A Day in the Life ANNUAL REPORT 2015
4 HUS 2015 6 Review by the CEO 8 Review by the Chairman of the Executive Board
12 Competitive tendering and robots save on medical expenses
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24 A practical nurse is a trusted team player
CONTENTS
HUS | ANNUAL REPORT 2015
A NEW HUS
16 Tower hospital reopened for medical care 17 In the air, on the ground and on the phone PERSONNEL 20 The one stop shop principle
25 Innovation workshop for collaboration MEDICAL CARE 28 Brain surgery requires precision navigation 32 Brain surgeon summer camp 33 Installing Finland’s first artificial heart RESEARCH AND TEACHING 36 Biobank: a tool for better treatment 38 More knowledge equals fewer unnecessary examinations ENVIRONMENT 42 Environmental year 2015 48 A beautiful environment is therapeutic FINANCE 50 Medical service production 55 HUS finances 56 Personnel 57 Investments 58 Funding 59 Profit and loss account 60 Balance sheet 62 Cash flow statement
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/hus HUS | ANNUAL REPORT 2015
HUS | ANNUAL REPORT 2015
HUS 2015
CONTENTS
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24 23 6 municipalities forming a joint authority:
1,616,221 inhabitants.
Situation as at December 31, 2015.
maternity hospitals:
hospitals.
17,687 babies.
2,396,066 patient visits.
HUS | ANNUAL REPORT 2015 HUS IN A NUTSHELL
5
EUR
Personnel:
22,425 professionals.
2.0 billion turnover.
HUS | ANNUAL REPORT 2015
HUS is ready for the sote reform
FROM THE CEO
6 WHAT WAS 2015 LIKE, CEO AKI LINDÉN?
HUS logged a record number of both patients and treatments.
The year 2015 was extraordinarily busy. We saw an amazing rate of growth compared with the year before, and HUS logged a record number of both patients and treatments. Cooperation between HUS and primary health care increased substantially, and the emergency clinics at Porvoo, Lohja and Peijas were transferred to HUS administration.
We worked hard through the year to stay on budget. In the end, we recorded a budget excess of 2.3%. On the other hand, HUS produced 5% more services than budgeted.
WHAT WERE THE MAJOR SUCCESSES IN 2015? One success is the return to the renovated Meilahti Hospital. This was an operation involving not just occupying new premises but a major change to the operating practices of the entire hospital: treatment times are now shorter, patient meals have been improved, and there are more ICU beds. The structural change at Meilahti Hospital reflects a broader change in hospital operations at large. Related to this is the HUS Lean model, the purpose of which is to streamline our functions. This has led to the launching of several good projects that have yielded concrete results. For instance, in HUS Imaging, the waiting time for MRI scanning has been cut down from 5 weeks to 3.5 weeks.
WHAT DOES THE FUTURE LOOK LIKE FOR HUS?
The future looks very bright. HUS is Finland’s largest public hospital organization, and this brings all kinds of advantages. Economies of scale enable in-depth specialization, which in turn translates into a high quality of care. For instance, HUS is Europe’s third largest center for breast cancer treatment. A very large amount of scientific research is carried out at HUS, with 2,000 scientific publications per year. Year on year, medicine introduces new benefits such as new medications and treatments. However, the state of society at large and of public finances forces a debate on prioritization: which treatments should be paid for by patients themselves and which not? The year 2016 will be financially challenging, as HUS will have a smaller budget than it did last year.
HOW WILL THE GREAT SOCIAL WELFARE AND HEALTH CARE REFORM (‘SOTE' REFORM) AFFECT HUS? The future of HUS is firmly bound up with the great ‘sote’ reform. HUS is currently an independent specialist medical care joint authority, but with the ‘sote’ reform it will become part of a larger entity. The challenge then will be to coordinate health centers, care for the elderly and specialist medical care and to figure out how to divide resources between them. However, the reform will not change the situation of HUS dramatically, as we are already responsible for providing specialist medical care for the entire population of Uusimaa, 1.6 million. HUS is ready for the great ‘sote’ reform.
FROM THE CEO
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HUS | ANNUAL REPORT 2015
FROM THE CHAIRMAN OF THE EXECUTIVE BOARD
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HUS | ANNUAL REPORT 2015
HUS | ANNUAL REPORT 2015
A pioneer in finest trim
HOW WOULD YOU EVALUATE THE YEAR 2015, ULLA-MARJA URHO, CHAIRMAN OF THE EXECUTIVE BOARD?
THE PIONEERING APPROACH IS FOREMOST IN THE HUS STRATEGY. HOW EXACTLY IS HUS A PIONEER?
HUS is a well-established specialist medical care organization whose expertise is in the finest trim. The year 2015 was even busier than anticipated in terms of the volume of services and finances. Ongoing social debates had little impact on our robust practical operations.
Our pioneering is above all about medical pioneering, such as translating research findings into patient treatments. HUS is also a pioneer in the use of premises, as witness our several ongoing construction projects.
HUS is an expert provider of specialist medical care In the future, specialist with a good reputation, and medical care will increasingly our pioneering status in be cast as a customer service. this respect is reflected in our recruiting. Availability of personnel is excellent, Digitalization and the new role of patients and 40% of the specializing are important developments. The patient used to be an object physicians in Finland end up working at HUS. but is now a customer who wants more information about the WHAT IS THE SCORE ON THE GREAT ‘SOTE’ treatment process and wants the opportunity to be involved.
THE HUS STRATEGY PERIOD 2012–2016 IS NEARING ITS END. HOW HAS THE HUS OPERATING ENVIRONMENT CHANGED DURING THIS TIME?
In the future, specialist medical care will increasingly be cast as a customer service with digital support. We will be responding to this with new procedures and flexible use of premises that we have already begun to put into place.
HOW WELL HAVE THE GOALS OF THE STRATEGY PERIOD BEEN ATTAINED? The goals for the strategy period were patient-oriented and timely treatment; high quality research and teaching; closer partnership with primary health care; and effective and competitive operations. Although there have been major changes in society at large, our strategy has resulted in the outcomes originally intended. For instance, waiting times are now shorter, and we engage in closer cooperation with primary health care.
REFORM? Preparing for the ‘sote’ reform has had no impact on the dayto-day work of HUS. If decisions regarding the ‘sote’ reform are actually taken this year, HUS will be expected to enhance its cooperation with primary health care and specialist services. Then again, this is what we have been doing all the time. It is often claimed that the ‘sote’ reform gives priority to specialist medical care. This is not true. In fact, I am concerned that university hospitals will be neglected in the ‘sote’ reform, given that social welfare and primary health care operate at so much larger volumes. It should not be overlooked in the ‘sote’ reform that HUS is a specialist medical care training and research facility of great national importance.
FROM THE CHAIRMAN OF THE EXECUTIVE BOARD
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A NEW HUS
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HUS | ANNUAL REPORT 2015
A new HUS
A NEW HUS
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COMPLETED IN 2015 Jorvi Hospital emergency clinic building New HUSLAB building Renovation of the Meilahti Tower Hospital New building and parking garage at Sairaalanmäki in Hyvinkää
UNDER CONSTRUCTION The new Children's Hospital Women’s Hospital extension and renovation Lohja Hospital Psychiatry Department, new building
HUS | ANNUAL REPORT 2015 A NEW HUS
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Competitive tendering and robots save on medical expenses HUS Pharmacy leverages economies of scale through competitive tendering and an automated pharmaceutical storage. HUS Pharmacy puts its pharmaceutical procurement out to tender every two years. The tendering process in 2015 involved 8,500 items. Hospital sales account for 26% of all pharmaceutical sales in Finland, amounting to more than EUR 0.5 billion; HUS accounts for one fourth of all hospital sales. HUS Pharmacy is also responsible for pharmaceutical services in most of the other municipalities in Uusimaa. “Competitive tendering brings the greatest benefits. Our largest discounts have been more than 99% of the recommended wholesale price,” says Kerstin Carlsson, Managing Director of HUS Pharmacy. The highest pharmaceutical costs at HUS are incurred in the treatment of cancers, hematologic disorders and infections. Among other things, pharmaceutical costs are increased by the fact that in an increasing number of cases the best medication is a biological one for which there are no competing products. “People are growing older, and pharmaceutical costs are rising. The drugs required for new treatments are expensive, and patients are better informed and more demanding. Our budget simply does not go as far as it used to,” says Carlsson. The silver lining to rising pharmaceutical costs is that as more and more patients are helped by new medications, this serves to decrease costs in other areas of medical care.
When stocking shelves, the robot arm picks up one package at a time. Stocking is interrupted if a request to pick drugs for an order comes through.
A NEW HUS
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Pharmaceutical assistant Sari Laamanen and pharmacist Teressa Lyly monitor the automated medicine storage unit.
A case in point is hepatitis C, the treatment of which has been revolutionized thanks to new oral drugs that are rather expensive. The expense should, however, be measured against the earlier standard treatment of interferon injections and, in the worst cases, liver transplants.
“This is the largest fully automated medicine storage system in the world, says Marita Saanila-Sotamaa, Development manager.
Some 5,000 drug packages pass through the robots’ domain every day. When fully stocked, the storage units contain some “For expensive new drugs like this, it would make sense to 150,000 drug packages. The robots manage virtually everything organize a nationwide except those packages that are competitive tendering,” too heavy and those that are says Carlsson. very expensive. Competitive tendering brings the
ROBOTS NEVER TIRE OF STOCKING SHELVES
greatest benefits. Our largest discounts have been more than 99% of the recommended wholesale price.
The greatest investment made by HUS Pharmacy in 2015 involved a fully automated medicine storage system.
This consists of two storage units with seven robots to sort the stock. The storage units are redundant copies of each other, the point being to ensure the continuity of pharmaceutical supply in case of malfunction.
“Automation allows us to free up about three person-years’ worth of pharmacists for more feasibly duties,” says Saanila-Sotamaa.
The system, supplied by Newicon in Kuopio, together with its maintenance agreement and startup project, cost about EUR 2 million. The aim is for the investment to recoup its costs in 8.5 years. As a bonus, the robots are quicker and make fewer mistakes.
The first units to return to the Tower hospital were vascular surgery, cardiac and thoracic surgery, cardiology, neurology, and the cardiac surgery ICU and monitoring unit. Patients were transferred from the Heart and Lung Center and from the Abdominal Center. The renovated Tower Hospital has 360 beds, as opposed to the earlier 540. The quality of the patient facilities was much improved. The new wards have rooms with no more than three beds each, and each room has its own WC and shower.
With the reoccupation of the renovated premises, patient care processes will also be reviewed. The goal is to test new procedures in order to establish a smooth and safe high-quality care process for patients and an efficient personnel plan following the Lean philosophy, making the best possible use of the competence of all professional groups.
ADDED ENERGY EFFICIENCY Energy efficiency and environmental friendliness were addressed not only in the elevations and window replacements but also in the use of geothermal energy for heating and cooling. Solar energy is used for the floor heating of wet rooms. LED lighting, presence detectors and timers add efficiency.
Patients thus enjoy greater privacy, and infection safety is improved. There is now a higher number of ICU and monitoring unit beds.
UNIVERSITY HOSPITALS UNDERGOING RENOVATION The Tower Hospital, colloquially known as ‘the Hilton’ because of its perceived similarity to a high rise hotel when it was built, is such a significant element in the Helsinki cityscape that its elevations are protected under the current zoning plan. Because of this, the renovation involved creating a double envelope so as to both improve the energy efficiency of the building and retain its traditional appearance.
The Tower Hospital is more energy efficient and more environmentally friendly than ever.
Many hospitals are being renovated and built in Finland at the moment, as many hospital buildings are of an age where they are beginning to require major renovation.
FLEXIBLE PREMISES, NEW PROCESSES One of the aims of the renovation was to improve the usability and flexibility of the premises. In the renovated building, each floor constitutes one ward. Modular technology and standard generic furniture make it easy to convert spaces to other uses.
Significant savings are expected in heating energy, whose consumption is expected to decrease by about one fourth from what it used to be. On the other hand, the demand for electricity will increase with the introduction of new equipment. Cooling in the air conditioning system will also increase the demand for energy.
15 A NEW HUS
The Meilahti Tower Hospital was opened for business again in 2015 after a thorough renovation lasting three years. The reoccupation was done in stages. The first patients were housed in the renovated premises in mid-April.
HUS | ANNUAL REPORT 2015
Tower hospital reopened for medical care
HUS | ANNUAL REPORT 2015 A NEW HUS
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FinnHEMS10 VANTAA IN 2015 Missions: 2,564, or about seven per day About 40% of the missions are responded to by car. Patients: 1,119 Patients transported by helicopter: 11 Consultations by phone: about 30 per day
the location is near, a car can actually be quicker. In fact, about 40% of the calls are responded to by car.
Helicopter physicians are the prehospital emergency care medical unit in the HUS special responsibility area. The principal duty of the Helicopter Emergency Medical Service (HEMS) is to bring a physician quickly to the scene in situations where an accident victim or an acutely ill patient is deemed to require a physician’s care urgently.
FinnHEMS receives its alerts from the Emergency Response Centre. The ERC decides on the basis of a set of criteria whether to call in the HEMS. The aim is to allocate care resources to those who need them. “It is difficult to judge from just one phone call whether a doctor is really needed. That's why cancelled alerts are par for the course. But the alert has to be sent to us early, because otherwise we would be responding too late in many cases,” says providing Ångerman-Haasmaa.
In addition to providing rapid response, the HEMS unit also provides consultation by phone to the emergency responders on In addition to the ground. The unit receives an average of 30 phone calls per day. rapid response, the HEMS On the phone, the unit employees unit also provides consultation give treatment instructions and also make decisions as to whether by phone to the emergency the patient should be taken to a responders on the ground. treatment facility or not.
The FinnHEMS unit includes a physician, a pilot and an HEMS rescue officer. The job of the HEMS rescue officer is to navigate and observe the environment when in flight and to assist the physician when on the ground.
The unit receives an average The FinnHEMS helicopters can evacuate patients, but this is rarely of 30 phone calls per day. The same trio responds whether done within the HUS area, beby car or by helicopter. If they take cause road connections are good the care, the HEMS rescue officer and distances are short. In other regions in Finland, where the drives and the pilot reads the map. distance to a hospital may be much greater, helicopters transport patients much more often. The FinnHEMS unit has three full-time specialists from Emer“We only bring a patient in by helicopter if it makes a crucial difference to the patient’s treatment,” says Susanne Ångerman-Haasmaa, senior physician at HUH Emergency Medicine and Services. In 2015, HUS helicopter physicians saw 1,119 patients. Only 11 of them were transported by helicopter to treatment. In the majority of cases, the physician stabilizes the patient so that he or she can be transported by ambulance. The physician accompanies the patient to the hospital if necessary.
CARS CAN BE FASTER A helicopter cannot fly in every weather. If the weather is bad or if the patient is in a location where it is not feasible or not possible to land a helicopter, the physician is taken to the location by car. It takes five minutes to start up the helicopter, so if
gency Care and one specializing physician. Emergency duty is manned by experienced emergency care physicians. The HEMS rescue officers are employees of the Keski-Uusimaa Department of Rescue Services. The pilots are employees of Skärgårdshavets Helikoptertjänst, the aviation service provider for FinnHEMS. The FinnHEMS unit is owned by Finland’s university hospital districts. FinnHEMS provides for helicopters, cars and bases. The hospital districts supply the physicians, medical equipment and drugs. This function is funded out of the central government budget.
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The work of an ambulance helicopter crew is much more than just flying to the rescue.
HUS | ANNUAL REPORT 2015
In the air, on the ground and on the phone
HUS | ANNUAL REPORT 2015
Personnel 2015
PERSONNEL
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22,425
Average retirement age:
employees, whose average age was
43.7 years
Situation as at December 31, 2015.
84.3% women and
15.7% men
12.5
years of employment with HUS on average
61 years
PERSONNEL
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The one stop shop principle The Lohja Hospital emergency clinic was restructured as a joint emergency services clinic. The aim is to get patients to the correct treatment more readily. This also reinforced the cooperation between the Town of Lohja and HUS. As of early autumn 2015, the emergency clinic at Lohja Hospital has been wholly under HUS administration. Before that, there had been two separate emergency clinics in the Lohja Hospital building since 2007: the specialist medical care emergency clinic had been run by HUS, while the primary health care emergency clinic outside office hours had been run by a private enterprise. The emergency care is now divided into two lines. The private service provider continues to care for the health center patients, while HUS cares for the specialist medical care patients. The most visible change is that all patients now check in with a nurse at the emergency clinic. The nurse assesses the patient’s need for care.
The emergency care line is determined on the basis of guidelines drawn up for the emergency clinic. When checking in, the patient is entered into the HUS IT system. Previously, patients arrived with a referral for specialist medical care or came to the health center emergency clinic at their own initiative. “Now we perform triage here and assess the need for care and the emergency care line required, based on criteria agreed beforehand. In other words, the patient’s care is no longer decided by the referring physician or the patient himself or herself,” says Jukka Vaahersalo, Chief of Emergency Services at Lohja Hospital. HUS procedures are also being merged; the guidelines used for care need assessment and triage are very similar as those used in the emergency clinic reform at Jorvi Hospital. At Jorvi, the emergency clinic reform relies heavily on emergency care physicians. At Lohja, the reform is being carried out on the basis of existing resources.
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“There are specialized and specializing emergency care physicians at Lohja too, but we cannot use them as extensively as they can at Jorvi,” says Vaahersalo.
DIVERSITY IS MEANINGFUL Christel Wennerstrand-Kekkonen, head nurse at the emergency clinic, says that the joint emergency services clinic has started up well, and the adjusted procedures ensure the quality of care.
According to deputy chief physician Valpuri Taulasalo, the reform involved input from Hyvinkää and Porvoo hospitals.
The joint emergency services clinic has gotten off to a good start. The adjusted procedures ensure the quality of care.
“The joint emergency services clinic requires nurses to have a wide variety of competence, which makes the job challenging. But diversity also makes the job more meaningful and improves their professional skills,” says Wennerstrand-Kekkonen.
“We were able to draw on the good and bad experiences of other emergency clinic. The Lohja emergency clinics. model was shaped on the basis of experiences in other places,” says Taulasalo.
There are differences, too: for instance, the physicians do not work in three shifts. At Lohja, on-call duties in specialist medical care emergency services are divided among physicians with specializations in surgery and internal medicine, but all physician are jointly responsible for patient care in accordance with their expertise. Vaahersalo expects the percentage of patients in specialist medical care to increase after this reform as soon as the
PERSONNEL
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There is an added emphasis on referring patients from the emergency clinic to local health centers during office hours; these health centers have also augmented their emergency care resources. “There has been some overlap. Some patients have first gone to the health center and been treated but then sent to specialist medical care, at which point the care practically starts again from the beginning. That translates into two emergency care bills: for the patient and for the local authority,” says Vaahersalo. With a shared IT system, patient details are much more easily accessible. Previously, the details had to be re-entered whenever a patient moved from one care facility to another.
CLOSER COOPERATION According to Valtteri Kiuru, locum chief physician of outpatient care with the Town of Lohja, it is to be expected that cooperation between the local authority and HUS will become even closer. “Our patient care approaches are interwoven, which is sort of the point with the ‘sote’ reform. We agreed to keep talking to one another, and we have done so,” says Kiuru.
The medical personnel are committed to the change and have proven flexible in this major change.
It is also expected that an increasing percentage of patients arriving by ambulance will be admitted directly to specialist medical care at the emergency clinic. These will be patients who are more difficult than usual to treat, even if their condition is not necessarily uncommonly serious. The principal university hospital backup for Lohja Hospital is Jorvi Hospital. The patients requiring advanced intensive care are referred to Jorvi, and the pediatric wards are also there. The distance to the Meilahti and Töölö hospitals is not great, and thus patients can be referred directly to the hospital where the appropriate care is available. Taulasalo notes that one point of the reform is to ensure that emergency care is an attractive workplace for employees. At the health center emergency clinic, everyone wears the same outfit even though they work for different employers. The Lohja Hospital emergency clinic was restructured as a joint emergency services clinic. The aim is to get patients to the correct treatment more readily. This also reinforced the cooperation between the Town of Lohja and HUS. Personnel were involved in the planning well before the joint clinic was opened. Ideas were solicited online and development seminars were held more than a year ago.
He notes that although the emergency clinic operates as a one stop shop, the specialist medical care side and primary health care side have separate organizations.
The emergency clinic estimates the need for care. If a patient requires specialist medical care, his or her treatment is taken over by HUS. But if the patient’s complaint can be dealt with by the health center, the emergency clinic may not need to do anything more than book an appointment. “The main thing is that a patient arriving at the emergency clinic must have his or her matter taken care of in some way,” says Kiuru. Mira Uunimäki, locum director of basic social services and chief medical officer with the Town of Lohja, hopes that the reform has made the emergency clinic more flexible and that patients will be able to get the right care in the right place more reliably. “I doubt that we will achieve any cost savings, but our operations will improve. It could even translate into savings if patients are more often directed to visit again during office hours, for instance,” says Uunimäki. Uunimäki notes that the cooperation between HUS and Lohja runs very smoothly. “Lohja is a town of suitable size and the Lohja Hospital is a specialist medical care unit of suitable size for this kind of cooperation,” says Uunimäki.
At the joint emergency services clinic, a HUS nurse refers incoming patients to primary health care or specialist medical care, depending on their care need. At the emergency clinic reception: in front, head nurse Sari Kortepohja; behind, chief physician Jukka Vaahersalo, head nurse Christel Wennerstrand-Kekkonen and deputy chief physician Valpuri Taulasalo.
HUS | ANNUAL REPORT 2015
FINDING THE RIGHT PLACE TO GO
“We are further developing our procedures with a view to multi-professional functionality. The medical personnel are committed to the change and have proven flexible in this major change,” says Wennerstrand-Kekkonen.
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routine develops for referring patients to the right treatment on their first visit.
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Further education is important for maintaining professional skills. The photo shows Tarja Komi.
A practical nurse is a trusted team player Komi is willing to share her knowledge and expertise. She is The work of a practical nurse or enrolled nurse is often seen the person responsible for registration and the Rafaela patient as consisting of helping patients eat, wash themselves and classification system on her ward and provides induction and move around. This is basic stuff that does form an important training for others. part of patient care, but in specialist med“My job is meaningful when my Treatments and medications have ical care nurses need supervisor gives me responsibility to have a much wider developed enormously, and you cannot and the chance to use my experrange of competence. tise. Lifelong learning goes on,” cope as a specialist medical care says Komi. Practical nurse Tarja professional if you do not update your Komi has been workHead nurse Sari Ranta, who is ing at Meilahti Hospital professional competence regularly. on the same ward as Tarja Komi, since 1985. has noted that it has taken some time for the nursing staff to come “It is important for me around to the idea of expanding the job description of practical to be able to participate in a patient’s care comprehensively. I nurses and enrolled nurses. have patients on the ward whose care is my responsibility. My job includes basic care, monitoring the patient’s condition, ad“Now it is easier for new nurses to exploit their full capabiliministering medication and executing the physician’s orders. I ties. Both the old hands and the more recently arrived pracalso rehabilitate, guide and support patients every day.” tical and enrolled nurses here now perform a wide range of duties. It is up to everyone’s personal initiative whether they Over the years, Komi has participated independently in several decide to embrace as wide a spectrum as Tarja has,” says training sessions organized by her employer and by external Ranta. parties. Her employer actually requires her to undergo further training. In the Cardiology Department, practical or enrolled nurses must have a competence evaluated as at least ‘qualified’, and “Treatments and medications have developed enormously they must demonstrate command of the treatment path and since the 1980s, and you cannot cope as a specialist medipharmaceutical treatment of a cardiology patient before they cal care professional if you do not update your professional can be assigned responsibility for patients. After that, they are competence regularly. I never wanted to be a registered nurse. allowed to manage everything from participating in a physiI felt that I can improve myself and have a diverse job as a cian’s rounds to handing off to the next shift; the only exception practical nurse. In my workplace community, I am a member is that they may not administer intravenous drugs. of a multi-professional team. Everyone can ask everyone else for advice; I can ask a physician and they can ask me.”
At this joint event organized by HUS, the Health Factory at Aalto University and the Faculty of Medicine of the University of Helsinki, opportunities for new, innovative cooperation were outlined. Ideas, seeds for innovation and solution needs in practical patient care were collected beforehand. HUS employees responded to an online survey with more than 50 identified problems seeking a solution. About half of these were discussed in the three workshops of Innovaatiohaavi [Innovation net]. “The research area of health and wellbeing is one of the strategic focus areas of Aalto University. We have a lot to contribute to university hospitals and to faculties of medicine and biosciences, and we expect to learn a lot too. After all, the Meilahti campus is one of the ten leading medical research clusters in Europe, says Professor Markus Mäkelä, head of the Aalto Health Factory. Aalto University and HUS are already running joint projects. A technology allowing quicker surgical access to the cortex is being developed at Aalto University in Otaniemi. Another project involves developing an operating room for skin grafts.
“We have common goals. We wish to generate added value for the patient and therefore for society at large. Innovations also yield financial benefits,” says Chief Medical Officer Markku Mäkijärvi.
SOLUTIONS TO PROBLEMS IN PATIENT CARE The problems presented at the idea workshops were very concrete and mundane, beginning with things such as the need for early identification of emerging wound infections. “It was a high energy day. Obviously there is a need for discussion like this. We hope that the word will spread that floating ideas at HUS is worthwhile. Working with Aalto is uncomplicated, says HUS Chief Development Officer Visa Honkanen. Honkanen notes that the ideas discussed in the course of the day included a couple of true gems that might become significant innovations if resolved. “It was fun to see how experts in different fields found one another. After all, that was one of our goals,” says director Nina Lindfors from HUH Musculoskeletal and Plastic Surgery.
Cooperation between HUS, the Health Factory at Aalto University and the Faculty of Medicine of the University of Helsinki is bearing fruit.
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The first innovation workshop addressed potential for cooperation that would improve patient care.
HUS | ANNUAL REPORT 2015
Innovation workshop for collaboration
MEDICAL CARE
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Medical care 2015
MEDICAL CARE
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Total number of patients in specialist medical care:
509,650,
2.9
%
Total number of patients treated, including health center patients at joint emergency services clinics
541,558
Treatment days:
185,402
persons
more than in the previous year
Surgical operations: A record-breaking
91,089, of which brain surgery:
935
Births:
17,687
391 organ transplants
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Brain surgery requires precision navigation During brain surgery, the neurosurgeon navigates with the aid of a pre-prepared map and locates areas of the brain controlling specific functions by using electrical stimuli as a guide. The purpose of brain tumor surgery is to achieve as good a result as possible while causing the patient as little damage as possible. When the operation involves parts of the brain housing functions vital for human beings, such as speech and mobility, very precise information is needed on where to cut and where not. “We know from anatomy that in a normal human brain the motor region controlling the right side of the body is located in this particular cortical domain,” says Aki Laakso, docent in neurosurgery, showing MRI images of the head of a patient scheduled for surgery on the following day and a 3D image created from the scans. The image shows a lump exactly where Laakso is pointing. The lump is a recidivist tumor, a glioma or growth of the supportive tissue of the brain. Gliomas grow among neurons with no specific boundaries, which means that the operating surgeon cannot clearly see where the tumor begins. At HUH, Laakso is the surgeon who operates on nearly all gliomas in critical cortical domains. The patient now examined by Laakso is experiencing some difficulty speaking, but the tumor is not yet affecting the patient's mobility, so it is probable that the motor cortex functions have actually relocated. With a slowly growing tumor, the brain has time to adapt and move functions away from the growth site.
Critical areas in the brain’s motor cortex can be mapped using nTMS before surgery. Another possible mapping method is functional magnetic resonance imaging (fMRI). The photo shows Aki Laakso.
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PRE-MAPPING IDENTIFIES ESSENTIAL POINTS The image studied by Laakso incorporates essential position points from a previously conducted navigated trans-cranial magnetic stimulation (nTMS) mapping. With nTMS, the motor cortex of the brain can be mapped before surgery. The Nexstim device at the Biomag laboratory of HUS Imaging is used to perform nTMS mapping.
The patient feels
nTMS and electrical stimulation of the cortex produce very similar mapping results in the motor cortex. Laakso notes that the anatomy of the brain is usually relatively simple as far as motor skills go. Speech is a more complicated issue, because speaking and vocabulary are controlled by different areas of the brain. Disrupting the neural pathways between these areas affects a slight snap speech ability.
“With this technology, we against the skull but not the MOVEMENT SEEN AS can use stimuli for mapREACTION, SPEECH AS ping without touching the electrical current in the brain itself. STAMMERING brain itself, from outside the head. The technology is Selja Vaalto performed nTMS also suitable for children, mapping on the patient two weeks before the surgery. Mapping says clinical neurophysiology specialist Selja Vaalto from HUS the motor cortex and speech areas takes about 1.5 hours altoImaging. gether. Movement responses (e.g. the twitching of a finger) are monitored using electrodes attached to the skin over the releNTMS is used for mapping essential areas in the motor cortex vant muscles. Speech responses are monitored by showing the before surgery if the brain surgery will involve areas controlling patient images that he or she must name. This examination is speech or movement. Alternatives to nTMS include functional recorded on video for consultation by a neuropsychologist. magnetic resonance imaging (fMRI), which measures changes in oxygen levels in the blood in the brain while performing a given task. The advantage of nTMS over fMRI is that nTMS directly activates motor neurons in a process that most closely resembles the electrical stimulation of the cortex performed during brain surgery.
“When a part of the motor cortex is stimulated, a muscle moves. For instance, a finger twitches. When the stimulus is directed to the eloquent cortex, it disrupts speech,” says Vaalto. An MRI image of the patient’s head is used as an aid in the nTMS examination.
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Operating on a brain tumor requires information, precision and time. The MRI image and the patient’s head are matched by marking certain reference points on the patient's head on the MRI image.
“nTMS helps you plan an operation: it shows you what is possible and what you can expect. It also shows whether neurophysiological monitoring will be needed during surgery.
During the examination, the patient wears a head band that reflects the light of an infrared camera.
ELECTRICALLY GUIDED SURGERY
A similar reflective surface is on the stimulation coil over the patient’s head. Data on the position of the patient’s head and the location of the coil over the head and over a specific area of the brain are recorded on a computer. The stimulation sites that generate movement or disrupt speech are visualized on the cortex in the 3D MRI image. Stimulation is felt as a snap in the magnetic coil of the Nexstim device. Stimulation is performed by a change in magnetic field, which induces an electrical field and current in the cortex. The patient feels a slight snap against the skull but not the electrical current in the brain itself. The electrical current on the cortex stimulates neurons on the cortex. This is manifested as a movement response if the stimulation is at the motor cortex. The surgeon can use the nTMS mapping to prepare a more detailed plan for the operation and a more precise perforation of the skull. This makes things easier for the patient, because the operation lasts less time and the hole to be made in the skull is smaller. Laakso regards nTMS as a tool but not something to be relied on implicitly.
nTMS has a resolution of 7 mm. That is not enough for tumor removal. Therefore mapping is continued during surgery by conducting a weak electrical current directly into the cortex. How deep the surgeon can safely go depends on how strong the current is that prompts a response. A current of 1 milliampere will penetrate the cortex to a depth of about 1 mm. A surgeon generally keeps a margin of 2 mm. On the computer, Selja Vaalto reads the muscular responses produced by electrical stimulation during the surgery. Because the patient’s speech must also be tested in the course of the surgery, neuropsychologist Henri Lehtinen is present. For the purposes of testing speech, the patient must be awake for part of the surgery. Lehtinen shows the patient images and talks. This enables him and the operating surgeon, Laakso, to estimate how close to the vital neurons controlling speech they are. The operation progresses gradually, with precision. Some of the tumor is removed. Then another test. “You can operate on the basis of negative responses, but positive responses are more reliable. Thanks to the mapping beforehand, I know where to start looking for the response,” says Laakso.
HUS | ANNUAL REPORT 2015
Brain surgeon summer camp
MEDICAL CARE
32
In summer 2015, a live course in microneurosurgery was held at Töölö Hospital for the 15th time. There were 109 participants from 31 countries, with several people from China, Spain, Italy, Brazil, Russia and the USA.
geons we see operating, continue to improve in their profession, says Reza Dashti, who works in Chicago and specialized in neurovascular surgery in Helsinki in 2005–2007. Since then, Reza Dashti has attended the course every year.
The 2015 course set a new attendance record.
One of the stars of the course was Professor Rokuya Tanikawa from Japan. Tanikawa praises live courses, because on a practical course one can see how things are done in different countries, and surgeons can learn from one another. The HUH live course is in a class of its own, even by international standards.
The course consisted of one week of extremely demanding neurosurgery that participants were able to monitor on location in the operating room or by video. “Here you can see many difficult and rare operations and learn new surgical techniques all at once," says Günther Kleinpeter, who is attending the course for the 11th time. He is the head of the neurosurgery unit at the Vienna General Hospital. “HUH Neurosurgery is the only place in the world where a neurosurgeon can see more than 200 aneurysm operations a year. It is wonderful to see how the stars of the show, the sur-
PATIENTS BENEFIT FROM STAR TREATMENT The operations for the course were prepared a few months in advance. The patients selected were those who would most benefit from the special expertise of the foreign neurosurgeons who would be operating on the course. Instrument nurses from the neurosurgery department at Töölö Hospital assist the visiting surgeons. “We could have routinely performed these operations ourselves. But it is in the patient’s interests if we bring in a neurosurgeon who is even more experienced,” says Mika Niemelä, Director of HUH Neurosurgery. The expertise of HUH Neurosurgery in all areas was praised by the visitors. Neurosurgeon Juha Hernesniemi is celebrated for his advanced surgical techniques where everything extra is eliminated. This philosophy has also been adopted by Mika Niemelä and Aki Laakso, who also operated during the course. Neuroanesthesiologist Hanna Tuominen notes that foreign neurosurgeons often wonder why the patient's brain is not swollen in our operations. That is due to good neuroanesthesia. “In our case, specializing in neuroanesthesiology takes two years after you qualify as a specialist, and that is reflected in our competence. Very few neurosurgery units abroad have dedicated neuroanesthesiologists.”
The microneurosurgery live course involves a large number of challenging operations and the learning of new surgical techniques. Participants observe the work of experienced neurosurgeons such as Juha Hernesniemi at close hand.
HUS | ANNUAL REPORT 2015
© WWW.SYNCARDIA.COM
MEDICAL CARE
33
Installing Finland’s first artificial heart Finland’s first artificial heart was installed in a patient at Meilahti Hospital in the spring. The surgery was performed by cardiovascular surgeons Karl Lemström and Jan Kiss from HUH Heart and Lung with cardiovascular anesthesiologists Mikko Lax and Seppo Hiippala and nursing staff. The patient’s treatment on the ward was supervised by Raili Suojaranta-Ylinen, Head of the Cardiac Surgical Intensive Care Unit. The artificial heart is a temporary solution to tide the patient over until a heart transplant that will be performed 3 to 12 months later. Installing an artificial heart is a rare occurrence worldwide; in all of the Nordic countries, for instance, only a handful have been installed to date.
“An artificial heart is used if the patient has bilateral ventricular failure or severe arrhythmia that cannot be controlled with medication or pacemaker, and if a heart transplant is not available quickly enough,” explains Head of Department Karl Lemström.
AN ARTIFICIAL HEART HAS NO HEARTBEAT A patient fitted with an artificial heart has no heartbeat, i.e. no EKG, and the patient’s entire circulation depends on the artificial heart. The artificial heart consists of two ventricles. In the surgery, the patient’s own ventricles and their valves are removed, and the artificial heart is sutured to the remaining atria in the patient’s heart. The patient may be discharged thereafter with a mobile unit that regulates the artificial heart. The mobile unit allows the patient to move freely, to walk and cycle and to take light exercise.
VENTRICULAR ASSIST DEVICE LEADING TO HEART TRANSPLANT Every year, half a dozen ventricular assist devices (VAD) are installed at HUS. Like an artificial heart, they are an interim measure pending a heart transplant.
A HEART TRANSPLANT REQUIRES SPECIAL EXPERTISE A cardiovascular surgeon who has specialized in installing artificial hearts is always involved in the operation. “Installing an artificial heart requires special expertise, and the subsequent heart transplant operation will be very challenging. The artificial heart causes a foreign body reaction in the body, and the system creates granulomatous formations around it,” says Lemström.
HUS | ANNUAL REPORT 2015
Research and teaching
RESEARCH AND TEACHING
34
187 specialists and about
5,000 health care students as interns
124 doctoral dissertations
1,872 international scientiďŹ c articles
5
dental specialists
RESEARCH AND TEACHING
35
HUS | ANNUAL REPORT 2015
HUS | ANNUAL REPORT 2015
Biobank: a tool for better care
RESEARCH AND TEACHING
36
Medical innovations often stem from the analysis of blood and tissue samples from patients. It was because of this that the Helsinki Biobank was founded in April 2015 to collect, store and administer biological samples in the HUS catchment area. The Biobank was established by three hospital districts: HUS, Eksote and Carea, and the University of Helsinki.
“The samples collected and administered by Biobank are a modern tool for developing better treatment. The people contributing the samples – healthy and sick – are helping future patients, just like blood donors. Perhaps direct descendants of a sample donor will benefit from a treatment developed with the aid of the Biobank,” says Pitkänen.
“Seven extensive hospital biobanks are being created in HEALTH TECHNOLOGY AS AN EXPORT PRODUCT Finland, and they are in close cooperation with each other. There has long been talk in Finland of a growth strategy for In the rest of the world, the situation is quite fragmented; in Finnish health technology and its importance as a future Sweden, for instance, there are about 700 biobanks. Together export product. Biobanks, as part of the national genome with the progressive Biobank Act and advanced medical care, strategy, will be an important part of this brings Finland to the internanew, innovative exports. tional cutting edge as far as using The people contributing the biosamples is concerned,” says “When a high willingness to become Kimmo Pitkänen, director of the samples – healthy and sick – donors is combined with effective Helsinki Biobank. administering of the samples, it is
PATIENTS HELPING EACH OTHER
are helping future patients, just like blood donors.
The core of the Biobank is of course about analysing blood and tissue samples from patients in order to find out the causes of their disorders and to develop new treatment methods. All other information on the patient’s condition and health is seen as increasingly important for this work.
very possible that we will be able to assemble an extremely large sample based within a short space of time. The HUS catchment area alone has a population of 1.9 million,” says Kimmo Pitkänen. The genetical makeup of Finns will also make the material collected here very interesting from the perspective of developing new treatments and medications. The only limitation is the small size of Finland's population.
HELSINKI BIOBANK WHAT? Collects and stores biological samples (e.g. tissue, blood, DNA) and health information on the donors for the purposes of medical research Differs from traditional research sample collections in that it collects samples for unspecified future re search needs, not just for the purposes of a specific study Collaborates with other Finnish and European biobanks
Established by HUS, the University of Helsinki, Kymenlaakso Social and Health Services (Carea) and the South Karelia Social and Health Care District (Eksote) Established in April 2015 Approved and supervised by the National Supervisory Authority for Welfare and Health (Valvira)
HOW? Donating a sample to the biobank is voluntary
Samples may be taken during a hospital visit, during participation in a scientific study or specifically for depositing in the biobank
WHY? Helps explore the causes of illnesses, prevent illnesses and develop treatments Supports the use of genetic information in research and the development of personalized medicine.
RESEARCH AND TEACHING
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More knowledge equals fewer unnecessary examinations An effectiveness study led to a way of eliminating unnecessary examinations in clinical neurophysiology. Unnecessary patient examinations erode the already limited resources of the health care service. “We should perform only those diagnostic examinations that have a bearing on the patient’s subsequent treatment, i.e. we need healthy prioritization. To do this, we need to know what is effective, says Erika Kirveskari, head of clinical neurophysiology.
An effectiveness study of ENMG examinations yielded information that can be used to reduce the number of unnecessary examinations. In the photo are chief physician Erika Kirveskari and Norma Välimaa M.Sc. (Tech.).
Kirveskari obtained the information required when Norma Välimaa conducted an effectiveness study on electroneuromyography examinations (ENMG) in clinical neurophysiology for her master’s thesis at the HEMA Institute of Aalto University. ENMGs are the most common type of examination in clinical neurophysiology; several dozen are performed at HUS every day. Waiting times for the examinations have been growing despite enhancements using Lean methods. Patients are principally referred to ENMG by primary health care physicians, physiatrists, hand surgeons, orthopedic specialists, neurologists and neurosurgeons.
EXAMINE AS NEEDED A typical case where ENMG is applied is when a patient experiences numbness in the extremities and it is not known why. An examination is particularly needed if the patient requires surgery. “Causes for symptoms cannot always be found through clinical examination. Sometimes you have to use imaging,” says Kirveskari. Kirveskari would like the patients referred to ENMG to be mainly those whose further treatment can actually benefit from the examination. For instance, if surgery is not even being considered, then it should be considered whether an ENMG is really necessary. “There is no point in performing examinations to confirm something you already know.”
Välimaa conducted the effectiveness study with questionnaires, interviews and case studies. Her research showed that physiatrists and health center physicians requested more ineffective and low-effective examinations than other physicians. “However, we must take into account that health centers and physiatry outpatient clinics have patients with extensive and complex conditions. Operating surgeons may find it easier to determine a focused question for an ENMG to explore,” says Välimaa.
FINDING THE RIGHT QUESTIONS The way in which the question is formulated in the referral has a huge impact on effectiveness. An ENMG is not a quick
HUS | ANNUAL REPORT 2015 RESEARCH AND TEACHING
39
overview of the nervous system; it is an examination used to answer a specific, focused question. The better delimited the question is, the more effective the examination will be. The effectiveness study revealed among other things that in about 30% of the referrals the questions were too broadly formulated. There were also too many ‘shots in the dark’. If the question is unclear or very broad, the physician performing the ENMG has to use some of the ENMG appointment for interviewing the patient and for performing a clinical examination to further specify the question in the referral. On the basis of the findings of the effectiveness study, various actions have been taken in clinical neurophysiology to reduce the number of non-effective examinations.
For instance, guidelines issued to primary health care spell out the questions for which an ENMG may be requested. Training for physicians has also been arranged. There is a helpline where physicians can consult ENMG specialists before requesting an examination. The message is plain if a bit blunt: do not send a patient to be examined unless you know what needs to be examined. “I was expecting a backlash, but many of the referring parties were actually pleased to be given guidelines. There had been a need for them,” says Kirveskari.
ENVIRONMENT
40 HUS | ANNUAL REPORT 2015
Environment
HUS | ANNUAL REPORT 2015 ENVIRONMENT
41
More than HUS Logistics Center produced geothermal heat totalling
The Meilahti Tower Hospital generated solar energy totalling
800 MWh
21 MWh
750
19
Total energy consumption
Greenhouse gas emissions about
Total waste generated:
269,000 MWh
environmental ofďŹ cers at HUS
58,500 tons CO2 eq
environmental forums in 2015
7,707 tons
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42
Environmental year 2015 HUS has set itself the strategic goal of becoming a known and acknowledged pioneer in environmental matters in its sector. New waste disposal instructions for HUS were issued in 2015. Use of renewable energy was increased, and the environmental organization was renewed. In 2016, HUS is preparing a new environmental programme period and energy efficiency agreement, developing monitoring of waste and waste water and issuing instructions on environmental considerations in building investments.
EFFICIENCY WITH NEW ORGANIZATION HUS reorganized its environmental functions in 2015. One of the two energy efficiency working groups and the HUS Environmental Board were merged into the environmental and energy working group. The new HUH departments organized their environmental functions in accordance with their new organizations. There are more than 750 environmental officers at HUS, organizing and guiding environmental matters in their respective units. The network of environmental officers is continuously being enhanced. In 2015, the HUS Environmental Center held four courses for environmental officers. Training for environmental officers and other HUS employees was organized for instance on the topic of waste sorting. The annual environmental seminar had an attendance of 116. There were 19 local environmental forums.
The new underground waste station at Meilahti taken into use in April 2015 stepped up waste management on the hospital campus. The photo shows Jorma Hirvonen from HUS Real Estate.
ENVIRONMENT
43
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SAVINGS AND RENEWABLE ENERGY HUS GREENHOUSE GAS EMISSIONS 2015 tons CO2 eq
Electricity 25,313 District heating 18,790 Nitrous oxide and nitrogen 5,632 Natural gas 5,555 Waste 1,853 Oil 1,093 Vehicles 287
The total energy consumption of HUS in 2015 was 269,000 MWh. In 2015, HUS achieved energy savings for instance by improving heat recovery in hospital building ventilation systems, replacing the power supplies to the computer room and installing time-controlled ventilation in operating rooms. In the Energy Efficiency Agreement for municipalities (KETS) for 2008–2016, HUS has committed to a planned increase of energy efficiency in its operations and to imputed energy savings of 25.1 MWh. This goal was already attained in 2014, and by now the savings achieved amount to more than 27 MWh. Confirmed energy savings for 2015 amount to 1.6 MWh. The HUS Logistics Center, completed in late 2014 and taken into use in 2015, has a geothermal energy field that generated 800 MWh in 2015. The Logistics Center used no purchased heating energy at all. The Meilahti Tower Hospital, reopened in April after an extensive renovation, uses geothermal energy for cooling and generated 21 MWh in solar energy.
HUS invests in practices that improve material efficiency, for instance by reducing the use of disposable surgical towels and sheets.
HUS | ANNUAL REPORT 2015
HUS COMMUNITY WASTE 2011–2015 tons 3,500 3,000 2,500 2,000 1,500 1,000 500 0 2011
2012
recovered material* biowaste for biofuel production energy fraction
2013
2014
2015
mixed waste recovered for energy production mixed waste delivered to landfill building waste**
* materials for recovery: glass, paper, data security paper and other material, board, cardboard, compostable biowaste and metal ** building waste includes furniture and waste from minor renovations.
HEALTH CARE WASTE tons 250
CLIMATE PARTNER HUS greenhouse gas emissions in 2015 amounted to about 58,500 tons of CO2 eq (carbon dioxide equivalent). This estimate includes energy consumption (electricity, district heating), energy production (natural gas, oil), nitrous oxide and nitrogen use, waste management and fuel consumption of HUS vehicles and work machines. The largest percentages of HUS greenhouse gas emissions come from electricity and district heating. Medical gases used in specialist medical care, particularly nitrous oxide, represent a major contribution to HUS greenhouse gas emissions. In March 2015, HUS joined the Climate Partners cooperation of the City of Helsinki and businesses. This climate partnership brought access to a new network and hence information and new ideas.
200 150 100 50 0 2011
In 2015, HUS generated a total of 7,707 tons of waste. HUS has a goal of raising the percentage of community waste
2013
2014
2015
Biological waste and sharps waste, buried at a landfill Biological waste and sharps waste, for incineration Data security biological waste
BIOLOGICALLY STAINED WASTE ELECTRICAL AND ELECTRONIC EQUIPMENT (WEEE) tons
WASTE TO MATERIAL
2012
2015 2014 2013 2012 2011
Biologically stained WEEE 4.0 3.4 2.3 1.6 0.7
ENVIRONMENT
45
HUS | ANNUAL REPORT 2015 ENVIRONMENT
46
recycled as raw material to 50%. In 2015, this percentage was 45%. Waste that can be recovered for raw material includes glass, paper, data security paper, board, cardboard, compostable biowaste and metal. Material recovery has increased by a couple of per cent in five years. Improved board collection has raised the recovery rate. A significant percentage of the mixed waste generated is recovered for energy production. This was influenced for instance by the startup of the Vantaa Energy waste power plant in summer 2014. Energy production uses not only mixed waste but also biological, unidentified and sharps waste.
FOCUS ON LIFE CYCLE AND RESOURCE LOSS
Material efficiency reduces the amount of waste generated by HUS and makes better allowance for the life span of supplies and equipment. Material efficiency is being monitored in sample product groups, including photocopier paper and disposable clothing, HUS has a goal of raising dishes and cutlery. Material efficiency is analysed principally in relation to the recovery rate for person-years.
community waste to 50%. In the year 2015 the recovery rate was 45%.
Biowaste is recovered for the production of biogas, soil, biofuels and field nutrients, for instance. The new Meilahti waste station, designed to meet the needs of the evolving waste management system, was taken into use in April 2015. A clinic-specific waste monitoring system is being prepared for the station. A new monitoring system for special waste will replace the old barcode system during 2016.
The biggest reduction in 2015 compared with the previous year was achieved in disposable kidney basins, surgical sheets and surgical towels. The largest reductions between 2010 and 2015 were achieved in the use of disposable kidney basins and photocopier paper.
Ravioli catering services ran a waste food project in autumn 2015 with the aim of reducing order waste. ‘Order waste’ is here used to refer to meal orders from patient wards that remain unused. Order waste causes unnecessary costs to wards and generates unnecessary biowaste and resource loss throughout the food life cycle. This project decreased order waste by about one third.
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47
GOALS FOR 2016 HUS will draw up instructions on taking environmental matters into account in building investments. HUS will also survey
the needs for waste water emissions monitoring and implement any measurements needed. Awareness of consumption monitoring opportunities will be increased. HUS is preparing a new energy efficiency agreement and will draw up an energy efficiency action plan for 2017–2025. HUS is also participating at the national level in the preparation of the new Energy Efficiency Agreement for municipalities.
HUS WASTE IN 2015 tons
ENVIRONMENTAL PROGRAMME PERIOD 2011– 2015
Hazardous waste Health care waste Pharmaceutical and cytostatic waste Mixed waste recovered for energy production Mixed waste delivered to landfill Recovered material Biowaste for biofuel production Waste from construction and property management
214 383 88 3183 304 2929 50 555
During the environmental programme period, energy efficiency and material efficiency at HUS progressed in the intended direction. In the interests of improving material efficiency, personnel were encouraged to reduce the use of disposable products and to choose alternatives that are the least harmful for the environment. HUS issued instructions for taking environmental aspects into account in procurement and for improving energy efficiency. Management of environmental matters was improved by mainstreaming them into HUS operations. Environmental working groups were appointed for each unit, reporting to their respective management groups. Environmental awareness among personnel and also among customers was boosted through publicity, training and guidelines.
HUS | ANNUAL REPORT 2015
A beautiful environment is therapeutic
ENVIRONMENT
48
Ilkka Taipale, chairman of the HUS art committee, pats the silvery sculpture Elämänkaari [Life span] by Veikko Nuutinen. “There is no evidence suggesting that people feel better in bad environments,” says Taipale. Now in its third year, the art committee is contributing to the aesthetic improvement of HUS care facilities for instance by distributing arts allowances with which units can put their own ideas into practice. The HUS art committee is part of a national campaign launched by psychiatrist Ilkka Taipale and Professor Seppo Seitsalo about five years ago, ’10,000 artworks for hospitals’. Thanks to this campaign, many hospitals across Finland have received artworks as gifts and on loan (depositions), and art purHUS hospitals chases have also been made.
THE ‘ONE PER CENT ART’ PRINCIPLE GAINS GROUND IN HOSPITAL CONSTRUCTION
As its name indicates, the ‘one per cent art’ principle means allocating about 1% of the construction budget to arts acquisitions. This principle has been observed in public construction in many cities and municipalities for many years, but it is only now starting to gain wider ground in hospital construction.
STRONG TRADITION OF CREATING NICE BUILDINGS The most robust tradition in the use of arts in care environments may be found in Finland’s oldest mental hospitals, but aesthetically pleasing construction and pleasant environments have been in focus in other care environments too. Laying out a beautiful garden was an important part of the construction of the Maria Hospital in Helsinki, completed in 1894, and of the Laakso Hospital in Helsinki, originally built as a tuberculosis sanatorium in 1929. HUS hospitals leading the way in the arts are Kellokoski Hospital and Jorvi Hospital; the latter has its own art collection, known as the Artoteekki. The Artoteekki has been augmented through regular arts exhibitions for two decades. The foyer of Jorvi Hospital is an exhibition space available to artists, who are charged a 'fee' of one donated artwork. This concept is now also being used to rent out exhibition space in the foyers of the Meilahti hospitals.
leading the way in the arts are Kellokoski Hospital and Jorvi Hospital; the latter has its own art collection, known as the Artoteekki.
Taipale considers the most important goal of the committee’s work to be ensuring that art is included at the design stage in new construction projects and major renovations. The ‘one per cent art’ principle putting this idea into concrete terms was adopted by Finland’s Parliament in 1939, and it was first put into practice in the construction of the Children’s Castle Hospital in the 1940s.
In the budget proposal for 2015, the Executive Board of HUS allocated EUR 150,000 to arts support and EUR 150,000 for arts acquisitions in construction projects.
ARTS GRANTS TO BRIGHTEN UP THE WORKPLACE In 2015, HUS units were given the opportunity to apply to the art committee for an arts grant. The total amount disbursed was EUR 30,000. There were 19 applicants, of which nine received a grant varying between EUR 400 and EUR 6,600. Some applicants were given artworks from the HUS collection.
The main themes in the art committee’s work in 2015 were raising awareness of therapeutic art, augmenting the HUS art collections and boosting activity and interest among HUS personnel in the use of art in care and workplace environments.
“Art improves patient recovery,” says Ilkka Taipale. There are several sculptures in the park at the Women’s Hospital, such as Elämänkaari [Life span] (2006) by Veikko Nuutinen.
ENVIRONMENT
49
HUS | ANNUAL REPORT 2015
Medical service production HUS | ANNUAL REPORT 2015
SERVICE DEMAND
FINANCIAL STATEMENTS 2015 – SUMMARY
50
Demand for HUS services continued to grow in 2015. The number of referrals to elective (i.e. planned) treatment increased by 2.7% on the previous year, and the number of emergency clinic visits increase by 0.3%. Of the patients admitted for elec-
tive treatment, 60% were referred by a health center, 30.9% by a private practitioner and 9.1% by other hospitals. These percentages were nearly unchanged from the previous year.
ELECTIVE REFERRALS
EMERGENCY CLINIC VISITS
no. of referrals
no. of referrals
2015 2014 2013
285,601 278,156
2.7% 0.8%
275,983
5.6%
2015 2014 2013
0.3% 8.2%
229,584 228,981 211,668
1.1%
Number of elective referrals and emergency clinic visits in 2013–2015 and change (%) on the previous year. The number of emergency clinic visits in 2014 was influenced by a significant expansion of joint emergency services clinic operations. The comparable number of emergency clinic visits in 2014 increased by 1.8% on the previous year.
SERVICE PRODUCTION MEDICAL SERVICE PRODUCTION
SERVICE PRODUCTION
FS 2014
Change in volume service production weighted according to billing share Psychiatry treatment days 1) 184,686 NordDRG products 664,401 DRG groups 156,223 DRG-O groups 135,150 Endoscopy 31,695 Minor procedures 92,516 900 group 248,647 Cost based period 170 Outpatient products, somatic care 1,259,224 Outpatient products, psychiatric care 451,488 Health center emergency clinic visits 63,057 Billable transfer delay inpatient days 1,346 Visit products 2,282,186 Emergency clinic visits (including DRG billing) 228,981 First visits 245,904 Treatment day interim performances 806,972 Surgical operations 91,598 Ambulatory surgery procedures 37,139 Births as at December 31, 2015 17,975
The volume service production weighted according to the billing share grew by 3.8% compared to the previous year, exceeding the budget by 6.3%. Outpatient care accounted for 41.9% of all care in 2015 (2014: 42.5%). The number of NordDRG products and the number of visit products increased by 4.3% and 4.6% on the previous year, respectively. Somatic care grew
BUDGET 2015
642,972 155,928 127,890 31,721 85,730 241,564 140
70,673
DIFFERENCE% FS 2015 / FS 2015 BUDGET 2015
CHANGE% FS2015/ FS 2014
6.3%
3.8% -5.3% 4.3% 2.4% 2.8% -0.9% 12.2% 4.0% 87.6% 3.6% 4.7% 33.2% -37.0% 5.0% 0.3% 3.1% -0.6% -0.6% -1.2% -1.6%
174,892 692,934 159,895 138,927 31,396 103,770 258,627 319 1,304,004 472,497 83,990 848 2,396,066 229,584 253,634 802,156 91,089 36,708 17,687
7.8% 2.5% 8.6% -1.0% 21.0% 7.1% 127.3%
18.8%
by 3.6% and psychiatric care by 4.7%. However, the number of treatment days in psychiatric care decreased by 5.3%, as per the goal. In 2015, a record breaking 391 organ transplants were made. The number organ transplants in previous years was 355 in 2014 and 285 in 2013.
25 MOST SIGNIFICANT INPATIENT TREATMENT PERIODS (DRG PRODUCTS)
Primary knee or ankle replacement Unusual combination of procedure and diagnosis, limited procedure Operation on the leg, ankle or upper arm, adult, no complications Cerebral infarction or other chronic cerebrovascular disorder, with complications Caesarian section, with complications Heart failure or cardiogenic shock Pneumonia or pleuritis, adult, with complications Natural birth, with complications Natural birth, no complications
187,308 171,008
42 43
99,677 88,289
73 77
85,385
205
65,264 36,898 31,629
229 200
95
29,320 27,774
290 208
15,749
682
12,579
512
9,247
663
8,927
719
8,535
775
7,045 6,275
1,858 1,835
6,214 5,663
1,138 1,423
5,312
1,710
4,927 4,293 3,747 3,281 2,114
The horizontal bar shows the average billing per product in EUR; the number following the bar is the number of products.
1,540 1,829 2,231 5,008 8,942
25 major medical service products.
PATIENTS TREATED MEDICAL SERVICE PRODUCTION
Individual patients in specialist medical care Individual patients at health center emergency clinics Average treatment period (inpatient care) 2) Somatic care, days Psychiatric care, days
The number of individual patients treated in specialist medical care was 509,650. This figure was 2.9% higher than in the previous year. The total number of individual patients treated at HUS, including health center patients at joint emergency clinics, was 541,558 . Patients treated in both specialist medical care and at a health center emergency clinic were only counted once each. The increase on 2014 was 4.3%. A total of 482,066 residents of member municipalities used specialist medical care services, an increase of 11,698 persons
FS 2013
FS 2014
FS 2015
CHANGE% FS2015 / FS 2014
481,749 53,252
495,309 44,424
509,650 62,534
2.9% 40.8%
4.0 18.3
3.8 24.5
3.8 22.8
-0.9% -6.9%
or 2.5% on the previous year. At the same time, the population of the HUS catchment area grew by 1.1%. About one in three (29.8%) of the residents of member municipalities used specialist medical care services provided or organized by HUS in 2015. The percentage of residents of member municipalities using the services increased slightly from 29.4% in 2014. Use of services in relation to population varies significantly between municipalities.
51 FINANCIAL STATEMENTS 2015 – SUMMARY
Heart transplant Neonatal, birth weight under 1,000 g Neonatal, birth weight 2,500 g or more, extensive operation Liver transplant Intensified care or intensive care requiring tracheostomy Allergenic stem cell transplant, adult Renal transplant Other open heart surgery or thoracic vascular surgery Operation involving several cardiac valves, or operation on a single valve with complications Demanding vascular reconstruction surgery, not open heart surgery, with complications Extensive operation on the small or large intestine, with complications Surgical treatment of an infectious disease Extensive operation on the small or large intestine, no complications Other vascular surgery, with complications Other spinal fusion, no complications Primary hip replacement, no complications
HUS | ANNUAL REPORT 2015
average billing EUR
PATIENTS TREATED, PERCENTAGE OF POPULATION BY MEMBER MUNICIPALITY
HUS | ANNUAL REPORT 2015
Population as at December 31, 2014; preliminary population figures for end December 2015. Source: Statistics Finland.
FINANCIAL STATEMENTS 2015 – SUMMARY
52
Raasepori
41% 40%
Hanko
38% 38%
Lohja
36% 35%
Porvoo
35% 34%
Inkoo
35% 34%
Askola
35% 34%
Siuntio
33% 34%
Karkkila
35% 33%
Lapinjärvi
34% 33%
Vihti
32% 32%
Hyvinkää
33% 32%
Pornainen
31% 32%
Sipoo
32% 32%
Loviisa
31% 30%
Kauniainen
30% 30%
Kerava
31% 30%
Espoo
30% 30%
Nurmijärvi
31% 30%
Mäntsälä
32% 30%
Vantaa
31% 30%
Järvenpää
31% 30%
Kirkkonummi
30% 29%
Tuusula
30% 29%
Helsinki
28% 27%
MEMBER MUNICIPALITIES
30% 29%
2015 2014
Percentage of patients out of total population, by member municipality, in 2014 and 2015. The City of Helsinki provides some specialist medical care services for its residents itself.
AVAILABILITY OF TREATMENT AND ACCESS TO TREATMENT
FS 2014
FS 2015
Number of referrals (elective) Referral processing time >21 days, no. of cases Patients waiting for inpatient care 3) over 6 months total Patients waiting for outpatient care 3) over 3 months total
278,156 6,399
285,601 2,620
2.7% -59.1%
158 16,909
267 17,961
69.0% 6.2%
1,406 24,986
1,315 24,912
-6.5% -0.3%
At the end of the year, the number of patients waiting for non-urgent outpatient examinations and care was 0.3% lower than in the previous year, while the number of those who had been waiting for more than 3 months was 6.5% lower than in
the previous year, at 1,315. By contrast, the number of patients waiting for inpatient care increased by 6.2% on the previous year, and the number of patients who had been waiting for more than 6 months increased by 69%, to 267.
PRODUCTIVITY
Labor productivity and overall productivity trends are measured in somatic service production using NordDRG productivity indicators . Labor productivity improved by 2.1% on the previous year (DRG points per person-year). The deflated DRG point cost, which measures overall productivity, decreased by 1.7%, i.e. productivity improved by 1.7%.
PRODUCTIVITY % 1.7% 2.1%
2015* 2014
Overall productivity and labor productivity trends 2009–2015. The productivity indicator, DRG point cost, does not fully take into account the shift in production structure towards outpatient care.
-0.1% 2.1% 0.9% 1.1%
2013
0.9%
2012 -0.4%
1.7%
2011
2.7% 4.2%
2010 1.9% 2009
4.0% 3.1%
* Deflated, price index of public expenditure, coefficient 1.003 (November 6, 2015)
Overall productivity Labor productivity
53 FINANCIAL STATEMENTS 2015 – SUMMARY
AVAILABILITY OF TREATMENT AND ACCESS TO TREATMENT
CHANGE % FS2015 / FS 2014
HUS | ANNUAL REPORT 2015
MEDICAL SERVICE PRODUCTION
HUS | ANNUAL REPORT 2015
MEMBER MUNICIPALITIES’ CONTRIBUTIONS (SPECIALIST MEDICAL CARE SERVICE BILLING)
FINANCIAL STATEMENTS 2015 – SUMMARY
54
Contribution billing from member municipalities for specialist medical care services stood at EUR 1,570 million. The combined contribution billing from member municipalities grew by 6.4% on the previous year, to EUR 94.7 million, which was 6% more than the budgeted EUR 88.5 million. The volume of operations in member municipalities’ specialist medical care grew by 3.2% on the previous year and was 5.5% over budget. The surplus refund of EUR 25 million paid out to member municipalities by a decision of the Council in June reduced the contribution billing. The Council decided at its meeting in December 2015, contrary to the proposal of the Executive Board, that the disposal of the financial result for 2015 will be decided on in June together with the adoption of the financial statements. After deducting the surplus accrued in 2015, contribution billing from member municipalities totalled EUR 1,515.3 and was 2.3% over budget. The volume of service use also exceeded that specified in the budget. Compared with the previous year, 3.2% in the increase in contribution billing for own service production was caused by the increasing volume of service use, and 0.8% was caused by increases in the average price of the services provided.
Costs per resident of HUS member municipalities in 2015 averaged EUR 971. This was 5% more than in 2014. After deducting the refunded surplus, the average costs per resident were EUR 938, 1.3% more than in 2014.
MEMBER MUNICIPALITIES' DEFLATED CONTRIBUTIONS 2011–2015 EUR / RESIDENT 2015* 2015 2014 2013 2012 2011
1.3% 5.0%
937.6 971.4 925.5 907.0 889.6
2.0% 2.0% - 2.0%
907.5
- 0.2%
Population as at December 31 in 2011–2014, population estimate for December 2015. Source: Statistics Finland. Deflated to the 2015 level, Price Index of Public Expenditure, Statistics Finland, local government, health care (2015 = average for January to September). * including imputed surplus refund of EUR 54.6 million.
Member municipalities’ contributions per resident, deflated, 2011–2015, with percentage of change on the previous year.
MEMBER MUNICIPALITIES’ CONTRIBUTIONS EUR million 2015*
1,515 1,481
2015
1,570 1,481
2014
1,475 1,444
2013
1 422 1,405
2012
1,353 1,331
2011
1,316 1,282
2.3%
The figure below shows trends in the Price Index of Public Expenditure, combined member municipality contributions and contributions per resident, index-linked, from 2009 to 2015.
6.0% 2.2% Index 2009 = 100 1.2% 1.7% 2.6%
* Including the imputed surplus refund of EUR 54.6 million but excluding the EUR 1.1 million deficit incurred in prehospital emergency care in the Länsi-Uusimaa Hospital Area. Billing for prehospital emergency care services is included under other income from services and not in contribution billing from member municipalities.
BUDGET Actual, nondeflated Deviation% Actual / Budget
Member municipalities’ contributions (non-deflated) 2011– 2015 and their deviations from budget (%).
120 115 110 105 100 95 90 TP2009
TP2010
TP2011
TP2012
TP2013
TP2014
TP2015
Price Index of Public Expenditure (November 6, 2015) Member municipalities’ contributions (deflated) EUR per resident (deflated) Member municipalities’ contributions (deflated) (including imputed refund of surplus to member municipalities) EUR per resident (deflated) (including imputed refund of surplus to member municipalities)
Finances at HUS %
Member municipalities’ contributions Other income from services Proceeds from other sales State subsidy for education and research Sales proceeds Other operating income and subsidies
The HUS Joint Authority recorded a surplus of EUR 53.5 million for the year under review. The HUS Council decided at its meeting in December that, contrary to previous years the disposal of the financial result for 2015 will not be decided until the adoption of the financial statements in June 2016. As a result, the refund of the surplus to the member municipalities could not be included as a deduction to the contribution billing from member municipalities in the 2015 financial statements. HUS operating expenses were 3.6% (EUR 65.3 million) over budget. At the same time, the volume service production weighted according to the billing share exceeded the budget by 6.3%. The budget excess in operating expenses was mostly caused by volume-dependent cost items: medicines and medical equipment EUR 40.1 million and purchase of medical care services EUR 15.1 million. Personnel expenses were EUR 16.1 million over budget. Because of the growth in production, overtime and extra work could not be reduced according to the goals set, and the number of person-years worked was higher than projected. During 2015, the following new functions were inaugurated in accordance with the division of duties agreed on with member municipalities: a joint emergency services clinic at Porvoo Hospital, City of Helsinki physiatry functions, demanding specialist terminal care at Terhokoti, part of the City of Helsinki pharmaceutical supply functions, laboratory services at the Porvoo Health Center and imaging services at the Porvoo and Tuusula Health Centers. The comparable increase in operating expenses, after deducting the costs for the above at EUR 7.9 million in 2015, was 3.9% on the previous year. Binding net costs were 2.3% over budget. This was caused by the excess in operating expenses that could not be compensated for by proceeds from other sales and payments income.
HUS | ANNUAL REPORT 2015
DISTRIBUTION OF OPERATING INCOME 2015
77.0% 15.2% 2.1% 1.4% 3.4% 0.9%
DISTRIBUTION OF OPERATING INCOME 2015 %
Personnel expenses Medical services Medicines and medical equipment Purchase of other services Other materials, supplies and consumables Other operating expenses and subsidies
60.8% 5.5% 16.5% 11.0% 2.9% 3.2%
55 FINANCIAL STATEMENTS 2015 – SUMMARY
Measured by the volume of services produced and the number of patients treated, HUS operations were larger than ever in 2015. In 2015, the operating income of the HUS Joint Authority exceeded EUR 2 billion for the first time ever. The main positive thing was of course that patients continued to receive the care they need, but in the current recession the member municipalities had not prepared for this volume of operations or the resulting costs. The HUS Joint Authority falls under local government finances in its catchment area. Operating income was EUR 119 million over budget; the majority of this, EUR 88.5 million, came from specialist medical billing to member municipalities.
PROFIT AND LOSS ACCOUNT
FS 2015
BUDGET 2015
DEVIATION% FS 2015/ BUDGET 2015
Operating income total Sales proceeds Member municipalities’ contributions Other income from services Proceeds from other sales State subsidy for education and research Sales proceeds Subsidies and grants Other operating income
2,039,199 1,951,331 1,569,960 309,681 43,569 28,121 68,497 8,911 10,460
1,920,186 1,844,946 1,481,418 293,954 39,226 30,348 61,322 7,368 6,550
6.2% 5.8% 6.0% 5.4% 11.1% -7.3% 11.7% 20.9% 59.7%
1,906,951 1,826,403 1,475,306 279,224 41,077 30,796 62,287 10,268 7,993
6.9% 6.8% 6.4% 10.9% 6.1% -8.7% 10.0% -13.2% 30.9%
Operating expenses total Personnel expenses Purchased services Materials, supplies and consumables Subsidies and grants Other operating expenses Operating margin
1,862,285 1,132,222 307,968 362,345 1,148 58,602 176,914
1,796,987 1,116,125 292,990 326,378 946 60,548 123,199
3.6% 1.4% 5.1% 11.0% 21.4% -3.2% 43.6%
1,784,232 1,101,698 285,970 339,981 893 55,691 122,719
4.4% 2.8% 7.7% 6.6% 28.7% 5.2% 44.2%
Financial income and expenses Result before depreciation and extraordinary items
13,210 163,704
14,644 108,555
-9.8% 50.8%
13,171 109,548
0.3% 49.4%
Depreciation and reductions in value Annual result
110,214 53,489
110,055 -1,500
0.1%
106,853 2,694
3.1%
1,972,499 1,516,470
1,907,042 1,482,918
3.4% 2.3%
1,891,085 1,472,612
4.3% 3.0%
HUS | ANNUAL REPORT 2015
PROFIT AND LOSS ACCOUNT (EUR 1,000)
FINANCIAL STATEMENTS 2015 – SUMMARY
56
TOTAL OPERATING EXPENSES AND DEPRECIATION BINDING NET COSTS
Personnel Person years of permanent employees totaled 18,016. Person years increased by 2.3% (405 person years) on the previous year; the total was 2.5% over budget. The average cost of a person year increased by 0.3% on the previous year, to EUR 62,328. At the end of 2015, HUS had 22,425 employees, 0.3% (61 employees) more than at the end of the previous year. Permanent employees accounted for a high percentage of the total, 79.6%, an increase of 0.9 percentage points on the previous year. The goal of 81% set for the year under review was not attained.
PERSON YEARS (PERMANENT EMPLOYEES) AND COST OF A PERSON YEAR person years FS 2015 Budget 2015 FS 2014 FS 2013 FS 2012 FS 2011
EUR 18,016 17,574 17,611 17,468 17,339 16,909
62.3 63.3 62.1 61.1 62.3 59.4
FS 2014
CHANGE,% FS 2015/ FS 2014
equipment investments and the minor equipment project program were executed as per the investment program, but some of the equipment procurement for construction projects nearing completion was delayed to the following year. This delay was mainly due to the annexe at Jorvi. EUR 25.2 million was spent in equipment investments in the hospital areas in 2015, EUR 4.8 million less than the reserve.
Construction investments came in at EUR 4.0 million under the budgeted figure of EUR 76.8 million. The largest items in unused construction project reserves concerned the underground facilities project at Meilahti and the final instalments on the emergency clinic annexe at Jorvi; these will need to be funded in 2016. The investment program reserve for minor (less than EUR 0.5 million) construction projects, EUR 13.3 million, was exceeded by EUR 1.7 million due to an unexpectedly high funding need for urgent indoor environment renovation and other repairs in hospital facilities. The poor condition of the hospital buildings and the resulting operational risks together with major repair needs complicate the improvement of service production and productivity particularly in the HUH Hospital Area.
About EUR 1.4 million was spent on fixed assets investments, specifically subscriptions to shares in Oy Apotti Ab and HUS-Asunnot Oy. Other long-term expenses recorded in the financial statements include a donation of EUR 13.3 million for the construction of the new Children's Hospital.
The hospital areas’ equipment procurement programs were executed as planned except for HUH. At HUH, four major
The investment program for 2015 included EUR 20.5 million for investments in IT Management. The actual amount invested in projects was EUR 18.1 million. The shortfall was mainly due to changes in project timetables: in the majority of the ICT projects, however, the funding need matched the revised investment reserve. Investments by business enterprises totaled EUR 17.2 million, of which EUR 8 million went towards equipment procurement by HUS Imaging. HUS JOINT AUTHORITY INVESTMENTS AND DEPRECIATION 2011–2015 EUR million 110
FS 2015
148 110
Budget 2015
161 107 148
FS 2014 103 132
FS 2013 98 116
FS 2012 FS 2011 Depreciation Investments
94 95
57 FINANCIAL STATEMENTS 2015 – SUMMARY
Investments totaled EUR 148 million, of which EUR 17.2 million concerned acquisitions by business enterprises. EUR 130.8 million was spent on construction projects, IT systems, medical equipment and other investments in profit areas. Compared with the investment section of the budget as revised by Council decision in December 2015, the implementation rate for the entire Joint Authority was 92%.
HUS | ANNUAL REPORT 2015
Investments
HUS | ANNUAL REPORT 2015
Funding
FINANCIAL STATEMENTS 2015 – SUMMARY
58
During the period under review, the HUS Joint Authority withdrew EUR 50 million in new long term loans; the original budget allowed for borrowing of EUR 90 million. EUR 10.2 million was spent on loan repayments. Adequacy of cash flow was 18.3 days. The equity ratio of the Joint Authority was 40.5%, which was higher than the preset minimum of 35%. Net financial expenses were EUR 13.2 million, EUR 1.4 million lower than in the original budget. The average interest rate on the Joint Authority loan portfolio in 2015 was 1.1% (2014: 1.3%), and the average interest rate earned on liquid assets was 0.3% (2014: 0.4%). At the end of the financial year, the loan portfolio stood at EUR 244.4 million and liquid assets at EUR 102.0 million. As at the financial statements date, 25% of the interest risk in the Joint Authority loan portfolio was hedged. For the net loan portfolio, which takes into account the Joint Authority’s short term liquidity investments, the hedging ratio was about 55%.
HUS JOINT AUTHORITY LOAN PORTFOLIO AND EQUITY RATIO 2011–2015 EUR million FS 2015 Budget 2015 FS 2014 FS 2013 FS 2012 FS 2011
% 244.4 284.4
40.5%
204.6 214.9 224.2
39.1% 40.1% 39.9%
35.0%
194.7
44.7%
Loan portfolio Equity ratio%
HUS JOINT AUTHORITY ADEQUACY OF CASH FLOW (DAYS) 2011–2015 days
days
FS 2015 Budget 2015 FS 2014 FS 2013 FS 2012 FS 2011
18.3 15.0 16.5 19.6 23.4 25.8
Adequacy of cash flow (days) Minimum target
15.0 15.0 15.0 20.0 20.0 20.0
PROFIT AND LOSS ACCOUNT
Operating income Sales proceeds Sales proceeds Subsidies and grants Other operating income Operating expenses Personnel expenses Salaries and fees Social security expenses Pension expenses Other social security expenses Purchased services Materials, supplies and consumables Subsidies Other operating expenses Share of business enterprises’ profit/loss Operating margin Financial income and expenses Interest income Other financial income Interest expenses Other financial expenses Result before depreciation and extraordinary items Depreciation and reductions in value Depreciation according to plan Extraordinary items Annual result Tax reserves Taxes for the financial year Imputed taxes Minority share Surplus for the financial year
1.1.–31.12.2015
1.1.–31.12.2014
1.1.–31.12.2015
1.1.–31.12.2014
1,966,629 68,497 8,958 12,669 2,056,753
1,835,429 62,287 10,320 15,051 1,923,088
1,951,331 68,497 8,911 10,460 2,039,199
1,826,403 62,287 10,268 7,993 1,906,951
-934,296
-907,028
-914,900
-887,993
-169,663 -52,456 -277,540 -378,271 -1,148 -61,642 -1,875,016 -399 181,338
-163,109 -55,219 -258,454 -351,709 -893 -59,059 -1,795,471 1,782 129,398
-165,904 -51,417 -307,968 -362,345 -1,148 -58,602 -1,862,285 0 176,914
-159,536 -54,168 -285,970 -339,981 -893 -55,691 -1,784,232 0 122,719
396 342 -2,562 -11,973 -13,797 167,541
712 316 -2,945 -11,952 -13,868 115,530
637 359 -2,404 -11,802 -13,210 163,704
1,031 313 -2,763 -11,752 -13,171 109,548
-114,173 0 53,368 -38 84 -144 88 53,358
-109,674 0 5,855 -11 46 -241 -19 5,630
-110,214 0 53,489 0 0 0 0 53,489
-106,853 0 2,694 0 0 0 0 2,694
HUS GROUP
HUS JOINT AUTHORITY
2015
2015
109.7%
109.5%
146.7% 2014
107.1% 105.2%
2013
107.6% 110.0%
2012
104.8%
148.5% 2014 2013
107.4% 110.2%
2012
65.7% 2011
106.9% 102.5%
104.5% 63.6%
105.9% 83.4% Operating income / Operating expenses,% Result before depreciation and extraordinary items/ Depreciation%
2011
105.7% 82.8% Operating income / Operating expenses,% Result before depreciation and extraordinary items/ Depreciation%
HUS | ANNUAL REPORT 2015
(EUR 1,000)
HUS JOINT AUTHORITY
59 FINANCIAL STATEMENTS 2015 – SUMMARY
HUS GROUP
BALANCE SHEET HUS GROUP (EUR 1,000)
HUS JOINT AUTHORITY
2015
2014
2015
2014
46 36,296 5,977 42,319
46 38,806 6,205 45,057
0 36,296 5,923 42,220
0 38,806 6,068 44,874
14,621 576,239 41,260 115,205 3,262 64,264 814,852
14,828 433,704 10,694 98,152 914 218,440 776,731
13,008 522,646 41,260 109,939 383 63,546 750,782
13,167 410,713 10,694 93,739 228 185,349 713,890
16,591 3,709
16,720 4,510
15,211 8,699
14,942 7,645
71 85 20,456
74 254 21,558
35,053 85 59,049
34,354 254 57,194
877,627
843,346
852,052
815,958
6,001
5,093
6,001
5,093
21,947
23,150
21,754
22,955
0 125,469 125,469
576 78,964 79,540
0 125,479 125,479
576 77,921 78,496
3,007
17,003
2,999
16,995
99,659
71,977
99,009
71,359
250,082
191,670
249,240
189,805
1,133,710
1,040,109
1,107,292
1,010,856
HUS | ANNUAL REPORT 2015
ASSETS
FINANCIAL STATEMENTS 2015 – SUMMARY
60
NON-CURRENT ASSETS Intangible assets Intangible rights Computer software Other long-term expenses Intangible assets Tangible assets Land and water areas Buildings Immovable structures and equipment Machinery and equipment Other tangible assets Advance payments and purchases in process 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 TOTAL ASSETS
BALANCE SHEET HUS GROUP (EUR 1,000)
HUS JOINT AUTHORITY
2015
2014
2015
2014
391,253 1,108 7,690 53,358 453,409
391,253 1,083 2,060 5,630 400,026
391,253 0 0 53,489 444,743
391,253 0 -2,694 2,694 391,253
3,092
3,167
0
0
0 0
336 336
0 0
0 0
1,605 54,065 55,670
2,480 54,699 57,179
1,605 54,065 55,670
2,480 54,699 57,179
6,001
5,093
6,001
5,093
251,213 1,506 12,350 350,468 615,538
213,562 1,363 12,321 347,061 574,307
234,171 0 10,238 356,470 600,879
194,409 0 10,238 352,683 557,331
1,133,710
1,040,109
1,107,292
1,010,856
MINORITY SHARES DEPRECIATION AND UNTAXED RESERVES Untaxed reserves DEPRECIATION AND UNTAXED RESERVES PROVISIONS Provisions for pensions Other provisions 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 LIABILITIES TOTAL LIABILITIES
FINANCIAL INDICATORS FOR THE BALANCE SHEET HUS GROUP
2015
2014
2013
2012
2011
HUS JOINT AUTHORITY 2015
2014
2013
2012
2011
Gearing ratio,%
40.7
39.3
40.3
39.8
44.7
Gearing ratio,%
40.5
39.1
40.1
39.9
44.7
Relative indebtedness,%
29.4
29.3
29.0
30.7
28.6
Relative indebtedness,%
29.0
28.7
28.7
30.3
28.2
61,048
7,690
-2,419 -12,313
27,025
53,489
0
-2,694 -13,260
25,748
Accrued surplus/ deficit, EUR 1,000 Loan portfolio as at Dec 31 (EUR 1,000) Loan receivables 31 Dec (EUR 1,000)
263,564 225,883 228,436 238,568 210,001
71
74
508
516
524
Accrued surplus/ deficit, EUR 1,000 Loan portfolio as at Dec 31 (EUR 1,000) Loan receivables 31 Dec (EUR 1,000)
244,409 204,648 214,886 224,156 194,696
35,053
34,354
36,523
29,976
Equity ratio% = 100 * Capital and reserves / (Capital and reserves total – Advances received) Relative indebtedness% = 100 * (Liabilities – Advances received) / Operating income Accrued surplus/deficit, EUR 1,000 Loan portfolio as at Dec 31 (EUR 1,000) = Liabilities – (Advances received + Trade creditors + Accruals and deferred items + Other creditors) Loan receivables 31 Dec (EUR 1,000) = Other loan receivables recognized under investments
24,376
61 FINANCIAL STATEMENTS 2015 – SUMMARY
CAPITAL AND RESERVES Subscribed capital Other own reserves Surplus/deficit from previous financial years Surplus/deficit for financial year CAPITAL AND RESERVES
HUS | ANNUAL REPORT 2015
LIABILITIES
CASH FLOW STATEMENT HUS GROUP
HUS | ANNUAL REPORT 2015
(EUR 1,000)
FINANCIAL STATEMENTS 2015 – SUMMARY
62
Operating cash flow Result before depreciation and extraordinary items Taxes for the financial year Adjusting items for cash flow financing Investment cash flow Investment expenses Investment expenses financing shares Capital gains for fixed asset items Operating and investment cash flow Financing cash flow Changes in loan receivables Increases in loan receivables Decreases in loan receivables Changes in loan portfolio Increase in long-term loans Decrease in long-term loans Change in short-term loans Changes in capital and reserves Changes in minority share Other changes in liquidity Changes in inventories Change in receivables Change in interest-free debts Financing cash flow Change in liquid assets Liquid assets as at 31 Dec Liquid assets as at Jan 1
HUS JOINT AUTHORITY
2015
2014
2015
2014
167,541 84 -2,533
115,530 46 8,730
163,704 0 -2,639
109,548 0 10,515
-152,160 938 3,460 17,329
-155,706 2 177 -31,221
-148,008 938 2,423 16,417
-147,803 2 167 -27,572
0 171
0 434
-3,400 2,869
0 2,169
50,047 -12,366 0 -13 -163
8,840 -11,374 -20 0 -0
50,000 -10,238 0 0 0
0 -10,238 0 0 0
1,203 -45,930 3,407 -3,644
-4,652 -2,740 27,804 18,293
1,201 -46,982 3,787 -2,764
-4,664 -2,384 29,727 14,610
13,686
-12,928
13,653
-12,962
102,666 88,980
88,980 101,908
102,007 88,354
88,354 101,316
FINANCIAL INDICATORS FOR THE BALANCE SHEET HUS GROUP
2015
2014
2013
2012
2011
110.8%
74.2%
81.1%
52.8%
75.9%
Five-year cash flow -108.7 accrual from operations and investments, EUR million
-158.4
-153.9
-140.7
11.4
8.3
8.8
4.4
4.7
2,054
1,978
1,900
1828
1,728
Adequacy of cash flow (days) 18.2
16.4
19.6
23.8
26.1
Investment cash flow financing,%
Debt coverage ratio Cash disbursements, EUR million
HUS JOINT AUTHORITY 2015
2014
2013
2012
2011
111.3%
74.1%
86.2%
53.6%
81.9%
Five-year cash flow -84.6 accrual from operations and investments, EUR million
-128.2
-126.5
-122.6
13.1
8.6
9.7
4.6
5.0
2,038
1,957
1,885
1820
1,719
Adequacy of cash flow (days) 18.3
16.5
19.6
23.4
25.8
Investment cash flow financing,%
Debt coverage ratio Cash disbursements, EUR million
Investment cash flow financing% = 100 * Result before depreciation and extraordinary items / Investment self-acquisition expense Five-year cash flow accrual from operations and investments, EUR million Debt coverage ratio = (Result before depreciation and extraordinary items + Interest expenses) / (Interest expenses + Loan amortizations) Cash disbursements, EUR million Adequacy of cash flow (days) = 365 days * Liquid assets Dec 31 / Cash disbursements during financial year
FINANCIAL STATEMENTS 2015 – SUMMARY
63
HUS | ANNUAL REPORT 2015
HUS is Finland’s largest provider of health care services and second largest employer. Our expertise is highly ranked internationally. We produce services for the nearly 1.6 million residents of our 24 member municipalities and have nationwide responsibility in certain areas of specialist medical care. Every year, half a million patients are treated at the 23 HUS hospitals. HUS's annual turnover is about EUR 2 billion, and we employ about 22,500 professionals.
Stenbäckinkatu 9, PO Box 100, 00029 HUS, Finland, 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-huswww.youtube.com/HUSvideot www.issuu.com/husjulkaisut HUS is a non-smoking organisation.