Self-supervision programme

Self-supervision is an area of internal supervision aimed at fulfilling the requirements set for service quality and service level.

Self-supervision concerns FSHS service provision. Its purpose is to ensure the basic rights of customers and patients, customer and patient safety and the good quality of health services.

Self-supervision involves the continuous evaluation and development of FSHS activities from the customer’s perspective. It helps to ensure customer and patient safety, service quality and good customer service. Supervision performed by the authorities helps to promote and ensure self-supervision and allows the authorities to step in when self-supervision is proving inadequate.

The FSHS is governed by Act 612/2021 on the organisation of healthcare and social welfare (laki sosiaali- ja terveydenhuollon järjestämisestä 612/2021). The FSHS is required to prepare a self-supervision programme concerning the duties and services for which it is responsible. By virtue of its responsibility for organising healthcare and social welfare services, the FSHS is under obligation to continuously guide and supervise private service providers and their subcontractors.

This FSHS self-supervision programme contains the principles that apply to the self-supervision of services.

This self-supervision programme helps to ensure that FSHS customers are provided with the services which they need and to which they are, by virtue of their basic rights, entitled, and that these services are of good quality and provided in a timely, equitable, accessible and safe manner. This goal can be achieved by ensuring good management, adequate human resources, competent staff and smooth work processes. Success is ensured by monitoring and supervising service quality and safety and by constantly developing processes.

The FSHS is responsible for the appropriateness of its activities and the quality of its services and for customer and patient safety. Self-supervision will be part of daily work and will include constant monitoring of the adequacy of staffing.

This self-supervision programme concerns the year 2024.

Approved on 1 January 2024

Approved by Teija Kulmala

Where each document is discussed, the FSHS’s self-supervision programme specifies

• who will prepare the document and who will approve it
• what methods will be used to monitor activities in the area concerned and how often
• who will report on the results for the area concerned, and to whom and how often they will report (not mentioning names, only titles/bodies)
• the document owners and update information.

The documents will be stored in accordance with the organisation’s archiving plan.

Availability of services

Self-supervision ensures that the content, scope and quality of healthcare, both planned and provided, meet customers’ needs (Health Care Act 1326/2010, section 17 and Act on student healthcare for higher education students 695/2019).

Self-supervision ensures that the services provided by the FSHS and those outsourced are described and monitored on the same basis. Services outsourced to private service providers will be monitored with the help of the agreement between the FSHS and the service provider concerned.

Services provided by the FSHS

• Services provided by the FSHS will be monitored on a monthly basis by the Service Development Team, the Management Team and the Board of Trustees.
• Meeting notes will be stored in accordance with the organisation’s archiving plan.

Outsourced services

• A FSHS service provider agreement will be drawn up by the Service Development Team and the contracting entity and approved by the Management Team, the Board of Trustees and Kela.
• Activities will be monitored constantly and meetings to monitor compliance with the agreement will be held at least twice a year and more often if needed.
• The service agreement and monitoring meeting notes will be stored in accordance with the organisation’s archiving plan.

Safety and guality of services

Self-supervision ensures that, to safeguard patient safety, work is carried out systematically at all levels to support the quality and safety of services, cooperation between professional groups and the development of working practices. Self-supervision also ensures that activities are continuously developed and risks regularly assessed.

Self-supervision plans describe how the experiences of customers and patients and their families will be monitored. The plans describe the procedures for responding to objections and complaints concerning service provision, the submittal of which is a right of patients and customers, and how the patient ombudsperson will help to promote customers’ rights.

The self-supervision plan describes how the appropriateness, safety and quality of healthcare services will be monitored.

• The FSHS’s self-supervision plan will be prepared by the Service Development Team and approved by the Medical Director.
• The FSHS will regularly monitor objections and complaints concerning service provision, the submittal of which is a right of customers.
• The Medical Director will be the owner of the self-supervision plan.
• The self-supervision plan will be stored in accordance with the organisation’s archiving plan.

Resources needed

Staff

The goal of staff planning is for each service unit to have the right number of suitable people performing the right job at all times. Staff planning ensures that the right amount of appropriate expertise is available for each unit and helps to predict the need for, and the costs of, staff development.

The FSHS will monitor the quality and sufficiency of both its own staff and that of contracted service providers.

FSHS activities

• The FSHS’s human resources are described in the service agreement between the FSHS and Kela, which is approved by both parties.
• The FSHS’s Regional Management is responsible for the region’s human resources needed to provide services in accordance with the service agreement, and actual numbers will be monitored regularly.
• Regional Management will report to the Managing Director and the Medical Director at monitoring meetings.
• The documents will be stored in accordance with the organisation’s archiving plan.

Outsourced services

• The outsourcing agreement for providers of outsourced services sets out the partner’s responsibility for staff quality and sufficiency.
• The activities of the providers of outsourced services will be monitored twice a year and more often if needed.
• Monitoring meeting notes will serve as monitoring documents.
• The documents will be stored in accordance with the organisation’s archiving plan.

Self-supervision plan

The self-supervision plan is a promise by the FSHS concerning the quality and safety of its services. It is prepared jointly by both the management and the staff so that self-supervision can become ingrained in daily work and so that staff can also learn to assess their own work. The self-supervision plan will be made publicly available and the extent to which it has been implemented will be monitored.

Self-supervision can be divided into three levels: personal self-supervision by a professional, self-supervision by service regions, and self-supervision by the FSHS.

• The FSHS’s self-supervision plan will be prepared by the Service Development Team and approved by the Medical Director.
• Self-supervision plans for service units will be prepared by Regional Management Teams and will be the responsibility of designated Regional Medical Directors.
• Providing information on self-supervision by professionals will be the responsibility of their supervisors.
• Near misses and adverse events will be monitored regularly by Regional Management Teams and at quality group meetings.
• The Medical Director will be the owner of the self-supervision plan and the Regional Director and the Regional Medical Director will be the owners of the service unit self-supervision plans.
• The self-supervision plan will be stored in accordance with the organisation’s archiving plan.

Pharmacotherapy plan

The medicinal treatment provided in healthcare units is based on a pharmacotherapy plan. This plan is part of a plan for quality management and for ensuring patient safety as laid out in the Health Care Act. A pharmacotherapy plan is a key part of training for those participating in the provision of medicinal treatment and integral to ensuring the quality and safety of medicinal treatment.

Ministry of Social Affairs and Health: Turvallinen lääkehoito -opas 2021 [”Safe Medicinal Treatment – A Guide”]

• The FSHS’s pharmacotherapy plan will be prepared by the Medical Director of Dentistry and a Chief Physician and approved by the Medical Director.
• Each region will prepare its own pharmacotherapy plan to be updated yearly.
• The Service Managers of Nursing will report on the implementation of the pharmacotherapy plan.
• The Medical Director of Dentistry and the Medical Director will be the owners of the pharmacotherapy plan.
• The pharmacotherapy plan will be stored in accordance with the organisation’s archiving plan.

Data security plan

The data security plan describes the FSHS’s practices concerning data security and data protection and how the self-supervision of data security and data protection is organised.

• The data security plan will be prepared by the Data Security Team and approved by the Management Team and the Board of Trustees.
• The implementation of data security and data protection will be monitored yearly, as scheduled in the annual plan, by the Data Security Team.
• The IMS system will provide an automated reminder when an update is needed.
• The Medical Director will be the owner of the data security plan, and the plan will be updated yearly.
• The data security plan will be stored in accordance with the organisation’s archiving plan.

The FSHS’s self-supervision plan describes how shortcomings will be addressed. Addressing any inadequacies identified in the availability, continuity, safety and quality of services or in the equal treatment of customers is the responsibility of the Medical Director responsible for service provision.

Any shortcomings or inadequacies found in the activities of the FSHS or one of its subcontractors will be investigated within the specified time limit. In such cases the FSHS will require the issue to be rectified within the specified time limit. If the shortcoming or inadequacy substantially compromises customer or patient safety, the FSHS will require the issue to be rectified immediately.

Customer and patient safety will be monitored regularly, for example through incident and adverse event reports and error reports. The FSHS’s self-supervision plan describes how these reports will be collected and analysed and reported to the authorities.

The FSHS will address and rectify any shortcomings identified through incident and error reports as rapidly as possible in order to ensure good treatment and care.

The FSHS will ensure that the provisions laid down in the Act on Supervision in Healthcare and Social Welfare and the Act on Health Care Professionals (559/1994) concerning the staff’s reporting obligation are described in the self-supervision plan.

Subcontractors are under obligation to immediately report to the FSHS and to the supervisory authority any shortcomings detected that have substantially compromised customer and patient safety.

Any events, injuries and incidents seriously compromising customer and patient safety as well as any other serious inadequacies must be reported to the FSHS and to the supervisory authority, especially if the subcontractor has not been or will not be able to rectify the inadequacies by means of self-supervision.

Monitoring data and public supervision data will be published online on a public FSHS webpage. Staff and stakeholders will be notified of self-supervision findings and related measures.