitals for specific diagnoses and surgical procedures. These data are anonymised prior to evaluation and fed back to the hospitals in form of an annual report. Mandatory threshold values (reference values) are specified for individual diagnoses and surgical procedures. If these are exceeded, the hospital in question has to issue a response and if necessary introduce concrete action for improvement (known as a structured dialogue). An overview of the summary of data relating to a particular year is published on the website of the Federal Office for Quality Assurance (BQS) and elsewhere.


The procedure for external quality assurance makes it possible to compare individual hospitals both at regional and at national level; in this way, the intention is to ensure an acceptable level of quality in patient care and to improve the transparency of treatment quality and outcomes.