Self-supervision plan

Published 1 January 2024.

At FSHS, self-supervision is conducted by following instructions of action and procedure. This self-supervision plan describes these instructions in detail. The plan’s aim is to prevent and rectify any risks, dangerous situations and inadequate quality of service within our operations, as well as to ensure the professional capabilities of our care personnel.

Our general self-supervision plan is monitored yearly and updated when necessary, as are self-supervision plans of individual service points.

1 Information about service provider
1.1 Values and operational strategy
1.2 Operating principle and mission
1.3 Service regions and service units
2 Self-supervision: organisation and leadership
3 Personnel
4 Facilities, devices, equipment and hygiene practices
4.1 Cleaning, waste management and handling of hazardous waste
4.2 Medical devices and equipment
4.3 Use of radiation in healthcare
4.4 Laboratories
4.5 Hygiene practices
5 Patient ombudsperson
6 Pharmacotherapy
7 Identifying risks and shortcomings, and corrective measures
8 Patient documents and handling of personal data
8.1 Names and contact details of persons responsible for data protection
9 Strengthening patient participation and handling objections
9.1 Processing objections, complaints, and suspected patient injuries
10 Monitoring and assessing self-supervision

Information about service provider

Service provider
Finnish Student Health Service (FSHS)

Service provider’s business ID
Y-0202637-8

Location name
Finnish Student Health Service (FSHS)

Postal address
Töölönkatu 37 A
00260
Helsinki
FINLAND

Directors responsible for services
Director responsible for healthcare services, Medical Director Teija Kulmala
Director responsible for oral healthcare services, Medical Director of Dentistry Krista Brander-Aalto

Phone numbers of directors responsible
+35841 7319 420
+35841 7322 165

Postal address of directors responsible
Töölönkatu 37 A
00260
Helsinki
FINLAND

Email addresses of directors responsible
teija.kulmala(at)ths.fi
krista.brander-aalto(at)yths.fi

Self-supervision: organisation and leadership

Managers responsible for healthcare services are in charge of activities in accordance with the Act on Organising Healthcare and Social Welfare Services (612/2021). They are also responsible for steering, planning, development and harmonisation of services for the entire FSHS. The Medical Director is in charge of health promotion and research for the FSHS.

Responsibility for the FSHS’s self-supervision activities rests with the foundation’s management and with the service region management working under the regional managers: Regional Medical Directors, Regional Medical Directors of Dentistry, Regional Head Nurses and supervisors. In practice, self-supervision has been organized in such a way that those directors responsible for healthcare services have appointed Regional Medical Directors and/or Regional Medical Directors of Dentistry for FSHS service units, who are responsible for the quality of medical care and patient safety as set out in this self-supervision plan in the respective service regions and service units.

The FSHS service and development team is in charge of updating and coordinating the self-supervision plan, with the manager or director of operations in each area of responsibility updating their own part of the plan. The HR manager provides the text for the HR section and the HR statement. The service development team scrutinises and approves the self-supervision plan, which is published on the FSHS website and on the intranet, to which everyone has access. Service units update their own self-supervision plans, which are publicly available in the service units.

Personnel

On the last day of 2022, the FSHS had 984 (960) employees in total. Most of them, 889 (870), worked on a permanent contract and 95 (78) on a fixed-term contract. In the HR statement the numbers in parenthesis are the corresponding numbers for 2021.

The majority of FSHS personnel are female, which is typical in healthcare organizations. In December 2022, 90% of the employees were women. Most of the rest were male. A minority were non-binary.

Amount of personnel 31.12.2022

28.68% (27.6%) of the foundation’s personnel worked part-time in 2022. Working part-time was most common among general practitioners, dentists and psychologists.

Occupational groups and working hours 31.12.2022

Under section 18a of the Act on Health Care Professionals, healthcare professionals must have sufficient language proficiency to perform their duties. Employers are required to assess whether a person has sufficient language proficiency. Before hiring a new employee, the FSHS assesses the person’s professional competence by checking their academic qualifications and their data in the register of healthcare professionals and assesses their language proficiency for the task concerned. Healthcare professionals must speak Finnish or Swedish fluently enough to be able to perform their duties. A knowledge of English and/or Sami is a bonus.

Read more about FSHS language strategy

It is the responsibility of the recruiting supervisor to check the person’s right to work in social welfare or healthcare with the National Supervisory Authority for Welfare and Health (Valvira) register JulkiTerhikki before signing an employment contract. The supervisor enters the person’s register number provided by Valvira in the HR system Sympa. If the person’s right to practise a social welfare or healthcare profession has been restricted, the issue should be resolved by contacting Valvira.

The FSHS provides workplace orientation for all new employees. Orientation takes place via an online training platform (FSHS Academy) and is arranged by the person’s immediate supervisor. The purpose of workplace orientation is to familiarise new employees with their work and help them adapt to their new working environment. New employees are introduced to the foundation’s organization, goals and operations and given guidance on their duties and the equipment they will use.

Employees are also given guidance after long leaves of absence and when their duties change. New managers are provided with guidance in their managerial duties. The purpose of the guidance is to strengthen the managerial skills and knowledge of employment relationships of those responsible for managing personnel.

All FSHS healthcare professionals who practise pharmacotherapy are required to obtain Laatupassi certification in the FSHS Academy as part of the FSHS orientation programme, which includes getting acquainted with pharmacotherapy plans and the basic range of medicines. A list of orientation issues is available for use by the manager and the employee. Orientation also includes getting acquainted with the FSHS’s pharmacotherapy plan and the service unit’s own pharmacotherapy plan. All employees who have had an extended time off work are required to undergo orientation. Employees who have been off work for longer than three years are also required to complete the theoretical training for a pharmacotherapy licence and possibly also to demonstrate their competence, even if it is less than 5 years since they obtained their pharmacotherapy licence.

Skills are developed in line with the FSHS’s competence needs and an assessment of the person’s current competence. Personal competence assessments and training plans are made during development discussions. The progress of these development discussions is monitored, and employees apply for training based on the training plan.

Personnel training refers to short-term and long-term continuing training offered to employees by the foundation in its role as employer. Continuing training includes all training used to support the employee’s competence and development as a professional and as a member of the working community. Continuing training is carried out either as foundation in-house training or as outsourced training.

The creation of a training plan is part of the foundation’s plan of activities and budget. It includes the general goals for personnel training and the personnel training plan based on these goals for the next budget period.

The annual training plan includes an assessment of the training needs of the entire workforce to achieve the goals set. Planning personnel training ensures that the training provided corresponds with changes in the operating environment and the financial resources available. The annual training rates per occupational group are shown in the HR statement.

At the FSHS, healthcare professionals (new employees, employees who have been off work for a long time, fixed-term employees and trainees) are required to complete the fourth section of Laatupassi certification as part of their FSHS workplace orientation programme. The section includes the key documents governing patient care quality, patient safety and self-supervision. Laatupassi certification is obtained through the FSHS Academy.

Licenced healthcare professionals (excluding physicians and dentists) and healthcare professionals with a protected occupational title are required to complete the online pharmacotherapy training course every 5 years and to provide proof of their competence.

Facilities, devices, equipment and hygiene practices

The FSHS is responsible for ensuring that its facilities are suitable for their intended use and, if necessary, suitably renovated. Access control and protection against intruders and fire are the FSHS’s own responsibilities. The FSHS operates in rental facilities in all its regions. Service facilities are designed and renovated to be appropriate for their intended use with respect to patient safety.

Any shortcomings found by occupational health and safety officials, or by another party, are rectified together with the lessor. All facilities have been inspected by the local Regional State Administrative Agency.

Patient ombudsperson

Wellbeing services counties are responsible for arranging the services of a patient ombudsperson. The wellbeing services county responsible for this is determined by the wellbeing services county in the area where the FSHS service is offered.

The duties of the patient ombudsperson include:

• advising patients about issues governed by the Act on the Status and Rights of Patients (785/1992), later Patient Act
• advising and, when needed, assisting the patient or their legal representative, family member or other close friend or relative on filing an objection as stated in section 10 of the Patient Act
• advising the patient on how to make a complaint, request a correction, lodge an appeal, bring an action for damages, bring an action for damages regarding patient injury or pharmaceutical injury, or other issue related to the patient’s legal protection in healthcare with the competent authority
• advising patients about their rights
• collecting information about patient contacts and monitoring changes in the rights and status of patients
• promoting and implementing patients’ rights in ways not mentioned in sections 1–5 above.

Each patient ombudsperson’s contact details are available from every service unit and on the FSHS website.

Pharmacotherapy

The FSHS has in place a pharmacotherapy plan and service unit pharmacotherapy plans (internal link) in accordance with the requirements set by the Ministry of Social Affairs and Health: Turvallinen lääkehoito -opas 2021:6 [”Safe Medicinal Treatment – A Guide”]. The directors responsible for healthcare services approve the pharmacotherapy plan for the FSHS and those for the service units. They are in charge of the foundation’s processes relating to pharmacotherapy and pharmaceutical services, ensuring they are up to date and compliant with the legal requirements. The service units’ pharmacotherapy plans are based on the FSHS’s pharmacotherapy plan. The Regional Medical Director or Regional Medical Director of Dentistry, who are the doctors responsible for pharmacotherapy, is in charge of planning, organization, allocation of duties and the proper functioning of pharmaceutical services in the service unit in accordance with the service unit’s pharmacotherapy plan. Supervisors guide and monitor pharmacotherapy, ensuring it is provided according to the pharmacotherapy plan. The foundation’s pharmacotherapy plan and the service units’ pharmacotherapy plans are updated when necessary, at least once a year. The medicines used within the FSHS are described in FSHS basic medicines.

The dentists, oral hygienists, and dental nurses/practical nurses who provide oral health services are involved in pharmacotherapy. This includes prescribing, dosing and administering medicines to patients, as well as guidance and monitoring of the effects of medication. The most common form of pharmacotherapy in oral health services is the injection of medicinal agents (anaesthetics), which is carried out by dentists and those oral hygienists who have completed additional training. Medicines which are administered via natural routes (tablets and solutions) are also used. In other healthcare services, general practitioners, nurses, public health nurses and practical nurses are involved in pharmacotherapy. Pharmacotherapy includes prescribing, dosing and administering medicines to patients, as well as guidance and monitoring of the effects of medication. Forms of pharmacotherapy include vaccines (PO, IM, SC, ID), injections (IM, SC, ventrogluteal) and medicines which are administered via natural routes: tablets, eye drops, creams, solutions and analgesics.
Employees are required to undergo both basic and further training to ensure their pharmacotherapy competence. Nursing staff complete further training in pharmacotherapy and are required to demonstrate their professional competence once every five years. Pharmacotherapy licences are approved by the doctor responsible for pharmacotherapy (Regional Medical Director/Regional Medical Director of Dentistry). The licence is valid at the FSHS.

Employees are required to undergo both basic and further training to ensure their pharmacotherapy competence. Nursing staff complete further training in pharmacotherapy and are required to demonstrate their professional competence once every five years. Pharmacotherapy licences are approved by the doctor responsible for pharmacotherapy (Regional Medical Director/Regional Medical Director of Dentistry). The licence is valid at the FSHS.

Incidents relating to pharmacotherapy may be near misses or adverse events. Service units make every effort to identify and anticipate the possibility of errors or such incidents in pharmacotherapy. Service units have operating models for different situations and incident prevention. These operating models are regularly reviewed with the personnel and included in workplace orientation. All service units are fully prepared for situations requiring first aid. The first aid preparedness and competence of the personnel are maintained on a regular basis. Immediate action is always taken to secure patient safety when an error or an incident occurs. Clear instructions for dealing with first aid situations and incidents, together with emergency medicines, are always readily available at all service units.

An employee reports any pharmacotherapy-related incident or error that has occurred by filing an incident report in the FSHS system Majakka. Incidents are also reported to the patient and to the supervisor. Supervisors are responsible for processing incident reports with the Regional Director or at a management meeting and, where necessary, procedures are improved to avoid similar incidents in the future. All incidents are regularly processed by the quality control team and operations are improved as a result. Summaries of incidents are presented twice a year in a quality review by the management and administration. Any adverse effects attributable to medication are reported to the Finnish Medicines Agency (Fimea); this also applies to vaccines and vaccinations.

The consumption and expenditure on medicines are monitored for each unit and for the FSHS as a whole. The use of CNS agents is monitored by the FSHS using package-specific consumption cards on which the information needed for monitoring is marked. Consumption cards for CNS agents are archived in the service unit for six years after the calendar year in question. When a medicine has been used up, any measuring losses are marked on the consumption card. Medicine consumption is monitored monthly from the CNS agent consumption cards by the nurse responsible and the Regional Head Nurse or the oral hygienist responsible at the service unit. When the medicine has been used up, the Regional Medical Director/Regional Medical Director of Dentistry responsible for pharmacotherapy signs the consumption card. Any issues are reported to the Medical Director or the Medical Director of Dentistry.

Identifying risks and shortcomings, and corrective measures

The management of the FSHS is in charge of the overall organization of risk management and safety. Directors in charge of services, Regional Directors and supervisors are charged, in line with their responsibilities, with ensuring that conditions in the service units enable safe working and customer service and safe, good quality patient care. Risk management is practised at all levels of the organization by all employees in their designated roles. The management and personnel are familiar with the key legislation, guidelines, rules, and policies regarding their work. Key processes are described in the Majakka system.

The FSHS complies with the requirements stated in the Government Decree on Chemical Agents at Work (715/2001). Possible hazards caused by chemical agents at work and the related health and safety risks for employees have been identified by the FSHS. Chemical risk assessment is carried out at FSHS units annually as part of other work-related risk assessment. Based on these assessments, improvement plans are made, and actions taken accordingly. Safety data sheets for the chemical agents used are available for the personnel either in digital format or in written format at the service units. Suppliers are required to provide safety data sheets when chemical agents are purchased. The chemical agents contained in the products used are listed in FSHS chemical agents list. Lists of chemical agents were updated at the service units during 2023. An assessment form has been introduced for the assessment of biological hazards. Biological hazards are categorised on the form according to the classification by the Ministry of Social Affairs and Health (decree on the classification of biological agents, 748/2020).

All employees and trainees at FSHS can make an incident report about any safety issue they have noticed that has caused or could have caused harm to a patient or an employee. The primary goal in the processing of incident reports is to improve operations and to learn from mistakes in order to avoid similar incidents in the future.

Reports on near misses and incidents regarding patient safety and employee safety, as well as suggestions for improvements are submitted using the near miss and adverse event notification form in Majakka. Issues relating to data protection are reported via the data protection notification form in Majakka.

Regional supervisors or the Regional Medical Director process the reports and make improvements wherever necessary. Reports on near misses and adverse events are approved by the FSHS administration, and guidelines are updated when necessary. The number of issues relating to quality and patient safety, objections, complaints and data protection issues is monitored monthly and submitted to Kela (the Social Insurance Institution of Finland). They are also discussed regularly at quality team meetings and actions are taken whenever necessary. This information is presented in the quality review to the foundation’s management and administration twice a year.

Patient documents and handling of personal data

The FSHS is obliged to keep patient documents in accordance with section 16 of the Act on Health Care Professionals, and section 12 of the Act on the Status and Rights of Patients (785/1992, Patient Act). In compliance with the legislation, FSHS professionals document the information needed to organize, plan, implement and monitor patient care.

The FSHS keeps digital patient documents using Acute-WinHit, a system provided by Vitec Acute Oy and InNet Oy. The FSHS is regularly in contact with the system providers. Patient documents are transferred to the Kanta archive from all services.

The director responsible for healthcare services has produced written instructions regarding the processing of information included in patient documents and related policies in accordance with the Decree on Patient Documents (94/2022). Patient documents constitute a single, shared, and up-to-date patient document register as specified in the European General Data Protection Regulation, GDPR (2016/679).

The obligation to inform, which is required in the GDPR, is met using the Data protection statements on the FSHS website. The FSHS carries out technical and organizational measures to comply with the regulation. These measures are documented, and also apply to outsourced processing of personal data.

The data security team appointed by the Managing Director produces the data security and data protection principles and guidelines for the FSHS. The data security team ensures that the different areas of data security are up to date and processes data security principles and guidelines before they are processed by the management team. Data security team meetings are held every two weeks.

The person responsible for data security at the FSHS is IT Manager Sauli Kleemola, who is also chairman of the data security team. As required in the The Act on the Processing of Client Data in Healthcare and Social Welfare (784/2021) and the European General Data Protection Regulation (2016/679, article 37) persons responsible for data protection are Chief Medical Officer of Digital Health Services Aleksi Schrey and dentist Marjo Tipuri. Persons responsible for data protection can be contacted via email YTHS.tietosuojavastaava@yths.fi or by using the ’Contact the person responsible for data protection’ form, which requires strong identification.

Information regarding data security and data protection at FSHS is documented in a separate data security plan (according to Act 703/2023), which is updated by the data security team annually and when important changes have been made. A list of systems containing patient data and currently in use is attached to the data security plan. Information management is responsible for updating the list.

The data security plan is designed to ensure that the service provider’s personnel master the use of the data processing systems being used and know how to take account of the requirements regarding client and patient data confidentiality and data protection. Matters relating to the operating environment, maintenance and updates of the patient information system are also considered in the data security plan.

All information produced by or stored in the FSHS’s data systems must comply with the basic requirements for secure data systems. These requirements include the reliability, availability, constancy and indisputability of data. The foundation’s main systems have been built in such a way that the data generated is stored on servers. Critical patient or administrative information is not permanently stored on workstations.

In problem situations, such as data communication failures or device malfunctions, users are provided with instructions for the particular system concerned. The main principle is that operations are not interrupted by error situations and that work can continue with temporary arrangements. Once the issue is resolved, data from the interruption is stored in the main systems in accordance with the guidelines for the system concerned. The FSHS has specific instructions for processes and communication in error situations.

There is a specified response time for all systems and technical devices during which they should be back up and running. Systems and devices are classified according to how critical they are to the foundation’s operations, and the response times for device maintenance are set accordingly.

To ensure the safety of the FSHS’s internal network, servers, systems and workstations, communications between facilities is outsourced, the operator being contracted to take charge of maintenance, service and monitoring. Devices should not be connected to the internal network without permission from the data management unit. The foundation servers are located in locked facilities, and the locations and data security of the outsourced servers are based on specific agreements. The right to access the operating system is limited to the administrative personnel. Servers and systems are checked regularly. In addition to hard disk encryption, all workstations have data protection software against viruses and spyware.

System administration rights are limited to the main users, who have the professional expertise required to maintain, install and update the data systems. The data systems are maintained and updated according to the manufacturer’s instructions. Integration interfaces and software connected to the data systems are audited to ensure that they do not compromise the data systems’ performance or data security and data protection. Usernames and passwords are required for the use of all foundation data systems and workstations. The interface between the foundation’s internal network and all external networks (e.g. Internet) is controlled by outsourced services like firewalls and by monitoring communications, scanning communications for viruses, spam filtering and strong digital identification. The operating environment is suitable for using the data systems in an appropriate way that ensures data security and data protection.

The supervisor is responsible for taking care of the access rights for data systems at the beginning or at the end of the employment contract, as well as when changes are needed. The access rights to the patient data systems for each user group are defined according to the basic principles approved by the directors responsible for healthcare services. At the beginning of an employment contract, the regional director can, if necessary, ask the head of data management to grant extended system access rights. The extended access rights granted at the request of the manager are cancelled when no longer needed. Usernames for data systems are granted for the applications needed for specific tasks with an access form approved and signed by the supervisor. The contracting partner is responsible for keeping usernames.

Data in the patient data systems and administrative systems is backed up daily by means of separate verification systems. The procedures involved include a separately agreed securing cycle and instructions. The backup data is copied into permanent storage at regular intervals. The verification principles are the same for both outsourced and internally maintained systems. The content produced by users outside the systems is stored in the users’ own file directories, which are backed up daily by means of a safety system. Users’ workstations are not secured. Workstation security is the user’s responsibility if they store data on the workstation. Data systems are acquired and introduced in conjunction with the data management unit. All data systems in which centralised personal data is collected require administration of the registry.

Since the implementation of GDPR, the FSHS has kept a privacy notice for handling personal data. The notice includes the protocols for sharing and deleting data, and the technical and organizational safety protocols for protecting the registry.

All persons using a workstation must familiarise themselves with the FSHS data safety policy and sign a user and confidentiality agreement. Computers and all individual systems containing personal data require usernames and passwords.

The FSHS offers workplace orientation and additional training to ensure that system users have the training and skills required to use the systems, and that the systems are used according to the manufacturer’s instructions. Instructions needed for the use of data systems can be found in the patient data system and in the FSHS Academy guidelines. FSHS operating instructions are available for the personnel in the intranet. The data security team updates the FSHS data security guidelines regularly.

Strengthening patient paticipation and handling objections

It is the policy of the FSHS to care for patients in an atmosphere of mutual understanding. Patients are given comprehensible information about their health, treatment and the related risks. Patients are involved in planning and implementing their treatment.

Patients have an opportunity to give immediate feedback during their contact with the service. They can also contact the person responsible for their treatment through the Self service. FSHS clients can use a feedback form available at yths.fi either using their ID or anonymously. The feedback is directed to the respective service unit and there will be a response if the contact details are included. Feedback that meets the criteria for objection will be dealt with as such.

Monitoring and assessing self-supervision

Self-supervision is a means of improving the quality of patient care and the legal protection of the patients. At the FSHS, the purpose of self-supervision is to ensure that the patient gets safe, good quality healthcare services. Self-supervision at the FSHS is implemented according to specific operational and procedural guidelines. The self-supervision procedures for preventing and correcting risks, incidents, and quality-related issues and for ensuring the professional competence of healthcare professionals are described in the FSHS self-supervision plan. Our operations are guided by self-supervision and its monitoring, assessment, and improvement.

The directors responsible for FSHS healthcare services will ensure that the self-supervision plan is kept up to date. The self-supervision plans for both the FSHS and its service units are revised and updated annually. The self-supervision plans are approved annually, even if there are no changes. Any changes in the guidelines for FSHS operations will be incorporated in the self-supervision plan with immediate effect and the personnel informed of this.

15.12.2023 Helsinki
Place and date

The self-supervision plan is approved and ratified by the director responsible for healthcare services.

Teija Kulmala

Further reading

FSHS self-supervision programme