HUS Annual Report 2012 by HUS Helsingin yliopistollinen sairaala

A day in the life ANNUAL REPORT 2012

pital A large hos n organisatio bility a p a c e h t s ha to deliver r vices e s y t i l a u q high vely. cost-effecti n Aki Lindé

HUS | VUOSIKERTOMUS 2012 | TOIMITUSJOHTAJALTA

Aki Lindén, CEO of HUS: The year 2012 was the busiest year ever in the history of HUS. Services provided increased by 2.5% on the previous year and exceeded the performance goals of the 2012 budget by 2.6%. In the structure of the services provided, there was a shift of focus towards outpatient care. This was particularly apparent in psychiatry, where inpatient care decreased by 6.2%. Despite increases in services provided, however, we did not manage to improve the situation of those queuing for treatment in 2012. An extensive debate was launched in 2012 on the reform of local government and the social welfare and health care service structure prescribed in the Government Programme. HUS took an active role in this debate. It is the considered opinion of HUS that a large hospital organisation where expertise can be clustered has the best capability to deliver high-quality services cost-effectively. • continued on page 5

Every day is a day of many stories at HUS HUS is a place where people are examined, treated and operated on, people are born and people die, day in and day out all year round. In the course of a year, HUS affects the lives of thousands of people. It is a companion in life’s greatest joys and sorrows. What we are trying to say here is that there is more to HUS than just numbers. HUS is above all the sum of its employees: expert professionals committed to their work.

Care

Indispensable professional skills 6 The key question: “How are you doing now?” 7 Expert Markku Kuisma 8 Rapid response saves Emma

12 Demanding emergency care 14 Department of Oncology is the epicentre of Finnish cancer treatment 16 Alternatives to coercion 20 1 in 3 babies are born at HUS 5 Review by the CEO

HUS | ANNUAL REPORT 2012

Work

Science

The sum of the HUS spearheading expertise of individuals research 22 Apotti project brings patient information together 23 Expert Outi Sonkeri 24 Finland’s most active workplace 26 Subs are born to roam

28 Nordic cooperation

9 Expert Lasse Viinikka 2 30 Important teaching and research institution 32 Cartilage replacement surgery develops

Responsibility For people and for the environment 34 A safe hospital 35 Expert Tapani Hämäläinen 36 Patient safety is about anticipation and prevention 38 Eco-efficient operations

Finance

Balancing growth and costs 40 Working at full strength and on budget 41 Expert Anne Priha 42 Construction investments 44 HUS in figures 50 Financial statements

5 Review by the Chairman of the Executive Board

Ulla-Marja Urho, Chair of the Executive Board:

HUS aims to provide patients with good care, to ensure a high level of quality in teaching and research, to improve cooperation with basic health care and to be effective and competitive.

HUS | ANNUAL REPORT 2012

FROM THE CHAIR OF THE EXECUTIVE BOARD | Ulla-Marja Urho

FROM THE CEO | aki lindén

HUS and HUCH must be kept intact

The tricky equation of 2012

HUS updated its goals and operating programme, i.e. its strategy, for 2012–2016. The goals may be summarised in four points: good care for patients; high-quality teaching and research; better cooperation with basic health care; and effective and competitive operations. How did we do in 2012?

HUS began the year 2012 in a difficult financial situation. The budget allowed for an increase of only just over 1% compared with the annual accounts for 2011.

More patients were treated than ever before. Waiting lists remained largely within the statutory limits, and no conditional fines were imposed. Patients were pleased with the care they received. The finances of the Joint Authority are a cause for concern. HUS has gone to great lengths to improve productivity, and these efforts have been successful: the costs of specialist medical care per capita in this hospital district are the lowest of all hospital districts in Finland. The budget for 2012 turns out to have been overly optimistic. Costs exceeded revenue, and the annual accounts show a substantial loss. The year under review included decisions on launching major investment projects. The traumatology centre that will replace Töölö Hospital will be housed in a new facility at Meilahti, as will the children’s hospital. The construction work will begin as soon as the renovation of the Tower Hospital is completed. It is difficult to recruit competent physicians for basic health care. Closer cooperation between HUS and basic health care will improve this situation, but there is still a lot to be done. Better cooperation is needed to benefit patients, and mutually compatible information systems will contribute to this. The procurement of such systems was launched in a joint municipal effort. The strength of HUS is in its expert personnel and its strong links to university teaching and research. The year under review saw the end of a local government electoral period. Both at the beginning and end of its tenure, the HUS Executive Board unanimously declared that HUS and HUCH must be retained intact as a comprehensive functional entity. Whatever the structure of local government may be, the providing of specialist medical care at a high level of quality and efficiency – especially its most demanding disciplines – requires a large population base. This also applies to the organising of university-level teaching and research in medicine and other subjects too. If it ain’t broke, don’t fix it. If an organisation works well, let it develop instead of breaking it apart!

HUS | ANNUAL REPORT 2012

Cost increase trends seemed unusually robust early in 2012 compared with 2011, but these trends evened out in the course of the year. The comparable growth of operating costs year on year was 4.4%. Non-discretionary net costs exceeded the budget by 2.1%. This excess was the smallest seen in five years. Invoicing from the member municipalities increased by 2.8%. The population in the catchment area grew by about 1%. Member municipalities’ average contributions per resident, as measured by the deflated hospital cost index, decreased. The operations deficit for 2012 was EUR 21.6 million, as opposed to the goal of EUR 12 million. One of the items contributing to the deficit was the increase in the holiday pay reserve resulting from the provisions of the new collective agreement for local government civil servants and employees: signed in November 2011, the agreement added about EUR 14 million to the deficit. The deficit eventually totalled EUR 35.5 million, absorbing previously accumulated surpluses for a cumulative deficit of about EUR 10 million. The productivity of service provision, as measure by the price of one DRG point, improved by 0.9%; however, measured by the number of DRG points per person-year, productivity actually declined by 0.4%. An improvement of 1.5% had been set as the goal for both these figures. The year 2012 was the final full year of service for HUS officials elected in 2009. I would like to take this opportunity to thank them for their diligent and selfless efforts in executing the demanding duties assigned to them in managing HUS, the flagship of Finland’s specialist medical care.

talking d n a g n i n e t L is ntering when encou a patient is ion of t a d n u o f e h t nship. o i t a l e r e r a ac en Sari Hytön

HUS | ANNUAL VUOSIKERTOMUS REPORT 2012 2012| |CARE TOIMITUSJOHTAJALTA

Sari Hytönen, nurse, neurosurgery intermediate care, Töölö Hospital: In a nurse’s job, listening and talking when encountering a patient is the foundation of a care relationship. For a nurse to find time even just once during a shift to sit down beside a patient and ask them “How are you doing now?” demonstrates genuine caring and creates a sense of security for the patient. One can always find time for such a moment however busy the day may be. In intermediate care, I cannot always have a conversation with my patient. In such cases, the care relationship evolves largely in interaction with the patient’s family members. It is important to give family members time and to listen to their accounts of the patient’s feelings and habits before being hospitalised. It is just as important to listen to and support the family members. Every encounter is unique and individual, and one has to have a psychological eye for them. It is not always easy to encounter patients and family members, but every moment of being actively present and talking to people empowers me for the next such encounter.

Hoito Care Care

The 22 hospitals of HUS treated

Markku Kuisma Chief Physician, Prehospital Emergency Care

497,826 patients

Prehospital emergency care services transferred to HUS

1,580,702 outpatient visits 452,998 individual patients in specialist medical care 89,455 surgical procedures 18,099 deliveries

Patient-orientated and timely treatment and care. This phrase in the HUS strategy for 2012–2016 describes one of the most important goals for HUS operations. The huge scale of the strategic goals becomes apparent when one considers the statistics from the year under review: nearly 500,000 individual patients, some 90,000 surgical procedures and 18,000 deliveries. There are 97 stated strategic goals for medical care, of which 16 were selected as key goals for 2012. There were three key goals for care: comparable quality of treatment results, availability of care and patient safety. How well did we attain the key goals in the first year of the strategy period? A new tool was introduced for comparing treatment results with the launch of the international BM programme. Availability of care fulfilled expectations: the numbers of performances exceeded the levels set in the budget.

HUS | ANNUAL REPORT 2012 | CARE

A pediatric cardiac operation almost every day

However, reduction of the number of patients waiting for treatment and examinations fell far short of that which was planned. The number relative to population of patients waiting for inpatient care for more than six months at HUS surpassed the comparable figure for all other university hospital districts in the course of the year under review. By comparison, the goals of the patient safety programme were largely attained. Naturally, even in medical care the attainment of goals is monitored using indicators. Behind these figures is the day-to-day care work on which all HUS operations are based. We can only attain our strategic goals if we treat every single patient we admit as the most important patient we have ever had. It is the encounter with and treatment of an individual patient that is the event that generates the results that we then see in the big picture.

Prehospital emergency care services are responsible for performing urgent triage on and providing first-response care to patients who have fallen acutely ill, for instance at home or in a public place. The new Health Care Act transferred the responsibility for providing prehospital emergency care services from local authorities to hospital districts. At HUS, this change was implemented in two stages. Prehospital emergency care services were transferred to HUS in the Porvoo and Hyvinkää Hospital Areas as of the beginning of 2012, and the other hospital areas followed suit one year later. The HUS catchment area is divided into seven prehospital emergency care sub-areas. Prehospital emergency care services are organised by the Hospital District alone or in cooperation with the local rescue services or private enterprises offering patient transport services. What does this major administrative change entail in practice? Even before the new regime, prehospital emergency care services in the HUS catchment area were of a high quality, and cooperation with member municipalities was close. The top priorities in planning prehospital emergency care include ensuring equal access to the services and for the service to reach patients requiring prehospital emergency care within the regionally specified time limits. Broader regional planning will facilitate successful co-operation with the Emergency Response Centre, the rescue services, the police and other officials and agents. From the patient’s perspective, the change had scarcely any direct impact and was not meant to. In the long term, the change will equalise the quality of treatment and service, improve patient safety and raise the level of competence of first-response care personnel. Patients will see this as a clear improvement in services.

One life, many savers Rotor blades churn the air as a helicopter lands at the edge of a field. The red ambulance helicopter has ‘FinnHEMS 10’ painted on its side in large white letters. The thumping noise of the helicopter breaks the calm of the low-rise neighbourhood. It signals that something bad has happened, that someone’s life is in danger. For Kari Kuukka, the sound is a relief: a doctor is coming to look at his young daughter Emma. • Text: Paavo Holi

Tuesday 30 October

Emma Kuukka 17.45 falls off her pony in Porvoo

HUS | ANNUAL REPORT 2012 | CARE

Back home, 18.30 Emma 18.38 begins to feel sick

A 112 emergency call is placed to the East and Central Uusimaa Emergency Response Centre

Care Care It is an ordinary Tuesday evening in October at a riding stable a couple of kilometres outside the city centre of Porvoo. Emma Kuukka, 8, is seated on a pony with a helmet on her head, enjoying the ride. Emma guides the little pony around the outdoor manege calmly along with other riders. Suddenly, a noisy group of joggers emerges from the surrounding darkness. Some of the horses are frightened and set off on a gallop. Emma’s pony is one of those startled. Unable to control her mount, she falls from the saddle and hits the ground. Yet almost immediately she gets up again and seems not to be hurt. Half an hour later, the mother of one of Emma’s riding

Rescue Services ambulance 18.40 receives emergency dispatch

18.45 Ambulance

arrives at the scene

HUS | ANNUAL REPORT 2012 | CARE

friends brings her home in a car and tells Emma’s mother, Sari Orkomies, what has happened. Emma is still dazed from the scare she had but seems otherwise fine. Emma’s father, photographer Kari Kuukka, comes home and tries to talk to his daughter about the incident. “Why are you talking to me?” Emma snaps. Kari takes Emma into his arms, but at that moment she begins to vomit. It’s concussion, Kari thinks, we have to get her to hospital. Then Emma’s gaze begins to drift to the upper left uncontrolledly. Kari, who used to study psychology and neurosciences at university, immediately realises that something is terribly wrong. “Call an ambulance!” says Kari to his wife. An ambulance from the Itä-Uusimaa Rescue Services arrives within seven minutes of the 112 emergency call, and only five minutes after receiving the dispatch. By fortunate chance, the ambulance happened to already be in the neighbourhood. The paramedics assess Emma’s condition, check her breathing, fit her with an IV and give her oxygen. Emma begins to lose consciousness; her gaze wanders. The paramedics decide to call in an ambulance helicopter, which lands in a field nearby some 15 minutes later. The emergency care physician brought by the helicopter begins treatment. Emma is fitted with a neck truss, and because of her loss of consciousness, she is sedated and hooked up to a ventilator. Watching the treatment being given his daughter, the father sees that Emma is in good hands. The crowd in the yard includes the flying doctor, the HEMS assistant, three paramedics and the four-man

FinnHEMS 10 ambulance helicopter receives emergency 18.58 dispatch at 19.17 Helicopter Helsinki-Vantaa lands Airport in Porvoo

Emma, now anesFlying thetised, is put in 19.58 an ambulance 19.23 doctor arrives that will take her at the scene to Helsinki

“Call an ambulance!” says Kari to his wife.

crew of the fire engine that arrived to safeguard the landing of the helicopter. The latter crew happens to include a former neighbour of the Kuukka family, who is a shift manager with the Itä-Uusimaa Rescue Services “That’s your Emma?” he asks Kari with empathy. By 8 o’clock Emma has been put in an ambulance that is taking her swiftly to the traumatology centre at Töölö Hospital. The normal alert call that a seriously injured patient is on the way has been made. Kari follows in his car. Sari stays at home with Emma’s younger brother Joonatan, 5, known as ‘Tintti’. By the time Kari arrives at Töölö Hospital, Emma has already had a CT scan of her head taken in radiology. The neurologist on duty tells Kari that Emma has a bruise on the right side of her frontal lobe, and blood is trickling into her brain. Her skull is not broken, but the impact •

Ambulance 20.19 arrives at Töölö Hospital

Emma has woken from anesthesia, Emma 22.00 and her intubation 20.33 is 20.55 Lab tube has been tests examined removed completed in radiology

• caused a slight intracranial hemorrhage. The decision is made to bring Emma out from the anesthesia to gauge the severity of the situation. The surgical team is standing by in case Emma does not wake up. When the anesthesia is removed, Emma quickly recovers and is transferred to the intermediate care at the neurosurgery department at Töölö Hospital with extra oxygen. Just over four hours have elapsed since she fell off her pony. She squeezes her father’s finger and falls asleep again. In the morning, Emma’s duty nurse tells Kari that the girl woke in the night and said to her: “You know, you look just like [Finnish champion figure skater] Kiira Korpi.” Emma wakes on Wednesday morning feeling refreshed and manages to eat some breakfast. She is transferred to pediatric surgery ward K5 at the Children’s Hospital. Emma is examined by a pediatric surgeon, a neurosurgeon and a neurologist. Kari spends the night on the ward with his daughter. On Thursday, Emma is given an MRI, which reveals that the fall from the pony has caused no permanent injuries. Sari comes to the hospital to pick up her daughter

at 17.00, and on Monday Emma returns to school. About one month later, Kari writes about the incident in his generally photography-themed blog, titling the article ‘About gratitude’ (www.karikuukka.com/kiitollisuudesta/). Within a short space of time, the article receives more than 20,000 hits and more than 4,000 shares. In the article, Kari thanks the dozens of health care professionals who contributed to his daughter’s treatment: “Someone might say that they were just doing their job or even that that’s what they’re paid to do. I’m sorry, but I just don’t buy that. I completely disagree. These people actually care,” writes Kari and goes on: “There is a lot of talk these days about health care costs. I can only say that these people are not machines and could never be replaced by machines. They are not cost centres. They are actual human beings. Although I dislike paying taxes as much as the next man, I hereby swear that I will never complain about them again. There is a lot of good in our society. I have a healthy second-grader at home, thanks largely to these incredible people and the system we have in place.”

So who exactly did take care of Emma? Initially, there were three paramedics, a flying doctor and a HEMS assistant involved, plus the neurologist on call. Thereafter, several physicians and nurses at the neurosurgery intermediate care unit and ward K5 at the Children’s Hospital participated. There were other health care professionals in the treatment chain at all times: radiologists, radiology nurses and lab technicians. All this was made possible by instrument maintenance specialists, cleaners, clerical staff and many other people working at HUS hospitals. Some 20 health care professionals were actively involved in Emma’s treatment, assisted by a similar number of other HUS employees.

WEDNESDAY

THURSDAY

31 OCTOBER 22.10

Emma is transferred to the neurosurgery intermediate care unit at Töölö Hospital

9.00

Emma wakes feeling refreshed and manages to eat some breakfast

HUS | ANNUAL REPORT 2012 | CARE

10.30

Emma is transferred to ward K5 at the Children’s Hospital in Meilahti

1 NOVEMBER 12.15

Pediatric surgeon checks on how Emma is doing

8.00

Neurosurgeon meets Emma

10.55

Neurologist talks to Emma

13.38 Emma is taken to MRI

Statement 14.27 on the imaging is completed

17.00

Emma’s mother picks her up at the Children’s Hospital, fully recovered

Hoito Care Care Kari Kuukka:

I have a healthy second-grader at home, thanks largely to these incredible people and the system we have in place.

And what about Emma and horses? Emma was boldly back in the saddle as soon as her exercise ban ended, two weeks after being discharged from the hospital. A couple of months later, however, Emma said that she did not want to ride any more. Her fall had left her with an underlying fear of riding that was difficult to overcome. But despite this, her neighbourhood stable remains a favourite place of hers: whenever she passes by, she goes to see whether her favourite Shetland pony Bosse is out on the manege. HUS | ANNUAL REPORT 2012 | CARE

Medical

rapidresponse force Emergency care is required by patients for every imaginable reason. The trickiest cases are brain injuries requiring neurosurgery. Their treatment may easily involve dozens of people.

Miika Hokkanen, Chief of Emergency Medical Services in the Porvoo Hospital Area, travels by ambulance to wherever emergency care is needed.

HUS | ANNUAL REPORT 2012 | CARE

Ambulances and paramedics are the archetypal medical rapid-response force. In 2012, some 150,500 ambulance missions were recorded in the HUS catchment area. Of these, 7,400 involved a life-threatening situation. Additionally, the HEMS ambulance helicopter stationed at Helsinki-Vantaa Airport was called in for support in 2,050 cases. Out of the patients with life-threatening injuries in 2012, 793 were treated in what is known as the ‘shock room’ at the traumatology unit at Töölö Hospital; 273 required neurosurgical treatment, and 120 of them had a brain injury only.

Care Care Every case is unique Specialist Martin Lehecka from the neurosurgery clinic at Töölö Hospital explains that the condition of patients with brain injuries is widely variable. “Some walk out of here in a couple of days, while those with severe injuries may need to spend several weeks in the intermediate care ward. Further care and rehabilitation may take anything up to several years.” The number of people participating in the treatment of a patient arriving through the emergency services varies depending on the time needed for treatment and recovery, and also on the number of procedures, lab tests and imaging tests required. Surgery within an hour There is a neurosurgeon on call around the clock at Töölö Hospital, attending to every patient who arrives with a brain injury. “We often get basic information on the injuries even before the patient arrives. But the main thing in brain injury cases is the CT or computer tomography scan of the head. We do this next door to the shock room, and for head scans we get the results in a matter of minutes. In some cases, the referring unit sends us their images in advance,” says Martin Lehecka. If the diagnosis indicates that the patient requires surgery, an operation is organised within about an hour, even in the middle of the night. The operating theatre team includes the neurosurgeon on call, an anesthesiologist, an anesthesia nurse and two scrub nurses. “A five-member team like this can cope with any patient requiring acute neurosurgery arriving from the HUS specialist medical care area. But we can bring another team in at short notice if required.”

HUS | ANNUAL REPORT 2012 | CARE

New services for patients Patients discharged from the neurosurgery unit often need further monitoring or rehabilitation. It was for this purpose, to help patients make the transition back to everyday life and work, that the Brain Injury Outpatient Clinic was set up in October 2012. The Clinic is a multidiscipline expert team that improves early diagnostics and rehabilitation referral functions. At the beginning of 2013, HUS also introduced a 24-h pediatric neurosurgery pool which is responsible for all children in southern Finland that need a neurosurgery consultation, operation or other treatment.

• Eeva Mikkonen is a nurse at the intermediate care ward of the neurosurgery clinic at Töölö Hospital.

Specialist Martin Lehecka (left) and Aki Laakso, Administrative Deputy Chief Physician of the neurosurgery clinic at Töölö Hospital. CT scans of the head are a vital tool in the treatment of brain injuries.

1 in 3 gets cancer “A positive attitude to life is something you remember” Statistics show that one in three Finns will develop cancer at some time in their lives. Such a diagnosis is often a life-changing event, sometimes completely upsetting daily routines.

HUS | ANNUAL REPORT 2012 | CARE

The HUCH Department of Oncology at Meilahti in Helsinki is the epicentre of Finnish cancer treatment. Each year, some 13,000 individual patients receive treatment at the department, which works out at about 500 patients a day. Every patient is different, their conditions are unique, and every course of treatment must be planned separately.

But for many the situation is much better than it used to be: cancer treatments are constantly improving, and more and more patients recover. For instance, more than 90% of those diagnosed with breast cancer are completely free of the disease five years later. “Cancer is no longer a death sentence. With better treatments, many people recover completely or at least gain more good-quality life,” says Minna Sissonen, a nurse at the Department of Oncology. At the heart of the HUCH Department of Oncology are its highly competent professionals, whose work makes a crucial difference to many people’s lives. Sissonen is one of those professionals. Her job includes patient-specific orders for cytostatic or cell-inhibiting drugs, preparation of customised treatments, and monitoring of the patient’s condition and blood values before, during and between treatments. Sissonen also provides patient advisory services by phone and makes treatment bookings.

“Every nurse in treatment manages six patients a day. In the course of the day, we also prepare six patients for the next day. We receive a varying number of phone calls per day,” says Sissonen. Smiling in spite of worries For the patient, cancer is not just a physical problem which gets treated or whose progress is curbed with clinical procedures. It is a disorder that has a psychological impact too. In the course of treatments, nurses must be able to observe and fulfil the patient’s needs and wishes across the board. Even little things are important. “Our care relationships with patients vary in length from months to years. We get more deeply involved with some of our patients, but I do not really see myself as a friend to any one of them. We have to listen to the patients and support them. And, if necessary or if the patient wants it, we say nothing at all and just carry out the treatment.”

Care Care

Nurse Minna Sissonen:

We have to listen to the patients and support them. And, if necessary or if the patient wants it, we say nothing at all and just carry out the treatment.

The Department of Oncology is highly respected in the scientific and care communities, both in Finland and internationally. Sissonen believes that nurses hold the department in high esteem too and that it is a desirable workplace. More important than the achievements of the department, however, is the strength of its workplace community: the work is mentally strenuous, and the support of colleagues is at times absolutely vital. “I am happy with HUS in general and the Department of Oncology as a workplace in particular. The atmosphere is good and the work is varied. This is important for the ability to cope at work.” Although one might not guess it, the same positive attitude may be found in patients too. When one is in good hands, it is easy to smile however difficult one’s life situation may seem. “I remember many patients simply because of the brilliant attitude they had to life and their future, keeping up their spirits,” says Sissonen.

HUS | ANNUAL REPORT 2012 | CARE

HUS Psychiatry – the full cycle of life Mental health problems are often dependent on the life stage and age. • child psychiatry • youth psychiatry • adult psychiatry • geropsychiatry • forensic psychiatry • addiction psychiatry

Aiming for treatment without coercion Coercive measures have historically been used in psychiatric care in Finland rather more than in the other Nordic countries. Vaihtoehtoja pakolle (Alternatives to coercion) is a HUS Psychiatry project whose purpose is to cut down significantly on the use of coercive measures.

HUS | ANNUAL REPORT 2012 | CARE

As the development of psychiatry progresses at a fast pace, outpatient care is a real possibility for an increasingly demanding range of mental health problems. As hospitals get smaller, the patients in inpatient care tend to be increasingly complicated cases. How can this equation be resolved so as to not increase the use of coercive measures but instead to decrease it? The response of HUS Psychiatry is the Vaihtoehtoja pakolle (Alternatives to coercion) project. Its purpose is to cut down significantly on the use of coercive measures: the goal is to achieve a 40% decrease from the 2011 level by 2015. According to project manager Raija Kontio at HUS Psychiatry, alternatives to coercion are surprisingly easy to find. If one spends time with the patient, one gets to know them and to anticipate any tricky situations that may arise. And if a previously unknown patient is brought in from home in an agitated and aggressive state, that patient must be encountered calmly and with respect. There must be more than one person meeting the patient.

“Of course, it is a matter of professional skill to be able to tell for instance when a psychotic and restless drug user is really dangerous. Some psychosis patients do benefit from isolation,” says Grigori Joffe, Chief of the Department of Psychiatry at HUCH. The ‘Alternatives to coercion’ project is a continuation of efforts undertaken in recent years that are now bearing fruit. For instance, the number of cases where isolation has been imposed has decreased by 39% at Jorvi Hospital over the past four years and by an impressive 66% at Peijas Hospital. This has not been a steady decrease, however. Some parts of the organisation – Lohja, Länsi-Uusimaa and Porvoo – have a longer history of little use of coercive measures. At HUCH and at Kellokoski, the figures have typically been higher, because the patients’ conditions are more difficult. •

Care Care

Mental health rehabilitee Eve, 17, described her experiences of coercive measures in hospital in Husari 4/2012.

HUS | ANNUAL REPORT 2012 | CARE

Raija Kontio, Deputy Head of the Department of Psychiatry in the Hyvinkää hospital area

Cumulative duration of coercive measures (isolation and restraints) in relation to the number of treatment days, Kellokoski

Restraints % Isolation %

The ‘Alternatives to coercion’ project is a continuation of efforts undertaken in recent years that are now bearing fruit. At HUS Psychiatry departments in all five hospital areas – HUCH, Hyvinkää, Lohja, Länsi-Uusimaa and Porvoo – the numbers of cases where isolation and restraints have been used have decreased, as has the average duration of the measures imposed. Some parts of the organisation – Lohja, Länsi-Uusimaa and Porvoo – have a longer history of little use of coercive measures. But even with a low baseline, the number of cases and their duration were further somewhat reduced in 2012. In the HUCH area and at Kellokoski Hospital, isolation and restraints are far more commonly used than elsewhere. However, in the year under review the number of cases involving isolation and restraints have been reduced significantly at HUCH and Kellokoski too, and particularly the duration of the measures.

Goal 2015 0.5%

• Coercion can only be eliminated with the patient’s help Coercive measures leave the patient with a deep-seated memory. However confused, psychotic and aggressive they may be, every patient certainly remembers how they were received at the hospital and how many nurses were involved in dragging them into restraints. There has been a sea change going on in psychiatric medical care for a decade, and it is now being implemented at the ward level. In this grand service structure reform, the rights of the patient, participation and role enhancement are of key importance. “Thirty years ago, there was a behaviourist tendency in society at large, the idea that people need the stick and the carrot. Now we no longer have the stick: punishments are absolutely forbidden. However defiant and brazen a patient may be, he or she is nevertheless a suffering human being who must be helped,” says Joffe. “Without the cooperation of the patients, it would not be possible to cut back on coercive measures,” says Kontio. He wrote his nursing science dissertation on alternatives to coercive measures.

There are treatment methods in somatic medicine too that have fallen by the wayside,” says Joffe. For a real change to happen, almost everything has to change: management, training, tools and means of evaluation. Eliminating random actions requires evidencebased information, patient participation and debriefing. “Debriefing is a stressful process for the patient and the personnel, but it is important to give the patient feedback to explain that we do not condone violence,” says Kontio.

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Good care is human and negotiation-based. Patients and their family members are now listened to more closely than before. The patient is in full possession of his or her rights when arriving at the hospital, and these rights may only be infringed if the patient’s condition so requires. The care concept is centred on the patient as a human being. “It is important for the nurses to spend time with the patients on the wards, listening to their thoughts and wishes,” says Kontio. Personal primary nurses are expected to be the most familiar with their patients’ background, situation and resources. Treatments change over time Even the most extreme coercive measures, such as isolation and restraints, were originally conceived as treatments. Their motivation was to calm the patient down by eliminating outside impulses. Although times have changed radically in this respect, no one is blaming physicians and nurses for practices that used to be mainstream treatments. “Medical personnel back in the day acted according to the best information and instructions available at the time.

The goal level for restraints has already been passed

Goal 2015 0.1% 2009

2010

2011

2012

The final resort Coercive measures can probably never be completely abandoned. They continue to be available as a last resort if the aggression of a patient who is a danger to himself or herself and others cannot be defused in any other way. “We must be honest about situations involving violence. Some of them are really serious, even potentially lethal. It is important for the personnel to have all the support and help they need,” says Kontio.

Hoito Care Care

Pass around the experience

“Finally people are beginning to ask mental health rehabilitees themselves what they want,” says Annikka Niinikoski. She is a mental health rehabilitee with personal experience of a psychotic disorder. She has also undergone

Online Mental Health Centre getting bigger and better The online service known as Mielenterveystalo (Mental Health Centre) developed at HUS will continue to be maintained but will also be expanded for nationwide coverage. • www.mielenterveystalo.fi • www.nuortenmielenterveystalo.fi

HUS | ANNUAL REPORT 2012 | CARE

experiential expert training provided under the National Development Programme for Social Welfare and Health Care (Kaste). She is a member of the experiential expert group at the Rehabilitation Clinic at Peijas Hospital. The purpose of the group is to leverage its collective experiences to help improve psychiatric services in Vantaa and Kerava. “The quality of services will certainly improve with the contribution of experiential experts,” says nurse Kristiina Kuusi. She is the liaison employee for the experiential expert group, which meets once a month.

HUS will be partnered in this project by the hospital districts of Lapland, North Ostrobothnia, Central Ostrobothnia, Vaasa, South Ostrobothnia, Tampere Region and KantaHäme. Contact information for treatment and service locations in all participating hospital districts will be added to the two Mental Health Centre portals, one for adults and the other for young people. The expansion of the online service is made possible by a grant of EUR 1.35 million from the National Institute for Health and Welfare. The Nuorten mielenterveystalo (Youth Mental Health Centre) portal was completed for launch in 2012. This service provides young people with matter-of-fact information in an accessible form about mental health, mental health problems and how to deal with them. “The point of the Mental Health Centre is to provide reliable information. Young people are used to finding information on the Internet, and there is a lot of stuff online about mental health issues. However, relevant information is not always easy to find, and it is not necessarily reliable,” says nurse Marko Muukka.

Annikka Niinikoski is helping to improve psychiatric services

20% of young people suffer from mental health problems Mental health problems are a major and expensive social issue.

1 in 3 babies are born at HUS 6 maternity hospitals. 18,333 babies born in HUS hospitals in 2012 Over 25 % of Finnish women of childbearing age live in the HUS catchment area

Ask the midwife – Katri Tuura answers “The most frequently asked questions in the Kysy kätilöltä (Ask the midwife) online service have to do with the poster’s own pregnancy or delivery experiences,” says Katri Tuura. “There are also a lot of questions about pain relief.” Katri Tuura is a midwife at Hyvinkää Hospital. “I like the rapid-fire pace of the delivery room, where you have to put yourself and all your expertise on the line.” She lists the qualities required of a midwife: “Alertness, humility and a willingness to help people.”

HUS | ANNUAL REPORT 2012 | CARE

Katri Tuura’s diverse job description includes managing the popular ‘Ask the midwife’ online service together with physicians. Users post questions and comments about pregnancy and delivery. “I try to make time to read the e-mail on every working day. I post answers to questions about once a week if I can.” Katri Tuura and the physician on call ensure that the answers are factually correct. They are also more generally concerned with the quality of the service. “The things people ask about are very personal and sometimes extremely difficult for them. We have to respect our clients in carefully considering the tone and language of our answers.” Katri Tuura points out that the online service is specifically intended for non-urgent matters.“It is not an emergency response service. If you are having contractions or your waters break, or if you have issues with foetus movements, you need to contact a maternity clinic.”

Hoito Care Care

5,671 Babies born at HUS in 2012

HUCH / Kätilöopisto Maternity Hospital

3,420 HUCH / Jorvi Hospital

5,729 HUCH / Women’s Hospital

1,702 Hyvinkää

982 Lohja

829 Porvoo

The number of babies born was 273 fewer than in 2011. Deliveries increased at Hyvinkää Hospital and in Porvoo but decreased at other hospitals.

In 2012, a total of 18,333 babies were born at HUS. One of them was this new resident of Karjaa born at Lohja Hospital in December, 12 hours old when this photo was taken.

Lohja prepared for 1,000 deliveries The renovated maternity ward at Lohja Hospital was opened in December. It was expanded as well as renovated, now having 19 beds. “We can now deal with more than 1,000 deliveries per year,” says Anna Sariola, Head of the Department of Gynecology and Pediatric Care. The number of deliveries at Lohja Hospital has increased since the closure of the maternity ward at Länsi-Uusimaa Hospital, now standing at more than 900 per year as compared with the earlier 700 or so. The renovation of the maternity ward involved stripping everything right down to the external walls. Patient wellbeing is of particular importance. Every patient room has its own toilet and shower. The rooms are designed as single or twin rooms.“And we can turn any room into a family room,” says Sariola. The maternity ward also has a neonatal observation ward, enabling the parents

HUS | ANNUAL REPORT 2012 | CARE

to remain close to their baby even when the baby requires monitoring after birth. Midwife Jaana Laine notes that the renovation was completed at just the right time.“The timing was excellent considering the renovation and expansion undertaken at the Women’s Hospital. Now if they have a buildup in Helsinki, they can refer women to us for delivery.” The maternity ward will gain even more beds in the second stage of the renovation (scheduled for 2014–2015). •

The Amor basin is a fixture in one of the delivery rooms at Lohja Hospital. Smaller basins are fitted in the other two delivery rooms.“Water is excellent for soothing pain,” say Jaana Laine and Anna Sariola.

Tinja Lääveri (left) and Marja Valjus work at the Apotti project office as project manager and press officer, respectively.

am Ever y progr logic, ent has a differ ’t talk n o d y e h t d an her. to one anot eri Tinja Lääv

HUS | ANNUAL REPORT 2012 | WORK

Tinja Lääveri, a HUS Head of Department, has been an expert consultant in the planning of a shared client and patient information system for municipalities in the Helsinki Metropolitan Area and HUS. The new information system has been christened Apotti. “It would be vital to get a shared patient information system used by both primary health care and specialist medical care, as treatment paths commonly cross organisational boundaries. Currently all treatment plans and patient records run up against these boundaries. Details on medication have to be entered several times as patients move from one organisation to another. This takes time and compounds the potential for error,” says Lääveri, explaining why the much-publicised Apotti system is vital. • continued on the next page

Brief facts about the APOTTI project • the project involves HUS and the municipalities of the Helsinki Metropolitan Area (except Espoo, which opted out in 2013) • the goal is to create a shared information system for social welfare and health care services • the cost estimate is EUR 350 to 450 million over ten years • current information systems cost EUR 500 million to maintain over ten years

Work Care Work

Finland’s largest medical care organisation

Outi Sonkeri HUS Human Resources Director

21,738 experts 2,160 nursing staff 1 5,759 other employees 2,783 physicians 1,036 special employees

Focus on supervisors

56% 26%

13% 5

• Tinja Lääveri’s job in the Apotti project is to acquaint herself with patient information systems used in other countries and to chart the needs of the various sectors involved. The current situation is a jumble of systems that Lääveri finds unattractive. “Information is now fragmented and stored in a variety of different systems. Physicians sometimes simply have to guess where a particular item of information may be found, if at all. HUS users have to be conversant with several different systems. Physicians use four or five different programs all the time. And they all work according to a different logic,” complains Lääveri. HUS physicians waste precious time trying to discover exactly what was done in primary health care to a patient

HUS | ANNUAL REPORT 2012 | WORK

14%

86%

referred to specialist medical care. The information resides in a completely different software application and is grouped according to a different logic than in the HUS system. Looking at the big picture is decidedly difficult. If a unified patient information system is ever achieved, the patients will benefit the most. “When there is only a single set of data and a single treatment plan for physicians and nurses to look at, instead of them having to root around in a variety of systems trying to piece together the information, the patient will get better and more efficient care. In an advanced information system, patients will be able to book their own appointments and update their own patient information,” says Lääveri.

All indicators for supervisor work in the Working Life Barometer showed a positive development in 2012. Target levels were not yet attained, but the trend remained promising. The three-day supervisor coaching courses that were well received were continued, and current affairs days for supervisors were also held. More extensive supervisor and management training courses were also launched in 2012. Development discussions are a tool for operations planning and management. The instructions and forms pertaining to development discussions were revised in 2012. Particular attention was given to the situation of specialists in training and of special employees. The number of development discussions increased slightly, and the Working Life Barometer indicated that employees consider these discussions useful. The findings of the Working Life Barometer show that on average employees consider their working capacity to be good. Absences due to illness have decreased, as has the number of employees retiring on a disability pension. This is due partly to early support practices and to cooperation between supervisors, employees and occupational health care as prescribed in the Työkyvyn tuki (Working capacity support) programme. Various wellbeing-at-work projects were launched or continued in various departments in 2012. In 2012, the HUS Joint Authority received the Most Active Workplace in Finland award.

The sum of the expertise of professionals Occupational Safety and Health Manager, bioanalyst, Language Ombudsman, resuscitation coordinator, nurse, institutional catering cook. They described their jobs in the Yksi meistä (One of us) column in Husari in 2012.

JOINT AUTHORITY ADMINISTRATION

ceo IT Management

Chief Medical Officer

Anything at all can come up in the course of the working day, and then I have to find the answer.

HUS | ANNUAL REPORT 2012 | WORK

Administrative Chief Physician

Director of Administration

Hyksin Oy

Subsidiaries

Human Resources Director

Communications Director

CFO

Audit Director

Hospital Areas HUCH

Hyvinkää

Lohja

LänsiUusimaa

Porvoo

Teaching and Research

Medical support services

HUS Occupational Health

Non-medical support services

Department of Medicine

HUSLAB

HUS Real Estate Ltd.

HUS Desiko

Department of Surgery

HUS Medical Imaging

Uudenmaan Sairaalapesula Oy

HUS Logistics

Department of Gynecology and Pediatrics

HUS Pharmacy

Housing and property companies

Department of Psychiatry

Assistive Device Centre

Heart and Lung Centre

Susanna Puumi, Occupational Safety and Health Manager

Chief Executive Nursing Director

Tytäryhtiöt

HUS Ei sairaanhoidolliset Servis tukipalvelut HUS

Facilities Centre Ravioli

HUS-Työterveys

Jouni Leimukoski, bioanalyst

Stig Stolt, Language Ombudsman

What is interesting in this job is the people, both patients and coworkers.

Everything that is done at HUS embraces human, soft values. I like that.

Work Care Work

HUS is the most active in Finland Last year, HUS received the Most Active Workplace in Finland award. The Finnish Sport For All Association chose HUS as the recipient for its merits in improving personnel exercise activities.

HUS bus to Lohja, Porvoo and Raasepori On weekday mornings, HUS employees in Lohja, Porvoo and Raasepori can take the bus to work. For free.

“This transport service helps us recruit employees at least for Raasepori,” says Tom Löfstedt, Chief Physician at Länsi-Uusimaa Hospital. Thanks to the company bus, young employees do not immediately need to relocate to a new community or buy a car. The bus is also a welcome option for other employees who do not wish to spend their commute driving. The bus is also available to hospital patients. The Helsinki–Raasepori–Helsinki bus departs from the bus stop outside Kiasma at 06.25 and arrives at Länsi-Uusimaa Hospital at 07.55. The return trip departs in the afternoon. HUS outsources the bus service by competitive tendering and provides it free of charge for passengers.

Leila Saari, resuscitation coordinator

Riitta Majala, nurse

Laura Ahokas, institutional catering cook

Everyone who works in health care should take a CPR test regularly.

I love Kirra [the Surgical Hospital]. The atmosphere is great, and everyone knows each other.

People who say that hospital food is tasteless are stuck in the past.

HUS | ANNUAL REPORT 2012 | WORK

SUBS are made to roam In-house substitutes, or ‘subs’, are permanent HUS employees whose job is to substitute for other employees in a number of departments. Nurse Susanna Kiuru is a sub, or in-house substitute, by her job description. Her shift begins with her checking the online worklist to see to which ward she has been assigned. She may spend her day at Peijas Hospital on any of the surgical wards, at the emergency clinic or at the multi-clinic that handles Leiko (‘home-to-operation’) and preoperative functions. Susanna Kiuru’s career as a sub began with a coincidence: When she graduated 15 years ago, the employment outlook for nurses was poor. Substitute positions were the only ones that were on offer. She spent some time working on the various surgical wards at Peijas Hospital. She encountered all kinds of patients from babies to the elderly and all kinds of conditions from ear infection to cataracts. Ultimately, applying for a position as a permanent temp seemed only natural. “I am privileged to be learning such a lot. I enjoy variety, and I don’t want to be caught short whatever I’m required to do. I am now familiar with the treatment of surgical patients from top to toe,” says Kiuru. To do well as a sub, one has to have a good memory, a curious mind and a flexible attitude. The induction training is lengthy, and Kiuru cautions aspirants not to expect too much of themselves too soon. “You have to be social and adaptable. You must be able to get along with various kinds of patients, physicians and a wide variety of other coworkers. A thirst for knowledge helps.” •

HUS | ANNUAL REPORT 2012 | WORK

Nurse Susanna Kiuru:

A sub has to be social and adaptable. A thirst for knowledge helps.

Work Care Work

Nurse Susanna Kiuru begins her shift as a sub by checking the assignment list, showing which ward Kiuru has been assigned to. She is booked for weeks ahead.

• Alleviating concerns Patient safety and treatment quality goals dictate that a hospital must always have a certain minimum number of nurses; but someone is always off sick, taking care of a sick child or in training. Supervisors have to spend time finding substitutes, and if they end up having to turn to a temp firm, the cost is huge. Inexperienced substitutes do not even know what to do with demanding patients, and concern for the quality of care is at the back of everyone’s mind. When nurse Siru Lamppu began to consider what to improve at her workplace at Jorvi Hospital for her university of applied sciences thesis, human resources were the first thing that came to mind. Lamppu presented her idea of exploring and enlivening the system of in-house substitutes to Pia Keijonen, Manager, Human Resources at HUS, and she was immediately on board: this was something that would

HUS | ANNUAL REPORT 2012 | WORK

Working on several different wards requires a broad outlook and a wide range of expertise. Having worked as a sub for a decade, Susanna Kiuru has the creativity, social skills and willingness to learn new things that are required to do the job well.

have to be developed throughout HUS. While HUS had had a system of in-house substitutes or subs in place for some time, at many locations it was far from active. Sub appointments were used for instance to fill permanent personnel gaps on some wards. Now, a new permanent directive on subs has been published, providing clear guidelines on how subs should be employed and new positions created. When Lamppu asked the supervisors she interviewed the sub system should be improved, the response was unanimous: more subs. There was also a call for subs to be better paid. “If only I could have five or six more nurses! I would also like to see ward secretary subs competent for instance in handling IT and bookings, freeing up nurses to do what they do best,” says Tarja Särkioja, Head of Ward Group at Peijas Hospital.

Kiuru is familiar with the treatment of a surgical patient from top to toe and is comfortable with working in a variety of treatment environments. Many subs have been confounded by the fact that the storage rooms on every ward are organised in a different way. At Peijas Hospital, safety has been improved by applying the same scheme to every storage room.

In-house substitutes or subs are permanent HUS employees whose job is to fill in for short-term temporary absences. The sub system was overhauled in 2012 to increase the use of permanent personnel at HUS and to reduce the use of hired labour. There are subs in almost all occupational groups, although the majority of them are nursing employees.

ountries c c i d r o N e Th ther e g o t k r o w t mus cient ffi u s a e t a e to cr base population search. e r r e c n a c r fo o Petri Bon

HUS | ANNUAL REPORT 2012 | SCIENCE

Petri Bono, Head of the Clinic Group of Oncology: Because cancers are being analysed into ever smaller sub-groups, the Nordic countries must work together to create a sufficient population base for cancer research and thereby continue to acquire new early treatment drugs for testing. Norway will shortly become the first country in the world whose national health care system will include mapping the genome of every cancer patient. We will be adopting the same method in the future too. What this involves is that when a cancer patient is admitted to hospital, his genome is compared to a series of 30 to 40 panels to find out whether a biological smart drug is applicable. In ten or fifteen years from today, the routine in treating cancer patients will be to attack the driver that makes the tumour grow, not its anatomical locus.

Science Care Science

International leadership in scientific research and

Diversity in training In 2012, 129 doctorates and 285 medical degrees were completed in the training provided by HUS and the University of Helsinki. Moreover, some 4,000 health care students received 20,000 credits’ worth of practical training at HUS. Scientific research continued at a brisk pace.

Training for physicians and dentists is provided by the Faculty of Medicine, but the hospital plays a vital role

HUS | ANNUAL REPORT 2012 | SCIENCE

Clinical medicine research is worth it The reason why medical research is conducted is to reduce the number of situations where physicians have to say: “I’m afraid there’s nothing more we can do for you at this time.”

102

129

physicians

134

doctorates

dental specialists

The Helsinki Academic Medical Center, formed by HUS and the Faculty of Medicine at the University of Helsinki, is an internationally respected research leader and a significant teaching facility. It produces nearly as much research as all other Finnish university hospitals combined, and almost half of Finland’s specialists are its graduates. The Helsinki Academic Medical Center is one of the top five medical research centres in Europe.

Lasse Viinikka HUS Research Director

specialists

dentists

in clinical training and specialisation training. The number of degrees completed in medical training is holding stable, and cooperation with health care schools in the Helsinki Metropolitan Area remains close. A survey of training needs up to 2025 based on attrition of physicians, nurses and health care special employees and on future patient care needs was conducted to provide background information for the work of the specialist medical care area training group recently set up.

Research is viewed in different ways. While many understand how vital it is, there are opposite opinions too, even at university hospitals themselves. Hard data contributing to the debate was obtained last year with the completion of the report by Professor Pekka Karma on the impact of scientific research on treatments at HUCH. The impact proved to be highly significant: more than 80% of the researchers reported that their findings had led directly to the improvement of practical treatments, while 80% to 90% of nursing managers considered that research had improved the professional competence of their employees, the effectiveness of treatment and the productivity of operations. Research is also financially worthwhile. For instance, the research group led by Professor Tari Haahtela made a discovery about how asthma develops, and the treatment practice was changed accordingly. The need for hospitalisation and disabilities caused by asthma decreased substantially, and health care costs from asthma dropped by about EUR 300 to 400 million per year. In other words, the cost savings resulting from a single breakthrough by a single research group could fund all of the medical research being done in Finland today.

Clinical medicine research:

Massive impacts on patient treatment Apart from running hospitals, HUS is one of the most important research institutions in Finland. It aims to ensure that the methods used to treat patients are always based on the most recent knowledge. Scientific research and patient treatment are inextricably linked. Research produces new types of treatment and improves existing ones. HUS is a uniquely diverse research environment in the Finnish context, where research is both an attraction factor for top-quality professionals and improves patient treatment. Moreover, research can be proven beneficial by other indicators than improvement of treatment: in the USA and the UK, for instance, research has been found to generate financial benefits many times greater than the funds invested in the research. Similar experiences have been reported in Finland. Finland has always been a net exporter of health care technology, which is largely due to the successful commercialisation of ideas and inventions originally discovered at research institutions. One of the specific goals of HUS for 2012 was to boost the status of clinical medicine research in Finland’s national science and research policy. To this end, active publicity was conducted for instance about a recent report, unique even in the international context, on the impact of research

HUS | ANNUAL REPORT 2012 | SCIENCE

conducted at a university hospital on patient treatment. The impact proved to be huge, and clinical medicine research was demonstrated to be of crucial importance for improving service development. Government research funding continued to decrease, and with the enactment of the Health Care Act, a substantial change was implemented in its allocation. Clinics no longer have access to basic funding not subject to competition: all government funding must be allocated to projects based on applications. Although the amount of other competitive funding obtained by HUS researchers actually increased, the situation would have become rather difficult if the hospital district had not allocated funding of its own to research. Scientific competence will probably become one of the criteria by which patients choose where to be treated in the future. To improve the availability of information, a daily updated website featuring publications by research groups at Meilahti was created (www.terkko.helsinki.fi/helsin kischolarchart/?articles). Go have a look.

At the core of cancer know-how Finnish cancer research and treatment are at the international cutting edge. In certain spearhead cancer research projects, Finland is a world leader. These top results are grounded in the mundane yet high-quality work done every day for instance at the HUS Department of Oncology. More than 95% of the cancer patients in the HUS area are treated in public health care. “The strength of the Nordic countries is in that our public health care system is comprehensive and functions well,” says Petri Bono, Docent and Chief Physician in Charge of the Oncology and Hematology Clinic Group.“With cooperation between screening, primary health care, physicians and surgeons, we have created treatment paths whose outcomes are generally very good. We cannot claim to be better than the best centres in the USA, but we are not much worse either.” Finland’s extremely Petri Bono, Head of the good reputation in this Clinic Group of Oncology: field is fuelled by research on breast cancer, prostate With cooperation, cancer and cancers of the we have created gastrointestinal tract, and treatment paths on excellent basic research. “It takes years to get to whose outcomes are the top, because clinical generally very good. cancer studies are very long-lasting projects,” says Bono.

Science

34,900

cancer patients were treated at various HUS clinics in 2012. Sirpa Leppä, Head of the Department of Oncology:

the most common types of cancer in the HUS area in 2012

• breast cancer • colorectal cancer • lung cancer

• prostate cancer • lung cancer • colorectal cancer

Although breast cancer and prostate cancer are the most common types of cancer, they are not the worst. An increasing number of patients make a complete recovery. Both are very well known, thanks to research, and they also respond to treatment better than the average cancer.“They are the ones that people talk about the most, but other diseases are far worse at cutting life expectancies. I would like to see Finnish research getting better to grips with types of cancer where the five-year survival rate is less than 10%. Cancer of the stomach, liver or pancreas kills quickly,” says Bono. Professor Jorma Keski-Oja says that the value of cancer research is in discovering the development mecha-

HUS | ANNUAL REPORT 2012 | SCIENCE

nisms of cancer and to use that information for creating new cancer treatments, some of which will become permanent. Research activities at HUS will probably improve even further in the near future, as HUS is currently the only Finnish hospital belonging to the academic Nordic NECT network searching for patients to participate in 1st-stage and 2nd-stage cancer research. The other members of the network are university hospitals in Oslo, Stockholm and Copenhagen.“In the USA, it is relatively easy to find a population base of millions for a study. “The Nordic countries must work together to obtain a sufficiently large population base for research,” says Petri Bono. Jorma Keski-Oja hopes for better treatments for cancers

Biomedicine knows a lot about cancer, but it is the job of us clinicians to find out how to beat it.

that typically present in young people: leukemias, neuroblastomas or tumours of the central nervous system and children’s tumours.

Professor Jorma Keski-Oja:

The Children’s Hospital already provides probably the best cancer treatments in the world.

Cartilage replacement surgery is a tiny speciality in the area of orthopedics and traumatology. HUCH has concentrated these operations at Jorvi Hospital. The area is subject to active research and development, even though cartilage replacement has already become an established treatment method. “It’s a marginal area of surgery with a very small patient base. It’s a sort of developmental activity, and as such exactly the sort of thing that university hospitals are supposed to do,” says Juha Kalske.

A scrap of cartilage fixes a young knee Surgeons Juha Kalske and Teemu Paatela at Jorvi Hospital are developing cartilage replacement techniques for treating knee and ankle joint problems. Their ambition is that in the future biological tissue transplants could postpone or even prevent the need for artificial joints.

Cells from Jorvi to Gothenburg and back

Espoo, Jorvi hospital Gothenburg, Cell Matrix laboratory

HUS | ANNUAL REPORT 2012 | SCIENCE

20–30 patients per year In any one year, there are 20 to 30 patients for whom cartilage replacement surgery is suitable. “The aim of cartilage replacement is to postpone the need for an artificial joint, but we do not yet have findings to demonstrate that we have succeeded in this,” says Kalske. “Besides, it would be difficult to create a relevant research setup in the light of current knowledge. After all, you would need to have a control group that would not be treated,” says Teemu Paatela. What we do know is that if cartilage damage is not addressed in one way or another, the result is devastating. Physically strenuous work in particular is greatly disrupted by cartilage damage. In tricky locations such damage can not only produce pain and swelling but even impede walking.“The operation improves the patient’s quality of life and functional capacity. It’s also a pain treatment method; all patients have pain symptoms,” says Paatela. Knee or ankle most common Cartilage replacement surgery is indicated in very specifically defined cases of joint cartilage damage: it is not used to treat arthrosis. It is, however, suitable for preventing arthrosis.

Damage caused by rheumatic infections can also not be treated with cartilage replacement: there is no point in replacing damaged cartilage with more of the patient’s own cartilage when the patient has an autoimmune condition where the body is attacking its own cells. Those who are admitted to surgery are those whom it will benefit the most: patients for whom the joint damage is a real problem and leaving the problem untreated would lead to premature arthrosis at the age of only 20 to 40. Cartilage replacement operations are most commonly performed on the ankle or the knee. A number of hip operations have been done in Finland too. Joints in the upper limbs, by contrast, are subject to much less strain than those in the lower limbs, and any cartilage damage there does not have nearly as much potential to disrupt the patient’s life. The first operation is keyhole surgery to evaluate the nature of the cartilage damage. If the damaged area is sufficiently sharp defined, a biopsy is taken of the cartilage. One million cells and sixteen tubes of centrifuged blood are then flown to a specialist laboratory in Sweden, where the cells are multiplied: two weeks later, ten million cells return to Jorvi from Gothenburg. At that point, the second operation is undertaken in open surgery. The multiplied cartilage cells are installed at the operated location. The aim is for the transplanted tissue to grow healthy cartilage – the patient’s own. The process takes two years, and the patient’s condition will slowly improve throughout. Patients undergoing cartilage replacement surgery are generally basically healthy and young, aged between 20 and 40. Joint cartilage damage in a person over 40 is often the first symptom of arthrosis. However, age is not in itself a criterion for selecting patients if the damaged area is sharply defined and no tissue changes typical of arthrosis can be detected.

JORVI, ESPOO

10 million cells

A sample is taken of the patient’s cartilage: one million cells and 16 tubes of centrifuged blood are sent from Jorvi to Sweden.

cell MatriX, göteborg

In two weeks, the laboratory multiplies the patient’s one million cells into 10 million cells, which are then flown back to Jorvi.

At Jorvi, an operation is GOAL performed where the multiplied cells are transplanted into the damaged area. The goal is for the transplanted tissue to grow healthy cartilage – the patient’s own.

Science Care Science Slow and silent articular cartilage Articular cartilage is a slippery and flexible tissue that covers the articulate surfaces of joints. Its purpose is to equalise pressures on the joint. Articular cartilage has a slow 3 and silent life. Cartilage cells are few and far apart, and as far as is known they do not divide in healthy cartilage tissue. There are also no blood vessels in articular cartilage; the cells get their nutrients mostly from the synovial fluid. Articular cartilage, unlike bone, is not able to self-repair. Its cells cannot move or divide, which would be necessary for repairing damage.

Eeva Valvio with a syringe containing cartilage cells to be transplanted to a knee joint. There are millions of cells in this 1 ml syringe.

HUS | ANNUAL REPORT 2012 | SCIENCE

1 Juha Kalske and 2 Teemu Paatela are beginning an operation to repair local cartilage damage in a knee joint using the cartilage replacement technique. The operating theatre team at Jorvi Hospital also includes 3 supervising nurse Marjo Kotila, 4 anesthesia nurse Anu Perkkala and 5 scrub nurse Eeva Valvio.

Aaro Toivonen, HUS Head of Security: The security services unit at HUS Real Estate Ltd had 65 employees at the end of the year, most of them permanent and part-time security guards. Security guards are the â&#x20AC;&#x2DC;muscleâ&#x20AC;&#x2122; in hospital security, used to defuse threatening situations and to ensure the safety of both patients and medical personnel. However, intervention by security guards should not be the only or even the primary way of addressing such situations. Violent encounters in a hospital environment generally ensue between patients and hospital personnel, and therefore every employee should have basic security skills competence. At present, basic vocational education in health care does not provide sufficient instruction on how to handle violent situations; health care personnel have to learn on the job. Psychiatry probably has the most advanced security procedures at this time; in somatic care, such procedures are only just being introduced, adapted for that environment.

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

Security is an absolute pital must in hos operations. nen Aaro Toivo

ResponsiVastuu bility

SHARED EXPERTISE IS THE BEST EXPERTISE

Tapani Hämäläinen Chief Physician, Specialist in General Medicine, HUS primary health care unit

HUS handles all organ transplants in Finland In 2012, 310 organ transplants were made.

199

kidney

liver

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

A solid foundation

Kemi

Pursuant to the Health Care Act, the HUS primary health care unit was launched on 1 November 2012. The purpose of the unit is to reinforce primary health care by bringing the primary health care perspective to the hospital district. The duties of the unit can be summarised in three points. The first is drawing up a plan for organising health care in the HUS area. We support and contribute to the drawing up of this plan, as required in the Health Care Act. Secondly, the unit harmonises the research, development, design of treatment and rehabilitation paths and continuing education in primary health care. The third major duty is to anticipate personnel needs and to coordinate specialist medical care, primary health care and, as applicable, social services. The primary health care unit is also involved in training. The main goal is to ensure high-quality training for physicians and specialists and to facilitate a supply of competent and committed physicians for primary health care services. This is already being pursued together with the university and member municipalities. I would personally like to see the unit become a strong lobbyist for a network of regional development. This is particularly important now that the National Institute for Health and Welfare is no longer able to support the Rohto network as extensively as before. There is a need for linking the development network created under Rohto to the primary health care unit.

Kajaani Kokkola

A direct video consultation link to HUS enables the delivery of thrombolytic therapy also in smaller hospitals. When a patient in Kuopio, in Rovaniemi or on Åland needs an organ transplant, the patient is referred to a HUS clinic in Helsinki. When a patient with a brain circulation dysfunction is admitted to South Karelia Central Hospital in Lappeenranta, HUS specialists assist in the treatment – where time is of the essence – through a

Rovaniemi

HUS

Mikkeli Hämeenlinna Lappeenranta Kuusankoski Kotka Åland

video link. When an infant requires open-heart surgery, HUS surgeons perform the operation. HUS top expertise plays a crucial role in other specialist procedures too. Having a hospital organisation the size of a small city means having a wide range of support functions, all of which work commendably at HUS.

26 lung 1 heart-lung

heart

8 pancreas (simultaneous pancreas-kidney)

small intestine

Patient safety is the most effective when it is invisible The new Health Care Act that entered into force in 2011 put added focus on patient safety. The purpose of the HUS patient safety plan is to ensure that the methods used or the hospital environment itself do not expose the patient to unrelated risks.

Sari Palojoki, Head of Patient Safety:

Anticipation and prevention are the cornerstones of patient safety.

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

Everything that is done at HUS aims to ensure that patients are given safe and high-quality treatment – performed effectively, correctly and at the right time. Care and the care environment are key elements in patient safety. “Patient safety is a component of care quality and one of the fundamental principles of our operations. Our employees are required to ensure that the methods used are tested and effective and that drug treatments are administered safely, and so on,” says Sari Palojoki, HUS Head of Patient Safety. “In the best case, hospital safety is invisible: it is embedded in the facilities, management system, division of responsibilities, functioning processes and

above all expertise,” continues Aaro Toivonen, HUS Head of Security. Palojoki has a broad domain in ensuring patient safety. Toivonen, on the other hand, focuses on external factors, which includes employee security. Both share a clear vision of how to foster safety in a hospital environment. “A safe organisation can be described with the expression ‘alert uneasiness’, or a constant awareness of potential threats. This means dedicating part of your mind to considering whether things are OK, all the time,” says Toivonen. “We can avoid dangerous situations through anticipation and prevention,” says Palojoki.

ResponsiVastuu bility

Safety is everyone’s business Palojoki notes that patient safety is the business of all occupational groups at HUS. Also, legislation stipulates that patients and their families and friends should always be engaged in the promotion of safe treatment. “At the organisation level, the HUS Executive Board adopts an annual plan for the hospital district based on statutory requirements. One key function is entering all events that endanger patient safety in the Haipro reporting system, and then reviewing these events and taking corrective action. The main thing is to achieve a transparent and constructive culture of patient safety throughout the organisation,” says Palojoki. The basics of safety are near at hand.“Safety stems from the competence and attitudes of individual people. Technology and systems are helpful, and they must be kept in working order. But safety should not be thought of as something that is separate from our work; it must be embedded in everything we do, day in and day out,” says Toivonen. Patient safety risks often become apparent through near misses. “A threat to patient safety often comes from a low tolerance for deviations in the treatment process. We have to consider why the near miss happened and address the underlying risk. Personnel competence is important to uphold in the organisation from the risk management perspective too. Every employee in the health care sector must be able to identify the dangers inherent in human activities,” says Palojoki.

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

Safety expert Mikko Helin teaching course attendees how to use a fire extinguisher.

High demand for safety training In safety training for HUS personnel, demand exceeds supply. Courses are fully booked almost immediately after they are announced, employees being eager to join. HUS employees well understand the importance of personal competence

“Safety stems from the competence and attitudes of individual people. Technology and systems are helpful, and they must be kept in working order. But safety should not be thought of as something that is separate from our work; it must be embedded in everything we do, day in and day out. Safety is a feature of operations, not a separate function,” says Aaro Toivonen. In 2012, the security services unit of HUS Real Estate Ltd. organised 140 training events for personnel. The unit was also actively involved in the safety design of construction projects and building services. “Anticipation and planning are a must for undisrupted hospital operations,” says Toivonen.

Small actions, large environmental impacts The long-term, systematic efforts of HUS to improve energy efficiency and the eco-friendliness of its operations continued apace in 2012. Energy efficiency and materials efficiency is on an upswing in accordance with the HUS environmental programme for 2011–2015, and energy efficiency goals have been defined in nearly all areas of the HUS Joint Authority’s operations. The halfway goals of the National Energy Efficiency Agreement signed in 2007 have been attained: the energy conservation achieved by early measures (conservation measures between 1997 and 2007) and further measures between 2008 and 2011 totals about 15 GWh. Ecological equals economical When well implemented, energy efficiency improvements are not only environmentally friendly but economically profitable too. In 2011, building services audits were conducted at various HUS hospital properties. Corrective action taken on the basis of the audits in 2012 resulted in an 11% reduction in heating consumption and a 3% reduction in electricity consumption. Like energy efficiency, materials efficiency is taken into account in all HUS operations: carefully considered procurement, use, waste sorting, recycling and waste management are all important. HUS Logistics, the joint procurement unit for the HUS Joint Authority, adopted an environmental annex to its procurement and competitive tendering guide-

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

lines in March. This will improve both materials efficiency and energy efficiency during use. “In the Annex, environmental and energy efficiency are evaluated by product group, from textiles to pharmaceuticals and from medical equipment to furniture. The minimum requirements and evaluation criteria given in the Annex are applied to procurements on a case-by-case basis,” says Mirja Virta, HUS Head of Environment Management. 550,000 kg less waste A special focus was put on materials efficiency in a product group specific monitoring of the use of photocopier paper and disposable items. The monitoring showed that the use of photocopier paper, kidney dishes and disposable plates and cutlery decreased in the course of the year under review, while the use of disposable clothing increased. In 2012, HUS generated 7,060 tonnes of waste, which is about 550 tonnes less than in 2011. The percentage

In an organisation the size of a small city like HUS, even small actions may have large environmental impacts. Along with looking at the big picture, HUS focuses on eco-efficiency in everyday routines. of mixed waste delivered to a landfill has decreased to the national goal level of 20% because of waste sorting separating the energy fraction and the burning of mixed waste. More than 1,000 trained environmental officers The environmental officers working at various HUS units play a vital role in deploying the environmental programme. In the course of the year, HUS Environmental Centre organised courses that trained 92 new environmental officers. The 1,000 mark was exceeded on the course held in March. More than 700 of the environmental officers trained are still working at HUS units. The courses have been going on for nearly 15 years. “The training has played a significant role in increasing awareness of and competence in environmental matters. Without a competent and committed personnel, we could not have attained these effectiveness figures,” says Virta.

Mirja Virta, Head of Environment Management:

In materials and energy efficiency, small savings have large environmental impacts because of the sheer size of HUS. The resources saved can then be allocated to our basic functions.

ResponsiVastuu bility Senior Planning Officer Pirkko Väätäinen:

When more than 20,000 employees switch off their computers and turn out the lights at the end of the day, the savings in electricity consumption on the annual level are quite considerable. The adverse environmental and health impacts of the electricity production that is then not needed are also avoided.

Decrease in volume of landfill mixed waste generated, 2003 to 2012

Energy conservation week: information to motivate action In October 2012, HUS held an energy conservation week focusing on active distribution of information about energy matters, training and a variety of special events. The HUS energy conservation week was also noted by the media.“Employees at the Women’s Hospital were

interviewed on the news on MTV3. Environmental forum discussions were held at Länsi-Uusimaa and Hyvinkää, and at Lohja they held an exhibition of art works by schoolchildren with valuable tips,” says Pirkko Väätäinen, a Senior Planning Officer at the HUS Environmental Centre. The annual energy conservation week is an excellent vehicle for raising awareness of energy topics. Energy conservation is an ongoing concern at HUS, both in large projects and in everyday actions. Energy conservation means savings, and that means more resources available for treating patients.

Rejuvenation of the Meilahti Tower

Pioneer in energy efficiency

tonnes 3 500 3 000 2 500

The largest renovation project in the history of HUS is currently in progress at Meilahti in Helsinki.

2 000 1 500 1 000 500 0 2003 2004 2005 2006 2007

mixed waste delivered to landfill

2008

energy waste

2009

2010

2011

2012

mixed waste burned

In 2012, HUS generated 7,060 tonnes of waste, which is about 550 tonnes less than in 2011.

HUS | ANNUAL REPORT 2012 | RESPONSIBILITY

The renovation of the 16-storey Tower Hospital at Meilahti will involve a considerable improvement to its energy efficiency.“The new double-skin façade structure, new insulation, new windows and heat recovery through the new ventilation system will significantly reduce energy consumption,” says Vesa Vainiotalo, Construction Management Manager at HUS Real Estate Ltd.

Energy conservation will be a consideration in all solutions employed in the design of the Tower Hospital renovation, to be completed in 2014, including selection of equipment and materials. Also, geothermal energy will be used for heating and cooling through an extensive energy well field with 49 wells. Solar collectors installed on the roof will be used for floor heating in wet spaces.

Professor Juha Hernesniemi, Chief Physician of the Neurosurgery Clinic, Töölö Hospital: We are a clinic with a high reputation, specialising in neurosurgery only. We have an excellent and committed personnel and a lot of guests from abroad. This translates into a continuous process of evaluation and information exchange, besides attracting patients requiring our special expertise from elsewhere in Finland and also elsewhere in Europe. We work at full strength; that’s why we are always on budget. The support of HUS administration has been particularly important for our development over the years. We are financially relatively independent due to the extra income we generate from beyond the HUS area. Good care and good results bring more patients. We are asked to admit more patients than we can handle – we would need a lot more resources to cope with the present demand. We will be getting new facilities and a wholly new hospital within five years, and we are looking forward to that. Neurosurgery will remain one of the strengths of HUS, an area worth investing in.

HUS | ANNUAL REPORT 2012 | FINANCE

We work at h; full strengt that’s why ys we are alwa on budget. mi

esnie Juha Hern

Finance Care Finance

CHALLENGE: GROWING DEMAND

INVESTments 2012 eur 116 Million 2011 eur 98 million

HUS INVESTS IN THE FUTURE

In 2012 • population of the HUS catchment area was 1,562,440 • there were 2,497,533 billable patient events • cost per resident were about EUR 866

The year 2012 was the busiest year ever in the history of HUS. The costs of specialist medical care are constantly increasing with expansion of operations and general cost trends, posing a substantial challenge for local government finances. Despite this, HUS has been able to provide specialist medical care cost-effectively yet at a high level of quality. Compared with other university hospital districts, HUS has shown only a moderate increase in costs, and the deflated cost per resident of specialist medical care has actually gone down from 2006. HUS finances are based on the annual service plans drawn up with member municipalities. Most of the revenue consists of specialist medical care orders from local authorities: member municipalities are billed on

Anne Priha HUS Investment Manager

+18 M€

a monthly basis in advance, with adjustment invoices sent out four times a year based on actual treatment numbers. The HUS Joint Authority bills its patients’ home municipalities at cost prices, as the Joint Authority is a non-profit organisation. Specialist medical care is a highly labour-intensive service. High-tech equipment does help, but without top-class experts nothing can be done. Of the total costs of HUS amounting to EUR 1.7 billion, 64% consisted of personnel costs. EUR 116 million was spent in equipment and building investments to improve hospital operations. Depreciations went up to nearly EUR 100 million.

A major step was taken in the new hospital projects at Meilahti in autumn 2012. Three architects’ offices drew up parallel proposals for the placement on the campus of a building housing a children’s hospital, a traumatology hospital and a cancer centre. These proposals provided innovative insights into the environment where the most demanding kinds of specialist medical care provided at HUCH will be housed 5–10 years from now. They also embodied visions of what hospitals will look like in the 2020s besides presenting challenges for providing high-quality patient care more competitively than at present. The HUS Executive Board and Council made history by launching two hospital projects simultaneously and by adopting a financing solution for the children’s hospital that is unique in the Finnish context. The traumatology and cancer treatment building is intended to form a new physical anchor for the national role of HUCH. The children’s hospital will be a major national undertaking, with a large number of movers and shakers in Finnish society contributing along with HUS personnel. The new children’s hospital is ambitiously scheduled for completion in 2017, the year which marks the centenary of Finland’s independence. The new hospital projects have now been secured to such an extent that it is now time for HUS physicians, nurses and other experts to show their capabilities in reforming examination and treatment processes.

HUS | ANNUAL REPORT 2012 | FINANCE

MAJOR CONSTRUCTION PROJECTS

Mäntsälä

Karkkila

Länsi-Uusimaa Hospital Area • 2010– 2012 • cost estimate: EUR 3.4 million • actual 2012: EUR 2.4 million

Järvenpää Nurmijärvi Pornainen Tuusula Kerava Espoo

Raasepori

Renovation of wings E and F at Länsi-Uusimaa Hospital

HUS | ANNUAL REPORT 2012 | FINANCE

Vihti Lohja

Siuntio

Hanko

Lapinjärvi

Hyvinkää

Lohja Hospital Area

This analysis excludes projects of less than EUR 500,000; such projects totalled EUR 16.8 million in 2012.

Porvoo Hospital Area

Hyvinkää Hospital

Lohja Hospital Paloniemi Hospital

Actual investments in 2012: Länsi-Uusimaa Hospital Area • HUCH EUR 40.4 million • Länsi-Uusimaa EUR 2.4 million • Hyvinkää EUR 8.4 million • Porvoo EUR 1.1 million • Lohja EUR 3.6 million

Kellokoski Hospital

Hyvinkää Hospital Area

Inkoo

Vantaa

Kauniainen

Loviisa

Porvoo

Sipoo

Helsinki

Kirkkonummi Jorvi Hospital HUCH Hospital Area

Länsi-Uusimaa Hospital Tammiharju Hospital

Askola

Porvoo Hospital Peijas Hospital Helsinki: Aurora Hospital Herttoniemi Hospital Skin and Allergy Hospital Surgical Hospital Kätilöopisto Maternity Hospital Children’s Hospital Children’s Castle hospital

Meilahti Triangle Hospital Meilahti Tower Hospital Women’s Hospital Psychiatry Centre Eye and Ear Hospital Department of Oncology Töölö Hospital

HUCH, Jorvi Hospital extension

Excavators dug into Espoo soil at the end of last year as work began on the Jorvi Hospital extension. Rock blasting was among the first things to be done. • Alteration work at the day surgery department, 2011–2012 cost estimate EUR 636,000; actual 2012: EUR 447,000 • Additional building for emergency services, 2010–2015 cost estimate EUR 55 million; actual 2012: EUR 1.7 million • Renovation of pathology facilities, 2011–2013 cost estimate EUR 1.1 million; actual 2012: EUR 547,000 • Pneumatic mail system renovation, 2012–2016 cost estimate EUR 1.4 million; actual 2012: EUR 53,000

Talous Care Finance

HUCH

Eye and Ear Hospital • Backup power source project, 2011–2012 cost estimate EUR 830,000; actual 2012: EUR 766,000 Women’s Hospital • Annexe extension and renovation, 2010–2015 cost estimate EUR 42 million; actual 2012: EUR 3 million Kätilöopisto Maternity Hospital • Alterations for department of child psychiatry, 2011–2013 cost estimate EUR 800,000; actual 2012: EUR 72,000 Department of Oncology • Renovation and expansion of the northern section of the 1st floor, 2009–2013 cost estimate EUR 10.7 million; actual 2012: EUR 5 million • Equipment facilities for linear accelerators 9–10, 2010–2014 cost estimate EUR 6 million; actual 2012: EUR 323,000

Huch, Meilahti hospital

• Renovation of Tower Hospital, 2009–2014 cost estimate EUR 90 million; actual EUR 21 million • Renovation of ground floor of TP wing, phase 1, 2012–2014 cost estimate EUR 1.1 million; actual EUR 11,000 • Subterranean service yard, 2007–2014 cost estimate EUR 30.4 million; actual EUR 4.6 million • Electricity distribution network connection upgrade, 2012–2015 cost estimate EUR 5.7 million; actual EUR 56,000

HUCH, Children’s Castle hospital

The renovation of the elevation of Children’s Castle was exceptionally demanding. The International Working Party for Documentation and Conservation of Buildings, Sites and Neighbourhoods of the Modern Movement (DoCoMoMo) has named Children’s Castle as one of the landmarks of Modernist architecture. • Elevation renovation, phase 1, 2009–2012 cost estimate EUR 2.5 million; actual EUR 1.1 million Children’s Hospital • Roof, B arch, 2010–2012 cost estimate EUR 2 million; actual 2012: EUR 1.5 million

HUS | ANNUAL REPORT 2012 | FINANCE

HYVINKÄÄ HOSPITAL

• Acute hospital annexe, 2009–2012 cost estimate EUR 9.9 million; actual 2012: EUR 3.1 million • Endoscopy unit alterations, 2010–2013 cost estimate EUR 2.1 million; actual 2012: EUR 876,000 • Central kitchen renovation, phase 1, 2011–2012 cost estimate EUR 1.2 million; actual 2012: EUR 815,000 Kellokoski Hospital • Renovation of Ohkola Hospital, phase 1, 2009–2012 cost estimate EUR 7.1 million; actual 2012: EUR 3.5 million • Renovation of Ohkola Hospital, phase 2, 2011–2014 cost estimate EUR 3.6 million; actual 2012: EUR 74,000

PORVOO HOSPITAL

• Renovation of patient wards, phase 1, 2011–2014 cost estimate EUR 3.9 million; actual 2012: EUR 223,000 • Construction of a waste station, 2011–2013 cost estimate EUR 1.2 million; actual 2012: EUR 904,000

LOHJAN HOSPITAL

• New psychiatry building, 2010–2015 cost estimate EUR 22.6 million; actual 2012: EUR 807,000 • Renovation of patient ward 2, phase 1, 2010–2012 cost estimate EUR 3.4 million; actual 2012: EUR 2.8 million

A YEAR OF ECONOMISING Care services The overall volume of care services increased on the previous year. In 2012, there were 1,580,702 outpatient visits (+0.8%), 607,245 treatment periods (DRG) and 233,755 inpatient day products (-6.2%). Volume growth weighted by billing share was 2.5% on the previous year, over budget by 2.6%. At the level of HUS as a whole, the cost per resident for member municipalities averaged at EUR 866. Costs decreased by 1.8% compared with figures adjusted by the 2011 hospital price index (deflation coefficient 1.036). The productivity goal (1.5%) was not attained during the year under review, as the actual production was more expensive than estimated. Productivity trends are monitored using DRG-based indicators for somatic care service production. Compared with 2011, the productivity of person-work decreased (-0.4%), while deflated DRG point productivity increased (+0.9).

HUS member municipality contributions, EUR per resident, and percentage of change on the previous year EUR/resident 900

+2%

850

-0.5%

-0.3% 800

-1.8%

750

-3.1% 700 Annual 2008 accounts

2009

EUR/resident, deflated

2010 EUR/ resident

2011

2012 Change, %

Costs to HUS member municipalities in 2012 averaged

EUR 866 per resident, 1.8% less than in 2011.

HUS | ANNUAL REPORT 2012 | FINANCE

Talous Care Finance

Patients treated, percentage of population by member municipality Population 2012, prediction (Source: Statistics Finland)

HUS treated nearly

500,000 patients

Sipoo Porvoo Pornainen Loviisa

in 2012. The number of persons treated increased by 0.9%

Lapinjärvi Askola Tuusula Nurmijärvi Mäntsälä

Patients treated The number of individual patients treated in specialist medical care (including outsourced services), excluding health centre patients at joint emergency service clinics, was 469,921 (+0.7% compared to 2011). The number of individual patients using specialist medical care services produced by HUS itself was 452,998 (+0.5%). The total number of patients treated, including health centre patients at joint emergency service clinics, was 497,826 (+0.9%). Specialist medical care services included in service plans were used by 445,932 individual residents of member municipalities. This represented an increase of 0.5% on the previous year, as opposed to the 1.1% growth of the population of the HUS catchment area. About one in three residents of the member municipalities (29%) used specialist medical care services produced or organised by HUS in 2012. Use of services in relation to population varies significantly between municipalities.

HUS | ANNUAL REPORT 2012 | FINANCE

Järvenpää Hyvinkää Vihti Siuntio Nummi-Pusula Lohja Karkkila Karjalohja Raasepori Inkoo Hanko Kirkkonummi Kerava Kauniainen Vantaa Helsinki Espoo Average for member 20 municipalities %

Availability of treatment, access to treatment and transfer delays The number of external elective non-urgent referrals has been increasing in recent years and in the year under review increased by 1.7% on the previous year. Health centres send the most such referrals, accounting for nearly 60% of all referrals each year. The total number of patients waiting for treatment increased on the previous year. At the end of the year, there were 16,678 patients covered by the care guarantee waiting for admission to inpatient care. At the end of the year, there were 409 patients who had been waiting for treatment for more than six months (2011: 119). Of the patients waiting to be admitted to inpatient care, 76% had waited for less than three months. At the end of the year, there were 24,991 patients covered by the care guarantee waiting for admission to outpatient examinations and treatment. The number of patients who had waited for an outpatient examination for more than three months also decreased significantly: at the end of the year, there were 964 such patients, 89 of whom had waited for more than six months. The number of transfer delay days in 2012 was 36,430 (+0.1% on the previous year). There were 8,227 transfer delay patients treated (2011: 8,136). The introduction of the billable transfer delay inpatient day as of 1 July 2011 has not affected transfer delays as anticipated. There were 11,341 billable transfer delay day products in the year under review, for a total billing of EUR 5.0 million.

HUS | ANNUAL REPORT 2012 | FINANCE

indicators

HUS

HUCH

2012

2011

2012

2011

NordDRG products

607,245

593,301

485,952

474,544

Inpatient day products

233,755

249,173

107,589

114,173

1,580,702

1,567,593

1,169,888

1,161,713

75,831

73,197

41,788

38,590

2,497,533

2,483,264

1,805,217

1,789,020

Operations

89,455

90,705

71,234

72,416

Births

18,099

18,328

14,605

14,873

452,998

450,913

361,058

359,190

2,935

3,106

1,988

2,129

Number of staff

21,738

21,322

11,690

11,500

Operating income, EUR million

1,747.6

1,674.9

1,251.5

1,217.8

Operating costs, EUR million

1,668.9

1,584.7

1,263.1

1,210.8

1,562,440

1,545,034

1,146,716

1,131,372

866.1

851.7

826.5

818.6

Visit products Health centre visit products Invoiced patient events

Number of individuals using HUS services (own activities, specialist medical care) Hospital beds

Population of the HUS catchment area 31.12. (Population 2012, prediction) Member municipalitiesâ&#x20AC;&#x2122; contributions, EUR per resident, average (non-deflated, population as at 31 December)

Talous Care Finance

Profit and Loss Account

Change, % FS 2012/ FS 2011

FS 2008

FS 2009

FS 2011

Budget 2012

1,490,522

1,547,869

1,584,430

1,674,917

1,711,642

1,744,580

1.9%

4.2%

1,425,532

1,479,476

1,512,931

1,598,822

1,632,714

1,668,651

2.2%

4.4%

49,328

52,874

56,916

57,052

62,207

58,679

-5.7%

2.9%

Subsidies and grants

7,028

6,256

5,873

9,822

5,838

6,815

16.7%

-30.6%

Other operating income

8,634

9,263

8,710

9,221

10,882

10,435

-4.1%

13.2%

Operating costs total

1,405,882

1,451,925

1,485,920

1,584,651

1,603,804

1,668,902

4.1%

5.3%

Personnel expenses

893,934

922,647

953,389

1,009,998

1,023,176

1,068,950

4.5%

5.8%

Purchased services

195,499

201,406

202,978

219,299

232,450

234,899

1.1%

7.1%

Materials, supplies and consumables

274,248

285,544

287,606

310,422

301,695

315,456

4.6%

1.6%

546

553

443

875

827

785

-5.1%

-10.3%

41,655

41,775

41,504

44,057

45,657

48,811

6.9%

10.8%

84,640

95,944

98,510

90,266

107,837

75,678

-29.8%

-16.2%

11,831

13,759

13,599

12,793

15,400

13,588

-11.8%

6.2%

72,809

82,185

84,911

77,473

92,437

62,090

-32.8%

-19.9%

Depreciation and reductions in value

75,521

82,181

85,711

93,573

104,437

97,597

-6.5%

4.3%

Surplus/deficit for financial year

-2,712

-800

-16,100

-12,000

-35,507

1,481,403

1,534,106

1,571,631

1,678,224

1,708,242

1,766,499

3.4%

5.3%

EUR 1,000 Operating income total Sales proceeds Payments income

Subsidies and grants Other operating expenses Operating margin Financial income and expenses Result before depreciation and extraordinary items

Total operating expenses and depreciation

HUS | ANNUAL REPORT 2012 | FINANCE

Deviation FS 2012/ Budget 2012

FS 2010

FS 2012

HUS finances The operating deficit for the financial period was EUR 21.6 million (budget: EUR -12.0 million). The financial performance was encumbered by a cost of EUR 13.9 million caused by the annual holiday reform in the local government civil service and employment collective agreements. The total deficit for the financial period was thus EUR 35.5 million. Billing for medical care services from parties other than member municipalities (EUR 127.2 million) developed favourably. The actual figure exceeded the budget by 5.3% and showed a growth of 8.0% on the previous year. The combined contributions of the member municipalities (for specialist medical care services) exceeded the budget by 1.7%, being EUR 22.2 million. In terms of volume, the use of services by member municipalities exceeded the budget. However, the average billing for the services used was below budget. The operating costs exceeded the budget by 4.1% (EUR 65.1 million). The compatible budget excess in operating costs was 3.2% (EUR 51.2 million), taking into account the aforementioned increase in holiday pay liabilities due to the collective agreement amendment. The compatible budget excess in operating costs (3.2%) was larger than the budget excess in operating income (1.9%), hence the greater than budgeted deficit. Compatible growth of operating costs on the previous year was 4.4% (EUR 69.6 million), taking into account the costs of the emergency case services that began in 2012 and the impact of the collective agreement annual holiday reform in 2011 (EUR 10.2 million) and 2012 (EUR 13.9 million).

DISTRIBUTION OF HUS OPERATING INCOME IN 2012

3.4%

Special Payments Other operating state income income and subsidies subsidies

10.2% 77.6%

Member municipalities’ contributions

4.7% Lohja

HUS | ANNUAL REPORT 2012 | FINANCE

Other Other operating materials, expenses and supplies and subsidies consumables

Drugs and medical supplies

Other service and sales income

Distribution of member municipalities’ contributions in 2012, %

3.2%

15.7%

16%

Purchase of other services

3.9%

64.1%

Personnel expenses

Purchase of medical care services

4.1% 1.4% 0.4%

Porvoo Group Assistive adminis- Device tration Centre

9.5%

Hyvinkää

2.7%

LänsiUusimaa

77.1% HUCH

Distribution of HUS operating costs in 2012

See the HUS financial statements and annual report for 2012 at: www.hus.fi/HUS-Tietopankki/Hallinto ja päätöksenteko/Talous

Talous Care Finance HUS LOAN PORTFOLIO AND EQUITY RATIO

Investments

220

HUS makes investments in the future, in the improvement of patient care and in the promotion of its competitiveness. Projects completed during the year under review include new facilities for acute care at Hyvinkää Hospital, alterations to the Day Surgery Unit at Jorvi Hospital, and the 1st phase of the renovation of the youth psychiatry facilities at Ohkola. The major HUS construction investments – the Meilahti Tower Hospital, the Women’s Hospital and the extension at Jorvi Hospital – progressed according to plan. Planning was initiated for new projects at Meilahti: the Children’s Hospital, the Traumatology Centre and the Cancer Centre. Investments in 2012 totalled EUR 116 million, of which EUR 73 million in new construction and renovations. Research and medical care equipment investments safeguard sufficient capacity for treatment andimaging of cancer and cardiology patients, leveraging emerging technology. In 2012, nearly EUR 22 million was spent on examination and treatment equipment. HUS Information Management invested about EUR 19 million in the development of patient information systems, various ERP and reporting systems and basic IT services in 2012.

160

98 M€

60 40

Investments

20 0 Financial 2008 statements

Poistot 2009

2010

2011

2012

140

Equity ratio

120

39.9%

100 Financial 2008 statements

2010

2011

2012

During the financial period, HUS withdrew EUR 40 million in long-term loans and repaid EUR 10.5 million on outstanding loans. Adequacy of cash flow remained at the planned level (23.4 days). The HUS equity ratio was 39.9%. Net financial expenses (EUR -13.6 million) were EUR 1.8 million under budget. The average interest rate for the HUS loan portfolio in 2012 was approximately 1.9% (2011: 2.3%), and the average interest rate for money market investments was 0.9% (2011: 1.5%). The loan portfolio stood at EUR 224.2 million as at the end of the year, while liquid assets stood at EUR 116.5 million. At the time of the closing of the accounts, 32% of the interest risk in the HUS loan portfolio was hedged. About 70% of the interest risk in the net loan portfolio, taking short-term HUS liquidity investments into account, was hedged.

Adequacy of cash flow

HUS makes investments in the future, in the improvement of patient care and in the promotion of its competitiveness.

23.4 days 20 Minimum target 15 2008 Financial statements

HUS | ANNUAL REPORT 2012 | FINANCE

2009

Funding

120

116 M€

224.2 M€

180

HUS investments and depreciation

100

Debt portfolio

200

2009

2010

2011

2012

PROFIT AND LOSS ACCOUNT (EUR 1,000)

Operating income Sales proceeds Payments income Subsidies and grants Other operating income

FINANCIAL INDICATORS FOR THE PROFIT AND LOSS ACCOUNT 1,675,597 1,605,250 1,668,651 1,598,822

HUS Group HUS Joint Authority 1.1.-31.12.2012 1.1.-31.12.2011 1.1.-31.12.2012 1.1.-31.12.2011 58,679 6,822 15,392

57,052 9,826 13,776

58,679 6,815 10,435

57,052 HUS GROUP 9,822 9,221 100 %

1,756,491 1,685,904 1,744,580 1,674,917

104.8

65.7 Operating expenses Personnel expenses Salaries and fees -881,975 -836,259 -863,963 -819,346 Social security expenses 2008 2009 2010 2 011 2012 Pension expenses -153,522 -142,933 -150,276 -139,849 operating income / operating costs, % Other social security expenses -55,756 -51,762 -54,712 -50,804 result before depreciation and Purchased services -208,890 -194,796 -234,899 -219,299 extraordinary items / depreciation, % Materials, supplies and

consumables Subsidies Other operating expenses

Share of business enterprisesâ&#x20AC;&#x2122; enterprisesâ&#x20AC;&#x2122; profit/loss

-1,676,160 -1,592,354 -1,668,902 -1,584,651 100 % -95

299

104.5 63.6

Operating margin Financial income and expenses Interest income Other financial income Interest expenses Other financial expenses

80,236 93,849

75,678

90,266

1,095 136 -3,997 -11,876

2,385 169 -4,289 -11,960

1,694 133 -3,670 -11,745

2,821 operating income / operating costs % 166 result before depreciation and -4,014 extraordinary items / depreciation, % -11,766

-14,642

-13,694

-13,588

-12,793

65,594

80,154

62,090

77,474

-99,820 0

-96,096 128

-97,597

-93,573

Result before depreciation and extraordinary items Depreciation and reductions in value Depreciation according to plan Extraordinary items

-324,462 -319,305 -315,456 -310,422 -785 -875 -785 -875 HUS JOINT AUTHORITY -50,769 -46,425 -48,811 -44,057

2008 2009 2010 2 011 2012

Annual result Tax reserves Minority share

-34,226 -15,813 -35,507 -16,100 -1,613 -501 1 13

Surplus/Deficit for financial year

-35,838 -16,301 -35,507 -16,100

HUS | ANNUAL REPORT 2012 | FINANCE

Talous Care Finance

CASH FLOW STATEMENT (EUR 1,000)

HUS Group 2012

2011

HUS Joint Authority 2012 2011

Operating cash flow Result before depreciation and extraordinary items 65,594 80,154 62,090 77,474 Extraordinary items 0 128 0 0 Adjusting items for cash flow financing 178 838 179 1,284 Investment cash flow Investment expenses -124,176 -105,737 -115,818 -94,738 Investment expenses financing shares 0 116 0 116 Capital gains for fixed asset items 4,814 2,591 4,510 2,300 Operating and investment cash flow

-53,590

-21,909

-49,040

-13,564

Financing cash flow Changes in loans Increases in loan receivables 0 -11 -9,000 -11,411 Decreases in loan receivables 8 99 3,399 572 Changes in loan portfolio Increase in long-term loans 40,230 30,030 40,000 30,000 Decrease in long-term loans -11,663 -13,561 -10,540 -12,425 Change in short-term loans 0 0 0 0 Changes in capital and reserves 0 0 0 0 Changes in minority share 0 0 0 0 Other changes in liquidity Changes in inventories 2,041 -633 2,031 -645 Change in receivables -8,361 -6,139 -8,594 -6,543 Change in interest-free debts 26,794 20,367 26,688 22,001 Financing cash flow

49,048

30,153

43,984

21,549

Change in liquid assets

-4,542

8,244

-5,057

7,985

Liquid assets Liquid assets as at Jan 1

119,103 123,645

123,645 115,401

116,489 121,546

121,546 113,561

-4,542

8,244

-5,057

7,985

Change in liquid assets

HUS | ANNUAL REPORT 2012 | FINANCE

FINANCIAL INDICATORS FOR THE CASH FLOW STATEMENT HUS GROUP

Investment cash

2012 2011 2010 2009 2008 52.8

75.9

73.2

75.6

89.3

68.6

90.0

66.0

68.8

77.1

flow financing, % Capital expenditure cash flow financing, % Debt coverage ratio Cash disbursements EUR million Adequacy of cash flow (days)

4.4 4.7 5.3 5.6 4.2 1,828 1,728 1,645 1,603 1,531

23.8 26.1 25.6 27.7 25.6

HUS JOINT AUTHORITY 2012 2011 2010 2009 2008 Investment cash flow financing, %

53.6

81.9

76.0

75.4

88.3

Capital expenditure cash flow financing, %

47.1

65.7

65.3

68.2

75.6

Debt coverage ratio

4.6 5.0 5.4 6.4 5

Cash disbursements EUR million 1,820 1,719 1,634 1,589 1,521 Adequacy of cash flow (days)

23.4 25.8 25.4 27.6 25.4

• Investment cash flow financing, % = 100 * Result before depreciation and extraordinary items / Investment self-acquisition expenses • Capital expenditure cash flow financing, % = 100 * Result before depreciation and extraordinary items / (Investment self-acquisition expenses + loans net increase + loan amortizations) • Debt coverage ratio = (Result before depreciation and extraordinary items + Interest expenses) / (Interest expenses + Loan amortizations) • Adequacy of cash flow (days) = 365 days * Liquid assets Dec 31 / Cash disbursements during financial year

BALANCE SHEET (EUR 1,000) ASSETS

HUS Group HUS Joint Authority 2012 2011 2012 2011

NON-CURRENT ASSETS Intangible assets Intangible rights Other long-term expenses Intangible assets

173 46,407 46,580

Tangible assets Land and water Buildings Immovable structures and equipment Machinery and equipment Other tangible assets Advance payments and purchases in process

12,279 12,375 10,745 10,866 484,322 497,569 458,594 473,437 12,550 13,521 12,550 13,521 85,929 89,118 81,339 84,363 761 813 138 138 99,226 64,621 83,098 53,033

Tangible assets Investments Business enterprise shares and similar rights of ownership Other shares and similar rights of ownership and revaluation reserve Other loan receivables Other receivables Investments NON-CURRENT ASSETS CONTRACT-RESTRICTED ASSETS CURRENT ASSETS Inventories Receivables Non-current receivables Current receivables Receivables Investments Cash in hand and at banks CURRENT ASSETS

173 42,295 42,468

0 45,907 45,907

0 41,913 41,913

695,068

678,017

646,465

635,358

14,649

14,927

14,716

14,766

3,054 516 254

3,054 524 254

6,344 29,976 254

6,344 24,376 254

18,472 18,759 51,290 45,739 760,119

739,243

743,663

723,010

4,057

4,094

4,057

4,094

18,203 20,244 18,046 20,077 577 78,275

586 69,905

577 78,099

586 69,496

78,852 70,491 78,677 70,082 44,071 56,792 44,063 56,783 75,031 66,853 72,427 64,763 216,158 214,380 213,213 211,705

TOTAL ASSETS 980,335 957,717 960,933 938,809 52

HUS | ANNUAL REPORT 2012 | FINANCE

Talous Care Finance

BALANCE SHEET (EUR 1,000) HUS Group LIABILITIES CAPITAL AND RESERVES Subscribed capital Other own reserves Surplus/deficit from previous financial years Surplus/deficit for financial year CAPITAL AND RESERVES MINORITY SHARES

HUS Joint Authority 2012 2011 2012 2011

391,253 1,031 27,025 -35,838 383,471

391,253 1,031 43,326 -16,301 419,309

391,253 0 25,748 -35,507 381,493

2,599 2,600

391,253 0 41,847 -16,100 417,001

DEPRECIATION AND UNTAXED RESERVES Depreciation difference Untaxed reserves

1,419 3,641

789 2,661

0 0

DEPRECIATION AND UNTAXED RESERVES

5,060

3,450

PROVISIONS Provisions for pensions Other provisions

2,737 38,212

2,737 36,692

2,737 38,212

2,737 36,692

PROVISIONS CONTRACT-RESTRICTED CAPITAL LIABILITIES Long-term interest-bearing liabilities Long-term interest-free liabilities Short-term interest-bearing liabilities Short-term interest-free liabilities

40,949 39,429 40,949 4,057

4,094

4,057

39,429 4,094

FINANCIAL INDICATORS FOR THE BALANCE SHEET Equity ratio 40.1% HUS GROUP

40.1 44.7 47.6 47.8 50.4

Relative indebtedness, %

30.7 28.6 27.9 28.2 26.1

Loan portfolio 31.12. (EUR 1,000) Loan receivables 31.12. (EUR 1,000)

197,518 2 12,482 278,831

214,886 0 9,270 310,277

184,156 0 10,540 283,590

LIABILITIES

544,199 488,835 534,434

478,286

TOTAL LIABILITIES

980,335

938,809

957,717

960,933

238,568 210,001 193,532 206,713 157,505

516 524 623 626 629

Equity ratio 39.9%

HUS JOINT AUTHORITY

Equity ratio, %

228,325 2 10,243 305,629

2012 2011 2010 2009 2008

Equity ratio,%

2012 2011 2010 2009 2008 39.9 44.7 47.8 48.1 51.2

Relative indebtedness, % 30.3 28.2 27.3 27.6 25.1 Loan portfolio 31.12. (EUR 1,000) Loan receivables 31.12. (EUR 1,000)

224,156 194,696 177,122 189,556 138,746

29,976 24,376 13,547 7,551 5,190

• Equity ratio, % = 100 * Capital and reserves / (Capital and reserves total – Advances received) • Relative indebtedness, % = 100 * (Liabilities – Advances received) / Operating income • Loan portfolio 31.12 (EUR 1,000 ) = Liabilities – (Advances received + Trade creditors + Accruals and deferred items + Other creditors) • Loan portfolio 31.12 (EUR 1,000 ) = Other loan receivables in investments

HUS | ANNUAL REPORT 2012 | FINANCE

HUS is Finland’s largest provider of specialist medical care services and second largest employer. Our expertise is of an internationally high standard. We produce services for nearly 1.5 million residents and have nationwide responsibility in certain areas of specialist medical care. Every year, nearly half a million patients are treated at the 22 HUS hospitals. Employing about 21,000 health care professionals, HUS has a turnover in excess of EUR 1.7 billion.

Stenbäckinkatu 9, PO Box 100, 00029 HUS, tel. +358 9 4711

www.hus.fi • www.facebook.com/HUS.fi • twitter.com/HUS_uutisoi • www.linkedin.com/company/hospital-district-of-helsinki-and-uusimaa-hus• www.youtube.com/HUSvideot • www.issuu.com/husjulkaisut HUS is a non-smoking organisation.

ANNUAL REPORT 2012 • Texts: Paavo Holi, Antti Kantola, Riitta Lehtonen, Sari Lommerse, Merja Mäkitalo, Johanna Saukkomaa, Totti Toiskallio, Lotta Tuohino • AD, layout: Teija Himberg, Zeeland • Cover image: Markus Sommers • Pictures: Mikael Ahlfors, Eeva Anundi, Mikko Hinkkanen, Jussi Kirjavainen, Timo Löfgren, Jarmo Nummenpää, Liia Pienimäki, Matti Snellman, Markus Sommers, Kai Widell • Printers: Hämeen Kirjapaino, 2013

441 209 Painotuote HÄMEEN KIRJAPAINO OY 2011

HUS | ANNUAL REPORT 2012