Expectations for Integrated Health Care and Building New Hospitals

Expectations for Integrated Health Care and Building New Hospitals Design and Health Europe, 2012 Biomedicum Helsinki Carola Grönhagen-Riska Professor, Chief physician

Finland today and in the future! 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

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) Länsi- Pohja 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 Vaasa Keski- Pohjanmaa Etelä- Pohjanmaa Pohjois- Pohjanmaa Keski-Suomi Pohjois-Savo Kainuu Pohjois-Karjala Doctors have run away from scarcely populated areas, leasing firms have tried to take over, even in population centres Ahvenanmaa Varsinais- Suomi Pirkanmaa Kymenlaakso Kanta- Häme Helsinki- Uusimaa Päijät- Häme Etelä-Savo Satakunta Etelä- Karjala Itä-Savo

OYS TYKS TAYS HYKS KYS University hospital city areas, mainly Helsinki, Tampere and Oulu have had a great influx of population University hospitals " Helsinki (HUCH, part of HUS) " Kuopio (KUH) " Tampere (TaUH) " Turku (TUCH) " Oulu (OUH)

HUS is the only uniformly arranged hospital network in Finland Hyvinkää Hospital Area Hyvinkää Hospital Kellokoski Hospital HUS is a municipal federation owned by Lohja Hospital Paloniemi Hospital 26 Uusimaa area municipalities. Hospitals belonging to HUS number 21. Hanko Länsi-Uusimaa Hospital Area Lohja Hospital Area Raasepori Karjalohja Nummi- Pusula Lohja Inkoo Karkkila Vihti Tammiharju Hospital Länsi-Uusimaa Hospital Hyvinkää Askola Nurmijärvi Järvenpää Pornainen Tuusula Kerava Porvoo Espoo Vantaa Kauniainen Siuntio Helsinki Kirkkonummi Jorvi Hospital HUCH Hospital Area Mäntsälä Sipoo Peijas Hospital HUCH Hospitals in Helsinki 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 Lapinjärvi Loviisa Porvoo Hospital Porvoo Hospital Area

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:! prevention, healthy living! early intervention! well functioning primary health care in co-operation with social services, and when feasible:

The Ideal Health Care Model and its Ideal Hospitals, cont.... and when feasible:! 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

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

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)! 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

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

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

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

Integrated Health Care Systems For the moment too many loose threads All of the previous require National! 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

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)

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

When you create the ideal hospital, remember.. A hospital may have different targets! university: research, teaching, philantrophy, cradle of wisdom! 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

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% 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% Cita4ons%per% paper%

Finnish clinical research may be in decline..

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

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

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

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

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

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...

Nursing schemes and shapes of in-patient wards Mixed shapes, worms and circles...

Single room, hygiene, visibility, safety, family

Modular clones, try to make it simple and easy for all concerned

Evidence Based Safe and Pleasant Design

Complex spinning wheel of big hospital/campus co-ordinates logistics Laboratory Food and distribution Other Diagnostics Buildings administration Maintenance Material Cleaning Imaging Pharmacy Drug dispension Stakeholder contacts Community contacts Information Technology Clinical activities: In-patient wards Out-patient spaces Operations Interventions Research & Teaching Technology Help desks PR and int. information Human Resources Economic management Waste Transportation services

Specialists direct clinical management of patients through a network of service functions Clinical guidance: - Defined processes for the continuum of patient care - Research and Education - Professional expertise Speciality1 Speciality 2 Speciality 3 Speciality X Speciality Y Speciality A Speciality B Speciality C Speciality D Emergency units Inpatient wards and IC Day investigation, therapy, intervention Outpatient policlinics Operations and Procedures 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 CHILDREN S HOSPITAL NEW TRAUMA & Ca CENTRES 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

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

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

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

Thank you!