Renewing and refurbishing a University Hospital

Design & Health Europe 2012 Helsinki 21.9.2012 Renewing and refurbishing a University Hospital Heikki Korvenranta, MD. Project Leader Hospital District of SouthWest Finland Turku University Hospital, Turku Finland

T-Hospital - The Hospital of Tomorrow New facilities New care providing models New organization New leading strategies 2003-2013

HOSPITAL DISTRICT OF SOUTHWEST FINLAND 29 municipalities and Turku University 465.000 inhabitants Turku University Hospital 4 local hospitals 6.500 employees 74.000 admissions/year 350.000 inpatient days/year 770.000 outpatient visits/year annual running costs 600 M /year

TURKU UNIVERSITY HOSPITAL Level I-IlI specialized care for the Hospital Districts of Southwest Finland 460 000 population Level III specialized care also for the Hospital Districts of Satakunta the Åland Islands 750 000 population + some special services for whole Finland

TURKU UNIVERSITY HOSPITAL ~ 70 % of all services in hospital district 829 beds 4 000 employees - c. 600 M.D.s - c. 2 900 Nurses annual running costs 400 M 1 600 students/year

2003 U 1968 A 1938 1880 T1,2003

2018 T Childrens and Womens 2018 A U

TYKS new T-hospital constructions will be completed 12.12.12 Total investment budget of enlargement 230 M (+50 M phase 1) Total of 108 000 square meters (1,1 million square feet) 240 000 outpatient visits/year 30 000 treatment periods/year 120 000 inpatients days/year 15 000 surgical operations/year Running costs around 160-180 M /year

New space facilities are not enough

We must also improve of the quality of care! Common problems in health care 2003 roles and responsibilities of various care providers not clear unnecessary repetitions/duplication common poor communication - misunderstandings how do we apply the evidence based care? are we following recommended care processes? high variation rate in care providing control of quality not very high system failures we did not exactly know what is happening in reality

700-1700 patients in Finland are dying every year due to avoidable causes (?) 10 % are getting wrong treatment, one out of one hundred suffers from serious harm (?) Only 10 % of side-effects of medicines are reported Patients dot not know enough to participate in decision-making concerning their treatment or to follow care regimens Hospital information systems compromize patient safety and take too much staff working hours Hospital expences are flying to unbearable level Service needs are increasing

Building remarkable amount of new facilities is one time in century possiblity to deeply enhance the working approaches

Oper theatres Inpatient wards Heavy activities Other activities Oper facilities Inpatient wards Outpatient care Outpatient care Oper. facilities Imaging Hot activities Labs Intensive care Oper theatres + facilities Inpatient wards 2003 Emergency primary care + specialized care Acute care

The Hospital of The Future - Providing care based on the needs of the patient All we do should profit the patient - not the care provider Emegency Imaging and labs Operations Intensive care & monitoring Cardiac patient 2003 Wards Supporting services examinations operations care Trauma patient Neuro patient monitoring protect privacy Patient with multiple problems isolation needs Cancer patient Other patient groups

Approaches from the very beginning Needs of our patients and our own organization in the future Analysis of the present situation (2003) Scenarios of the future; how to adjust in possible future situations Locally and country-level Improve the quality of care and care processes Layout-planning Layout should support care processes Patient flows in the hospital Materials & other supply-chain logistics Healthcare information systems Electronic patient records Hospital resource planning Human resource planning How to lead and manage

T-hospital architecture and spaces The hospital architecture and lay-out will support the care processes the lay-out model is based on the evidence based analysis of needs of high volume patient groups

Main (80 %) patient flows overview (product flow analysis)

Patient flow in relation to intensive care/monitoring important connections Cons. treatment ward Monitoring Emergency 250 510 1940 Intensive care 2895 patients 500 1450 A- or U hospital Cons. treatment ward Card. unit Neurology ward Op. theatre 350 850 190 780 400 Surgery ward Surgery ward Radiology 3050 700 Intensified monitoring 5260 patients 3100 860 200 Traumatology ward Op. theatre Stroke unit Radiology Stroke unit

Patient flow in relation to operating theatre area important connections Emergency Surgery ward Cardiology ward Monitoring Traumatology ward Intensive care Intensified care 300 650 720 5050 2600 400 200 Operating theatre 9920 potilasta 1940 3050 2650 2060 220 Intensive care Intensified care Surgery ward Traumatology ward Cardiology ward ICU

Patient flow stroke functional - detailed home 6000 1000 Ultrasonic 4500 Emergency 2000 Radiology 500 Monitoring Cardiologic monitoring 2000 Invasive cardiology Intensified treatment Stroke unit 780 3000 700 1000 1500 1200 Neurology ward 500 Intensive care 500 500 500 3500 home

Patient flow stroke (neurology) functional layout flow line (product) layout (today) (future) Emergency Emergency, Rad 1 Radiology Ultrasonic Stroke unit Monitoring Intensified treatment Neurology ward Stroke unit, Rad 2, Ultrasonic Intensified treatment Neurology ward Monitoring

Patient flow trauma patients functional layout flow line (product) layout (today) (future) home home Inten- Sified treatment Radiology Traumatology ward Op. theatre Op. theatre Intensified treatment Emergency Emergency, Rad 1 Traumatology ward, Rad 2 home home

Walking route analysis of a nurse in ward (6-12 km/workshift)

T-hospital The hospital architecture and the space lay-out should support the care processes the lay-out model is based on the evidence based analysis of needs of high volume patient groups Final layout is not optimal.. It is a result of numerous compromises Harmonization of the patient flow in care providing lines Emergency/admission diagnostics operative care intensive intermediate standard ward discharge home Avoid bottlenecks, remember that greatest wastes happen before and after those

T-hospital Emergency area (joint primary and special care) outpatient short-term inpatient area (diagnosis & treatment) Operating rooms (14) Intensive care intermediate care area Cardiac care area Trauma care area Care area for patients needing angiological services Cancer care area Others

TYKS T-hospital Inpatient wards (mainly for acute or level 3 care patients) Supporting services not centralized Lab - everywhere Medical imaging in critical nodes Pharmacy planned supply chain - pharmacist in ward Storerooms and material supply chain balanced Maintenance, security Others Teaching function of the hospital Opportunities and facilities to learn especially bedside and netside

Are our working policies up-to-date? Are we effectively able to make use of all the possibilities medicine and nursing sciences have developed during last decades for patients benefits? Can we effectively make use of modern information and communication technology? 3 x No that s why we need High-perfomance processes, which are balanced resourced Organization and management system to support those goals Reasonable support from hospital information systems

TYKS T-hospital Production of the care is organized and led as care processes not on the basis of functional silos Why Somebody must be responsible for the patients and payers Goal is harmonization of the care (production) line activities Avoid bottlenecks Eliminate waste Product is health value for the patient measure and evaluate it great patient experience Function-based models cause sub-optimization products like numbers of patient visits, treatment episodes, imaging investigations etc. these are only secondary measures

TYKS T-hospital Main care lines (segmented further into specific treatment processes) Cardiac care (ischemic disease, rhythm disorders, insuffiency) Trauma care Gastroenterological care Neuro care Cancer care Others Patient with multiple conditions Emergency services jointly with primary & specialized care

Our six goals We change our care providing models for supporting patient centered care providing. Care line management must support the same goal. We create effective work processes by analysing and renowating the contents of all actions we carry out in our hospital We change the organizational model and management system to support the process-oriented working models We analyze the information and knowledge needs concerning patient- and workflows, work contents, planning and management. Then we know, what we should demand from HISs Staff mastermind facilities and working processes, Staff mastermind also managerial functions and organization structure from the viewpoint of everyday work and also analyze the information needs We create potentials for the patients to participate in decision-making by using comprehensible communication to increase health literacy, so patient can understand what is happening and what is important PricewaterhouseCoopers HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Waste spends resources without productivity Waste recognition and elimination in hospital Redundant activity, useless for the patient Errors (all kind of) Waiting (bottlenecks often root causes) Searching (takes time) Overprocessing (no use for the patient, often interest of provider) Useless storing (koskee tavaroiden lisäksi tietoa, potilasohjeet) Useless motion Underutilization of staff expertize Focusing on relevant doings we reach better results cheeper, when we release resources wasted on errors, chaos and frictions for the use of patient care at least 20 % new resources without a single new Space and space layout can support elimination of waste PricewaterhouseCoopers HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Admission Value stream mapping of the care line - - what benefits the patient Discharge Emergency Medical imaging Labs Operation room Intevive care Rehabilitaion Ward Pharmacy etc jne HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Value stream mapping -what benefits the patient All expertiese must be present at same time End to end process Problem identification Waste identification Improvement identification Why why why why why neverwho HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Sydänhoitolinja: sepelvaltimotautipotilaan prosessinohjausmalli Sairaalan ulkopuolella Ensihoito sairaalan ulkopuolella Triage (YP) Sairaanhoitaja (YP) Yleislääkäri (YP) Sisätautilääkäri (YP) Potilas päivystykseen ohjeistuksen perusteella Potilas ensihoidossa Elvytetään (A) Ennakkoilmoitus Hälytetään ensihoitotiimi Ohjeistus: milloin potilaat tuodaan suoraan kardiologille (SHP:n protokolla olemassa; kardiologin hot line ) Ei elvytetty potilas Triage Ohjeistus Ambulanssilla saapunut B- ryhmä Ohjeistus 1) Terveyskeskukset 2) Yksityiset lääkärikeskukset 3) Sairaanhoitajan puhelinneuvonta Tieto saapuvasta potilaasta kommunikaattorilla kardiologille Todetaan / epäillään sepelvaltimotauti, oireena mm. rintakipu EKG, Laboratorio (kiireelliset) D Kiireetön (oire voidaan tulkita sepelvaltimotaudista johtuvaksi) C Kiireelliseksi epäilty oireiden perusteella (kivuliaisuus); ei varmennusta EKG tai lab. tuloksista C Kiireellinen (nähdään EKG:n perusteella, oireet/huonovointisuus vaihtelee; <72 h angioon) B Erittäin kiireellinen (nähdään heti EKG:n perusteella; <30 min angioon, saapuu kävellen) Tehdäänkö verikoe jos ekg jo vahvistaa? 1. verikoe tai EKG vahvistaa Pullonkaulana lääkärin sanelun puhtaaksi kirjoittaminen 2. verikoe 6h päästä Stabiili C tai C- epäily päivystysosastolle Epästabiili C Kardiologi Angiolaboratorion tarkkailutila (jos mahdollista) Verikoe tai EKG vahvistaa: odottaa päivystysalueella hoitopäätöstä Verikoe ja EKG ei vahvista Korkean riskin potilas varjoainekuvaus 72 h sisällä Kiireellinen angiopotilas odottaa vuodeosastolla? Sisätautilääkärin konsultaatio Potilas kotiin, aika pikapoliklinikalle Sisätautilääkärin konsultaatio (tarvittaessa) Triageluokittelu: A-ryhmä, kriittinen, hoidon aloitus heti B-ryhmä, erittäin kiireellinen, hoidon aloitus 10 min sisällä C-ryhmä, kiireellinen, hoidon aloitus 30 min sisällä D-ryhmä, kiireetön, hoidon aloitus 60 min sisällä Ryhmä sisältää hoidon eri kiireellisyysluokitusten mukaan aloittaneita potilaita Tehohoitohuone (YP) Päivystys osasto (YP) Pikapoliklinikka A-ryhmä (Kriittinen tai elvytetty, <30 min angioon; jos ei pääse suoraan angioon) B-ryhmä (<30 min angioon; saapunut ambulanssilla) Kuormitus suuri; järkevää jos jatkohoito 1 vrk sisään Tarkkailu päivystysosastolla Sisätautilääkärin ohjeistus (milloin lähetetään pikapolille) Kardiologin arvio viikon sisällä (kardiologin arvio ennen PPKL, jos potilas ei vielä hoitolinjalla) Rasituskoe Uä-tutkimus Angiolaboratorio Leikkausosasto Tehoosasto Tieto päivystyksen kautta saapuvasta angiografiapotilaasta ja EKG-konsultaatioista/ mahd. angiografiapotilaista kardiologin puhelimeen Varjoainekuvaus Erit. ryhmä B PCI Leikkausta edeltävä tehohoito Stabiilit C-ryhmän potilaat ja epäilyt Leikkaus Postoperatiivinen tehohoito Sydänvalvontaosasto (CCU) Leikkausta edeltävä sydänvalvonta Sydänvalvonta Vuodeosasto Missä järkevää? Epästabiili C Leikkausta edeltävä osastohoito Osastohoito Poliklinikka HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Staff engagement We have had up to over one thousand staff members involved in hunderds of working groups since 2004 in planning and realizing activities. Crucial for success PricewaterhouseCoopers HOSPITAL DISTRICT OF VARSINAIS-SUOMI

Does it pay back? According to our cost-benefit analysis we can easily increase productivity and cost-efficiency at least 5 % but up to 20 % Waste elimination Right at first time (balanced expertise) Reducing errors (standardization, checklists) Flexible use of resources Reduced use of materials More proper investments Fewer admissions (not goal but consequence) Shorter hospital stays (not goal but consequence) Great patient experience Great staff experience

12.12.2012-2.4.2013

Kiitokset Thanks to Hundreds of staff professionals in TUH T-hospital, T-Pro and U2 planning teams in TUH Architect Mikael Paatela Sauli Karvonen, Ska-Research Oy PricewaterhouseCoopers Oy Finland Plus numerous others

copyright Mikael Paatela / Sweco Paatela Architects Oy

copyright Mikael Paatela / Sweco Paatela Architects Oy

Turku University Hospital, T-Hospital copyright Mikael Paatela / Sweco Paatela Architects Oy