Bispebjerg Hospital -- A place in history

Here is a touristic Copenhagen interlude, although with a medical tilt, thanks to a tour given by Dr. Peter Skanning. The site we will discuss is Bispbjerg Hospital, built between 1907 and 1913, with a marvelous layout of buildings and gardens. I present more on the architect, Martin Nyrop (1849-1921), and the architectural features in the post below. Peter is an anesthesiologist who runs the hospital's poison center, but he has a strong interest in architecture and history, and he kindly gave me and others an extensive tour.

Let's start with the history lesson. After the Nazis took over Denmark, they tried to round up all the Jews to send them to concentration camps. The people at this hospital played a special role in foiling that attempt. Here's an excerpt from one presentation:

In September Hitler approved the deportation of the Danish Jews. Werner Best of the SS, Hitler's chief in Denmark, received the final order to proceed with deportation of Jews to death camps, on Sept.28, 1943. The Nazis were prepared to deport the 7,500 Jews, starting at 10 PM. on Oct. 1, 1943. Georg F. Duckwitz, a courageous German maritime attaché and Best's confidant, at great danger to himself leaked out the order to a leading Danish Social Democrat, Hans Hedtoft. Hedtoft later recalled:

"I was sitting in a meeting when Duckwitz asked to see me. 'The disaster is going to take place', he said. 'All details are planned. Your poor fellow citizens are going to be deported to an unknown destination'. Duckwitz's face was white from indignation and shame."

According to Duckwitz, 1 October was set as the zero hour and Hans Hedtoft immediately warned C.B. Henriques, the head the Jewish Community, and Dr. Marcus Melchior, the acting chief Rabbi of the Krystalgade Synagogue.

On September 29th, two days before the projected round up on Rosh HaShannah, the Jewish New Year, Dr. Marcus Melchior implored his stunned congregants and the whole Jewish community to go into hiding immediately.

Two German passenger ships, docked in Copenhagen’s port, were ready to ship approximately 5,000 Jews to Germany on their way to kz camp Theresienstadt. Buses were to take the remaining 2,500.

The word was passed and the Danes responded quickly, organizing a nationwide effort to smuggle the Jews by sea to neutral Sweden. The Danes dropped everything to help family members, neighbors, or friends and offered their support, conveying warnings and finding places for the Jews to hide. The Danes felt that persecution of minorities was a breach of Danish culture and they were not prepared to stand for it. From all strata of Danish society and in all parts of the country, clergymen, civil servants, doctors, store owners, farmers, fishermen and teachers protected the Jews.

Dr. Koster, who was in charge of Bispebjerg Hospital, was instrumental in arranging for hundreds of Jews to be hidden at the hospital before they made their escape to Sweden. The psychiatric building and the nurses' quarters were filled with refugees, who were all fed from the hospital kitchen. Virtually the entire medical staff at the hospital cooperated to save Jewish lives. Once it became known among Danes what the hospital was doing, money was donated from all over the country. The Danish police and coast guard also took sides with the oppressed by refusing to assist in the manhunt. To make their escape, many refugees were driven to the coast in ambulances belonging to the hospital.

One reason it was possible to hide all these people is the layout and architecture of the hospital. See the model in the photo at the top or the architectural drawing to the right. The hospital has thousands of rooms, almost impossible to count. It also has dozens of buildings connected by miles of underground tunnels. It is virtually impossible for anyone unfamiliar with the buildings and the tunnel system to find people who are hidden throughout the campus.


But, let us not understate the bravery of those involved in this rescue attempt. This was a spectacular humanitarian mission carried out by the populace of an occupied country. They truly risked their own lives for the sake of others. This was a mitzvah of the highest order.

Bispebjerg Hospital -- A place in architecture

As noted in the post above, Copenhagen's Bispebjerg Hospital is a marvelous architectural and landscape achievement. Here is a summary of that history from an article in Dan Medicinhist Arbog, interspersed with some photographs I took today. Thanks again to Dr. Peter Skanning for a marvelous tour. (More photos are posted on Facebook, here.)

The architect Martin Nyrop (1849-1921) who had just completed the monumental and beautiful Copenhagen City Hall along with the engineer AC Karsten (1857-1931) and landscape architect Edvard Glaesel (1858-1915) were entrusted with the task to develop the design of the hospital.... The 6 red 2-story brick pavilions are located around an axis along Bispebjerg hill with southeast facing bedrooms over viewing the lush patient gardens.

These sick rooms all had large double windows at the southeast providing excellent daylight. On the walls are washable frescoes with motifs from nature. Pavilion buildings are flanked by two avenues with linden trees on both sides and connected by crossroads between the buildings.

Underground tunnels link the buildings. On both sides, the two lower pavilions on the same side of the central avenue staircase are linked together by a long covered bridge leading from the first floor of the first building to the ground flour in the next building because of the terrain slope.

My note: The tunnels are not only extensive, but they are beautifully constructed. The masonry is designed in a distinctive pattern, and there is a different mix of light and dark bricks as you proceed through the tunnels. So, if you are familiar with them, you can orient yourself in the hospital by the pattern in the tunnel wall.

This bridge connects the two pavilions with a building with operating theatres so that patients can be transferred indoors between operation theatre and sick room.

My note: The operating theatres face north so they can receive glare-free natural light through their glass ceilings and walls. Medical students viewed the surgeries from a raised gallery just inside the outside windows, seeing the operations through a plate glass separating wall.

Surrounding the sick pavilions administrative building, rheumatic outpatient department, laundry, kitchen and engine house are placed. Between the buildings, avenues and crossroads gardens designed with benches, beautiful flowerbeds and bouquets were established to the leisure of the patients.

The hospital offers a wealth of fine architectural designs and presents itself as a kind of garden village within the city.

Note, for example, this light fixture. The bulb holder and lens are in the shape of an acorn. On the right, designed into the ironwork just below the curved portion, is a portrayal of the three towers of the Copenhagen City Hall. Other designs, many with representations of plant life or symbols of the city, are found throughout the campus.


Finally, we should note how Nyrop borrowed classical architectural forms from earlier eras. He appears to have had a fascination with Roman architecture in particular. You can see one example here where he used Hadrian's villa as a model for one building. And below, you can see where he used the design of Roman baths as the model for the bathing building of his hospital. In one part of the bath building, he also used a specific room from Pompei as the pattern for a bathing room.

The Danes consider going public with medical errors

And now a final report from the Copenhagen conference. By the way, it was entitled, "Fremtidens Hospitalsledelse", or "Future Hospital Management." I was asked to present our experience at BIDMC with regard to quality and safety improvement and transparency of clinical outcomes. Regular readers will have seen much of that history here.

Part of the story was our decision to widely publicize a wrong side surgery throughout our hospital in July of 2008. The result was a concentrated effort by dozens of people to evaluate what had gone wrong and to implement changes in our pre-op procedures.

I explained that the decision by our Chiefs to go public with the event took less than five minutes of discussion -- and that five years earlier, it would likely also have taken five minutes, but with the opposite result. The point was that a change in organizational culture takes time. There is an old expression, "Culture eats strategy for lunch." I think there is a lot to that, and I explained that the comfort our people felt with transparency was key to many improvements that led to an enhanced level of quality and safety.

Then, for fun, I used the polling electronics at the conference to ask the attendees whether they thought that their hospital would broadly publicize and disclose the kind of medical error that I had described. Here are the results:


This is quite different from the results at the Risky Business conference in London last year, where only a handful of 300 attendees gave a positive reply. Why the difference? Passage of time? An audience, here, that comprised more senior level people? A cultural difference between Britons and Danes? You can suggest your own theory.

Johan reports from Belgium

I just heard an excellent presentation here in Copenhagen from Johan Kips, Director of the UZ Leuven, a large hospital in Belgium. (He is seen here before the talk making last minute translations in his PowerPoint slides, English being the lingua franca!) UZ Leuven is the first hospital to get accreditation by the Joint Commission International. Johan views that kind of accreditation as helpful in establishing a culture of continuous quality improvement in the hospital. But most of his talk was how to engage the MDs and other staff in disease specific quality improvements, building on the foundation of a general safety culture to structure the care within each disease. He described both parts working together as adding value, a strategic imperative.


He explained how the medical staff created modules (i.e., clinical pathways) for diagnosis, therapy, rehabilitation, and follow-up for various diseases and physical conditions. Then, using their health information systems, they can follow up on specific patients to see how well these pathways were being followed. In addition, they could link the costs of service lines to the income received for lines, looking for opportunities for cost savings, and then further designing the clinical pathways to be more cost-effective consistent with excellent patient experiences.

Similar approaches were applied to operational systems. Here, for example, is a chart showing the shift in waiting times for a certain set of eye conditions.


All in all, a superb presentation and a great story. In addition, it was presented modestly, with Johan making clear that he and his folks still had a lot to do. He was especially interested in hearing suggestions from the assembled audience.

Talking about transparency in Copenhagen

I am in Copenhagen to speak at a conference sponsored by Dagens Medicin, a newspaper for professionals and decisions makers in the medical and health care sector. According to my host, Kristian Lund, editor-in-chief, "The overall purpose of the conference is to inspire decision makers in Danish health care to improve leadership by using quality data. We are especially interested in hearing about your way of working with data and patient safety." As an outside guest, I am joined in a related topic by Johan Kips, Director of the UZ Leuven, the largest hospital in Belgium (2000 beds), who is here to address the attendees on the use of data to direct quality improvement. (Kristian -- another blogger! -- and Johan are in the accompanying photo.)

This is a fascinating topic to discuss in this venue, as the Danish health care system is quite good, but it does face interesting challenges. Here is a part of a summary from the WHO European Observatory on Health Systems and Policies.

Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment.

. . . More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system.

This gives part of the context for a point Kristian wrote in my letter of invitation, "You will have a unique opportunity to influence Danish health care management in a rare situation since the government is ready to invest more than 5 billion Euro in new hospitals. Denmark is also about to reform the allocation of specialities and we are in the process of re-evaluating the education of specialists."

Here is a bit more background. Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

I have talked on several occasions about the convergence of issues and health care design between the US and the nationalized systems of other developed countries. Denmark seems to provide another example of this. As my hosts indicated, we face the same demographic challenges and the same desire on the part of the public for the latest and best in health care technology. It is always helpful to share stories and ideas in pursuit of improved care for all.

The Jubilee Project helps on Hep B

Here's the latest video from the Jubilee Project. As always, when you view it, a donation will be made to a charity. Co-founder Eric Lu sent me a message and press release:

We are happy to announce that The Jubilee Project has released its first music video, "Why I Sing," by Rooftop Pursuit. This video is used to help raise awareness and funds for Hep B Free, an organization dedicated to tackling the problems of hepatitis B. Every view raises 2 cents for Hep B Free, and anyone can choose to become a sponsor by pledging to donate a penny per view. Sponsors may also set a cap if they'd like.

Over half of those infected with chronic hepatitis B in the US are Asian Americans and Pacific Islanders, and one in ten Asian Americans and Pacific Islanders have the disease. It is the only disease where you will find such a huge racial disparity.

"We wanted to be involved in raising awareness for hepatitis B because of the prominence of the disease in the API community and among our own friends and families," said Eddie Lee, co-founder of The Jubilee Project. "We have to end hepatitis B transmission today, and the first step is awareness."

Also known as the "Silent Killer," Hep B currently affects 1 in 10 Asian Pacific Islanders, compared to 1 in 1,000 of the general public, and is the primary cause of liver cancer. Despite this, Hep B can be prevented with by vaccine, and treatments prevent liver cancer.

The Jubilee Project is also seeking sponsors to support this effort. Sponsors offer one penny per view, but can cap how much they ultimately choose to donate, as low as $50.

Funds will be used for national Hep B Free efforts to end Hep B and liver cancer including public awareness, clinician education, screening, vaccination and linkage to care.

"Hep B Free has a multi platform approach to outreach," says Hep B Free co-founder Ted Fang, director of the AsianWeek Foundation. "Not only are we on the ground with person to person connections, but we are also spreading the word and raising money using social media, events, partnerships, foundations and business partners."

For more information about the collaboration, or to pledge as a sponsor, contact Eric Lu at (469) 688-0988 or email to Eric_Lu [at] hms [dot] harvard [dot] edu.

Click here if you cannot see the video.

WIHI on Crisis Management

Reports from the Frontlines of Effective Crisis Management
Thursday, April 7, 2011, 2:00 PM – 3:00 PM Eastern Time

Jim Conway, MS, FACHE, Senior Fellow, Institute for Healthcare Improvement

Anthony A. Armada, FACHE, President, Advocate Lutheran General Hospital, Advocate Lutheran General Children’s Hospital

Michael A. Fisher, President and CEO, Cincinnati Children’s Hospital Medical Center (CCHMC)

Uma R. Kotagal, MD, MBBS, MSc, Senior Vice President, Quality, Safety and Transformation, CCHMC; Executive Director, James M. Anderson Center for Health Systems Excellence

Michelle Hoppes, RN, MS, President, American Society for Healthcare Risk Management; Senior Vice President and National Director for Healthcare Risk Management and Patient Safety, Sedgwick Claims Management Services

It’s every hospital executive’s worst nightmare – a phone call carrying the news that a patient at the facility has died or been seriously injured due to an adverse event. Action is now called for on multiple fronts. Do you have a plan for what to do?

Jim Conway and three co-authors developed the IHI white paper, Respectful Management of Serious Clinical Adverse Events, to guide senior leaders on a comprehensive set of “best practices” not just to handle and respond to unforeseen incidents, but to learn from each incident so that future medical tragedies are less likely. One key is that everyone in the organization has a role to play and no one in the organization is ignored. Transparency with and attention to the needs of patients and families are foundational.

Since the IHI white paper was published in the fall of 2010, thousands of senior and frontline staff have benefited from its clarity of purpose and advice. Not only that, some organizations have turned to its guidance when faced with serious situations. We’re going to hear from two of those organizations – Cincinnati Children’s Hospital Medical Center and Advocate Lutheran – on the next WIHI. Their leaders – Michael Fisher, Uma Kotagal, and Tony Armada – are eager to share what they learned and continue to learn about crisis management. Jim Conway and Michelle Hoppes, a risk management expert, will offer the context in which all of health care delivery must consider its obligations to patients, staff, and the larger community when it comes to safety and principled actions if and when things go wrong.

WIHI host Madge Kaplan hopes you’ll join this important and timely discussion. To enroll, please click here.