The Future Hospital in Finland: Our Changing Expectations

Expectations for Integrated Health Care
and Building New Hospitals
Design and Health Europe, 2012
Biomedicum Helsinki
Carola Grönhagen-Riska
Professor, Chief physician
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Finland today and in the future
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Urbanization
Ageing
Decreasing work force
Economy weakened
Primary Health Care weakened
Social Care under pressure
Specialized Care functioning, but smaller
districts under pressure. Networking between
hospitals insufficient (except HUS)
The goal: Integrated Health Care System – How?
Much pressure to build new Health Care Facilities,
Hospitals not in the least
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Finland has 20
hospital districts
Lappi
Population was 5 347 000 in 2010
The population of hospital districts varied 46 000 –
1 528 000 (HUS)
LänsiPohja
Primary health care is arranged by the communes
and there are hundreds of health care centres and
communally arranged nursing homes and long-term
in-patient wards
Communes have varying capability to take
care of their responsibilities
PohjoisPohjanmaa
Kainuu
KeskiPohjanmaa
Pohjois-Savo
Vaasa
Pohjois-Karjala
EteläPohjanmaa
Keski-Suomi
Doctors have run away from scarcely populated areas,
leasing firms have tried to take over,
even in population centres
Ahvenanmaa
Itä-Savo
Satakunta
VarsinaisSuomi
Pirkanmaa
KantaHäme
HelsinkiUusimaa
Etelä-Savo
PäijätHäme
EteläKarjala
Kymenlaakso
OYS
KYS
TAYS
TYKS
HYKS
University hospitals
" Helsinki (HUCH, part of HUS)
" Kuopio (KUH)
" Tampere (TaUH)
" Turku (TUCH)
" Oulu (OUH)
University hospital city areas,
mainly Helsinki, Tampere and
Oulu have had a great influx of
population
HUS is the only uniformly arranged
hospital network in Finland
Hyvinkää
Hospital Area
Hyvinkää Hospital
Kellokoski Hospital
Mäntsälä
Lohja
Hospital Area
Lapinjärvi
Hyvinkää
Karkkila
Askola
HUS is a municipal
Järvenpää
NummiNurmijärvi
Pornainen
Pusula
federation owned by
Tuusula
Vihti
Kerava
Porvoo
Lohja Hospital
26 Uusimaa Paloniemi
area Hospital
Sipoo
Vantaa
Lohja
Espoo
municipalities.
Karjalohja
Kauniainen
Hospitals belonging
Helsinki
Siuntio
Peijas Hospital
Kirkkonummi
to HUS number 21.
Inkoo
Raasepori
Jorvi Hospital
HUCH Hospitals
in Helsinki
HUCH
Hospital Area
Hanko
Tammiharju Hospital
Länsi-Uusimaa Hospital
Länsi-Uusimaa
Hospital Area
Loviisa
Porvoo
Hospital
Porvoo
Hospital Area
Childrens´castle hospital
Childrens´hospital
Midwives´hospital
Skin- and allergy hospital
Surgical hospital
Cancer centre
Women´s hospital
Meilahti Tower hospital
Meilahti Triangle hospital
Psychiatry centre
Trauma centre, Töölö
Eye and Ear hospital
Some rented facilities
The Ideal Health Care Model
Integrated health care systems are in vogue to sustain the
feasibility and success of nation wide,
publicly funded and equally provided health care services
(U.K.,Canada, Australia, New Zealand, USA, Sweden, Finland etc. )
They are believed to save healthy years and costs through:
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prevention, healthy living
early intervention
well functioning primary health care in co-operation with social services,
and when feasible:
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The Ideal Health Care Model and its
Ideal Hospitals, cont.
........ and when feasible:
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the integration of less demanding (?) specialized care,
particularly in scarcely populated areas
integrated hospitals or hospital networks for more
demanding services,
Providers should have open books on their performance
and should also reach out into the surrounding
community
and adjust services according to publicly recognized needs
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Integrated Health Care Models
!  Until now, there is no one-size-fits-all model,
!  nor any empirical foundation for specific
integration strategies
!  However, many conclusions have been drawn from
research and implementation attempts and these
experiences can be used for guidance
Suter et al. , 2009
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Integrated Health Care Models,
Some Main Principles
!  Comprehensive services across the care continuum
!  co-operation between health and social care organizations
!  multiple access to care continuum (documentation)
!  emphasis on wellness, health promotion and primary care (active
prevention)
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Patient focus
!  focusing on patients´ needs
!  patient engagement and participation
!  focusing on population-based needs assessment
!  Geographic coverage
!  maximize patient accessibility and minimize duplication of services
!  responsibility for identified population; right of patient to choose and exit
Suter et al. , 2009
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Integrated Health Care Models,
Some Main Principles
!  Information Systems and Management
!  State-of-the-art information systems to collect, track and report medical (and
social) service activities
!  efficiently and clearly (succinctly) kept records, no duplication between care
providers or professional groups
!  information flows freely over the continuum of care
!  committed to quality of services, evaluation and continuous care improvement
!  diagnosis, treatment and care interventions linked to measurable clinical
outcomes
Suter et al. , 2009
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Integrated Health Care Models,
Some Main Principles
!  Financial management is a must, mixed channels confuse
the picture
!  Implementation
!  Many think that the minimum population for well functioning
integrated health care is 1 million people
!  Within reasonable limits, the concept has to be applied in its
natural habitat
!  metropolitan areas differ from
!  scarcely populated rural areas
there is no one-size-fits-all model
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Integrated Health Care Models,
Some Main Principles
!  Physicians are pivotal for the success of integrated care !
!  Doctors are the gateway to integrated health care systems
!  Without their co-operation there are no single-points-of entry into
the HC circle,
!  nor continuous, coherent patient records
!  Engage doctors from the start, both on the Board and on the Floor
Suter et al. , 2009
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Integrated Health Care Systems
For the moment too many loose threads
All of the previous require National
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Guidelines
Standards
Reporting
Analysis
Official Comparisons
Benchmarking
!  Primary measures should be
!  clinical outcomes (short term and long term)
!  complications included (as a measure of safety)
!  costs per adjusted population
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What is the problem with hospitals ?
!  Health and social care costs per capita must come down
in ageing populations. Hospitals are the
most expensive in the health care chain
!  There are disturbing signs of hospitals being dangerous
places with mistakes and infections causing a lot of damage,
even unnecessary deaths and extra costs
!  Hospital care may have other serious shortcomings,
e.g., waiting times both in emergency units and for elective
treatment, even misguided priorities (time limited guarantee of care
may not be so healthy)
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What is the problem with hospitals ?, cont.
!  Neutral
information about hospitals should be produced
!  to enable patients and their sponsors to compare
!  quality of care (long and short term outcomes) and services
!  safety issues
!  and costs
!  and to make their choices
!  Requires nation wide public registries
!  tangible measures of all of the above
!  reports
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When you create the ideal hospital, remember..
A hospital may have different targets
!  university: research, teaching, philantrophy, cradle of wisdom
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regional (small or large), a certain population
one/few/all organs
serving or earning
!  A university hospital may be all of the above, which may blur the
picture and require strategic choices
!  Research and Teaching should always remain in Focus
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Top European institutions in clinical medicine
21 May 2009, Times Higher Education
(Thomson Reuters Essential Science Indicators database, 1 January 1998-31 December 2008)
Rank%in%
Europe%
University%
Papers%
Cita4ons%
Cita4ons%per%
paper%
1%%
Erasmus%University%Ro7erdam%
7,108%%
166,015%%
23.36%
2%%
University%of%Cambridge%
4,795%%
107,088%%
22.33%
3%%
University%of%Oxford%
6,706%%
149,545%%
22.30%
4%%
University%of%Glasgow%
4,908%%
104,245%%
21.24%
5%%
University%of%Helsinki%
10,169%%
206,196%%
20.28%
6%%
Imperial%College%London%
7,550%%
145,914%%
19.33%
7%%
University%of%Amsterdam%
8,123%%
150,269%%
18.50%
8%
Karolinska%Ins4tute%
12,787%%
236,174%%
18.47%
9%
Humboldt%University%of%Berlin/
Charité%
6,097%%
112,420%%
18.44%
10%
Leiden%University%
8,150%%
149,851%%
18.39%
Finnish clinical research may be in decline..
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When you build the ideal hospital, remember...
!  that big hospitals are very complex buildings housing very complicated
and demanding functions, which constantly change
!  that you should not build a monument, nor an object which will become
an eternally protected building immune to changes
!  that you are not the first one to build a hospital, there are models,
norms, standards and specialized people who will guide you.
!  check the check list and use the experience and examples of others
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Check list for a new hospital, the building
!  Size and interconnection of the basic functions:
!  In-patient wards (# of beds, # of rooms, nursing scheme, floor plan, visibility,
external and internal transportation, interaction between clinical and other functions
!  Out-patient related activities, ever increasing, big hospitals should connect with
!  Patient/visitor hotel
!  Emergency functions
!  Diagnostic and Therapy/Intervention functions
!  Research and Teaching functions
!  Cost-Effectivity
!  Group together and combine functional areas and patients with similar requirements
!  Write a detailed functional program to describe intended operations involving
patients, staff, supplies and waste
!  Apply process improvement tools to improve functional efficiency
!  Accomodate space to process
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Check list for a new hospital, the building
!  Cleanliness
!  materials and finishes
!  requirements of sterility
!  housekeeping facilities
!  indoor air, patient room pressure and temperature
!  Accessibility
!  remember patient handicaps
!  niveau changes, width of corridors and doors
!  mark glass doors (not with hand made paper signs)
!  Controlled Circulation,
!  no unwanted cross or through traffic, separate routes for different categories of
patients, staff and stuff
!  separate normal from unpleasant
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Check list for a new hospital, the building
!  Flexibility and Expandability
!  follow modular concepts of space planning and layout
!  use generic room sizes and other plans, rather than highly specific ones
!  be served by modular, easily accessed and easily modified mechanical,
technological and electric systems. If possible, include walk-through
technology
spaces between floors
!  open-ended structures, which can be expanded side ways and up without
interrupting clinical work
!  Therapeutic Environment
!  calm and peaceful, good lightning, pleasant interior design
!  address, as needed, patient profiles
!  easy and logic way-finding and clear signs
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Check list for a new hospital, the building
!  Security and Safety
!  protection of all, also incapacitated patients, and staff
!  safe control of violent or unstable patients
!  protection of sensitive information and drugs
!  Sustainability
!  hospitals use much energy and water and produce a lot of waste
!  therefor they should have a sustainable design
!  performance within these areas should be followed, ,recorded and shown
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The Heavy Chains of History
Protected
Protected
Protected
Protected
Protected
Protected
Protected
Protected
The fine, old, unpractical, malfunctional, but historic hospitals and other
buildings of the Meilahti Campus, 2004
New Hospitals, new ways of working,
Haartman and Triangle hospital, 2009-10
Floors 4 to 7
Typical 2 ward plan
copyright © Mikael Paatela / Sweco Paatela Architects Oy
Nursing schemes and shapes of in-patient wards
Squares, triangles, half circles............
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Nursing schemes and shapes of in-patient wards
Mixed shapes, worms and circles.........
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Single room, hygiene, visibility, safety, family
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Modular clones, try to make it simple and easy
for all concerned
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Evidence Based Safe and Pleasant Design
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Complex spinning wheel of big hospital/campus
co-ordinates logistics
Other
Diagnostics
Food and
distribution
Buildings
administrationMaintenance
Material
Laboratory
Cleaning
Imaging
Clinical activities:
In-patient wards
Out-patient spaces
Operations
Interventions
Research & Teaching
Pharmacy
Drug dispension
Stakeholder
contacts
Community
contacts
Information
Technology
Technology Help desks
Waste
Transportation
services
PR and int.
information
Human
Resources
Economic
management
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- Defined processes for the continuum of patient care
- Research and Education
- Professional expertise
Clinical guidance:
Specialists direct clinical management of
patients through a network of service functions
Speciality1
Speciality 2
Speciality 3
Emergency Inpatient
units
wards
and
IC
Outpatient
policlinics
Day
investigation,
therapy,
intervention
Operations
and
Procedures
Speciality X
Speciality Y
Speciality A
Speciality B
Speciality C
Speciality D
Hospital and HCC managers, unit managers and staff
Routine, documented processes in functional units:
- Serving patients´ and staff´s needs
- Similar in all comparable units and hospitals
- Lean philosophy
Design, light and clear signs
The new Meilahti Tower 2014, double
facade saves energy
Don´t underestimate the benefit of
concentration – Meilahti prospect 2019
NEW TRAUMA &
Ca CENTRES
NEW CHILDREN´S
HOSPITAL
New HUSLAB
wing
Adjust to the clientele
MIAMI CHILDREN’S HOSPITAL, FLORIDA, USA
What better way to make child patients feel at ease than
with a hospital designed with bright colors and fun shapes?
HEALTH CENTRAL HOSPITAL, OCOEE, FLORIDA
With a mix-up of architectural styles, Health Central
Hospital is a Cubist-inspired in-bed acute care facility.
Emergency and
Peace & Quiet
ST. CLARE HEALTH CENTER, FENTON, MO
Spiraling staircases and artful water features give
St. Clare Health Center a peaceful atmosphere
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Emerging Hospital Issues Compatible with
Integrated Care
!  The decreasing # of GP´s and transfer of emergencies (also minor)
to hospitals and specialized care
!  Emergence of geriatrics and palliative care as important functions of
medical centres
!  Preventive care and care of the sick
!  Hospitals should be designed to function as health/wellness centres
!  Community may come to the Hospital and
!  The Hospital reaches out to Community (satellite functions) concepts
!  Patient and family participation in hospital routines
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Hospitals and Primary Care
One cannot exclude the other:
!  They must co-operate
!  Have mutual patient records
!  Many functions will be concentrated to hospitals/networks
!  but should also reach patients at home/close to home
!  All activities should be recorded and
!  Measured for Outcomes and Safety
!  Be constantly improved
!  And more cost effective
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Building a Hospital
When your investment is big, you want to do it right:
!  specify goals and means to implement them
!  have a separate planning organization in place
!  consult with experts, external and internal
!  make it beautiful and functional
!  engage your staff (enthusiasm and experience)
!  use the project to establish momentum for change
!  check, change and document your habits (also called processes)
!  make it lean , i.e.,
!  ensure safety and cost efficiency
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Thank you !