Another longtime physician and a community board member at Providence St. Patrick Hospital in Missoula have resigned, indicating they don't believe meaningful changes were made after an unprecedented “no confidence” vote in the hospital’s administration last month.
Hospital administrators say a “vocal minority” is disgruntled, and that fundamental shifts in the health care industry are causing upheaval nationwide.
But Dr. Joseph Knapp, a cardiologist who has spent three decades at the International Heart Institute, gave his 90-day notice this past week.
“Things haven’t changed for the better” after an emergency meeting of the medical staff last month, Knapp told the Missoulian. “My hope in this whole thing was we would have a response from an administration that showed some understanding of major concerns by a dedicated and committed group of physicians, who pride their relationship with this community and this institution. But, honestly, that has not been forthcoming.”
A few days before Knapp resigned his employment from St. Pat’s, Alex Philp, a member of the hospital’s Community Ministry Board, submitted a letter of resignation, a copy of which was obtained by the Missoulian.
Philp wrote in the letter that “the lack of engagement, involvement, and communication with the Board by local, regional and national-level administration regarding a wide-range of urgent issues is completely unacceptable, not accidental and violates various aspects of our governing By-laws.”
Philp did not respond to a phone call seeking comment, but the Missoulian independently verified the authenticity of his resignation letter.
Philp’s resignation followed on the heels of the resignations of several other Community Ministry Board members including Dan Barz, Faye Hanson Warren and Tom Acevedo. However, since those former board members likewise did not respond to phone calls for comment, their reasons for resignation are unclear.
The “no confidence” vote took place on March 7. Physicians at the meeting and in subsequent interviews with the Missoulian said they had grave concerns that there is a lack of local control and decision-making within the corporate structure of Providence Health and Services.
On March 15, the Missoulian published a story about the vote and quoted several physicians, one of whom described a “culture of fear and intimidation” and a “widespread fear of retaliation and retribution” within the hospital.
The medical staff was also concerned about a cascade of resignations of several longtime and well-respected hospital leaders, including that of Dr. Matt Maxwell, the longtime head of cardiac surgery at the International Heart Institute, and Martin Burke from the Community Ministry Board. All cited their frustration with what they perceived as the lack of local decision-making power at St. Pat's.
In the aftermath of the meeting and the Missoulian story, the hospital’s COO Joyce Dombrouski was given the title of chief executive, in a move that she says gives her a title that “better reflects her role” and her “accountability.”
Many physicians had expressed concern over the forced resignation of hospital CEO Jeff Fee last year, which the physicians said gave St. Pat’s less autonomy and less decision-making control within the regional power structure of Providence Health and Services, the nation’s third-largest nonprofit health system. It is based in Washington state and includes 50 hospitals and more than 100,000 employees in seven states.
“There is always room for improvement,” Dombrouski said in a Friday meeting with the Missoulian. “Of course we are not perfect. But health care is fundamentally shifting. The way that health care is changing is causing unpredictability and is unsettling at many levels – for hospital administrators and for physicians. But there is no doubt that our relationship (with the medical staff) is critical. Changes are difficult for all of us.”
Stacy Rogge, the director of communications and external affairs for Providence Western Montana, said that the March 15 Missoulian article didn’t paint a full picture of how all the employees of the health system in Western Montana feel.
“What we’re not being exposed to is the quiet majority of what’s going on,” she said. “Our clinical quality has never changed and continues with award-winning recognition.”
Rogge referenced multiple national awards and health care rankings that give the hospital high marks for the quality of patient care.
Both Rogge and Dombrouski make it clear that they take any concerns shared by any employee very seriously, and said also that they want to make clear they are not dismissing the concerns of even what they believe to be a vocal minority. They are trying their best, they say, to take as much input from all employees as possible and make the best decisions for the future of the hospital and for the quality of care provided.
“The steps we have taken (since the March 7 meeting) rotates around communication,” Dombrouski said. “We want caregiver engagement, physician engagement. We have a good communication structure in place. There are places where we need to be better. I recently had a physician tell me he wanted to be in fewer meetings and get fewer emails. So how do you communicate internally? This is a 24/7 business, so we are reassessing how to make that better.”
Dr. Stan Seagraves is the medical director of the hospitalist program at St. Pat’s and has worked there for 28 years. He said he was satisfied with the administration’s response to the March 7 meeting.
“I would say that we very much have the attention of our leaders in a lot of very constructive things are happening around here," he said. "I’m confident that that meeting, and the momentum generated subsequently, is going to pay off.”
Prior to the March 7 meeting, a letter titled “A Summary of Physician Concerns” was circulated among the medical staff. In it, they decried “a loss of local organizational autonomy” and a feeling of “disempowerment.”
Maxwell, the veteran cardiac surgeon who resigned prior to the meeting, said he left in frustration for those reasons.
Knapp said his resignation this past week was in “full alignment” with the reasons Maxwell cited and for the reasons summarized in the physicians' letter. He made it clear that he maintain his privileges at St. Pat’s. However, he feels that the administrative structure of the hospital is not listening to physician concerns.
“This is not about Joyce in any way, shape or form,” he said. “This is not about any one person. This about an institutional response to a physician request that has been sadly and sorely lacking. There is an enormous amount of work that needs to occur locally and throughout the entire Providence system to get this pointed in the right direction.”
Knapp does not disagree with Dombrouski’s assessment that the health care industry is rapidly changing.
“Health care, fundamentally, is a one-on-one interaction between a provider and a patient seeking assistance,” he said. “And everything else needs to take a secondary position to that relationship. And unfortunately, that perspective and position has to a great extent been lost, at least in my perspective, by an awful lot of people.”
His decision to walk away from the hospital where he spent three decades was not taken lightly, he said.
“Ten times in the last 15 years, the International Heart Institute has been ranked among the top 1 percent of hospitals in the country,” Knapp said. “The achievement did not occur by happenstance. It occurred by incredible dedication and a degree of hard work and a level of commitment that is incredibly laudable. That, unfortunately, has been tarnished. Neither Matt (Maxwell) nor I walk away from that lightly.”
Dombrouski said she has a lot of respect for Dr. Knapp and that he is “very passionate.”
“He feels like the response (to the medical staff emergency meeting) was inadequate,” Dombrouski acknowledged. “We’re not trying to discount Dr. Knapp. We’re not discounting passion. In fact, I’m meeting with him Monday.”
Dombrouski said that she has a seven- or eight-page document of action steps that she’s presented to the executive board at the hospital to try to respond to the physicians’ concerns. She said that document is "internal."
“We have responded to our medical staff, and we’re doing additional things,” she said. “Our physicians are very caring and want to know what’s going on. We want to move ahead on the positive side of things. We have been here 144 years. We’re not going anywhere. There is great care happening every day.”
She also said that being part of a larger system has provided the hospital stability as “we’ve fallen on uncertain times.”
“We are going to focus on taking care of whoever walks through our doors,” she said. “That’s the bottom line. If your friends or family members fall ill, you want them to seek care at St. Pat’s and we hope that we are doing all of the right things. We’re going to continue to be better.”
In his resignation letter from the Community Ministry Board, where he served for six years, Alex Philp wrote that Dombrouski’s title change from COO to chief executive was made without the input of the board he served on.
“To the best of my knowledge, neither the Executive Committee of the Board of Directors nor the full Community Ministry Board, other than Dr. (William) Bekemeyer, was engaged in any way regarding the content of (a letter from regional administrators) to the Med. Exec. Committee,” Philp wrote.
The Community Ministry Board doesn't perform ministerial services as the name implies, but was created to provide leadership in operational performance, strategic development and oversight. The board has delegated authority and a shared governance role in such things as quality management, medical staff issues and patient, physician and employee satisfaction.
Philp said his board was simply copied on the letter. Philp also wrote that he pushed for a special meeting to assess information and engage meaningfully in “our delegated and shared accountabilities."
“This lack of engagement, acknowledgement and simple communication speaks to one of two things: 1) gross incompetence or 2) a willful disregard for the role of the board,” Philp wrote. He concluded his letter by saying that St. Pat’s faces key challenges in governance, leadership, communication and medical staff engagement.
“I have found systemic disregard for or severe diminution of the Board’s role, an almost cavalier attitude when question, and an insulting, ambiguous utilization of our authority to potentially justify or condone decisions being made without our knowledge,” he wrote. “I have no interest in being part of our organization that behaves in this way. Now more than ever it would appear that we need to think carefully about how we will serve the needs of the poor and vulnerable, maintain an outstanding local hospital and address the strategic health needs of Western Montana.”
Seagraves said that he would wager that there is a meeting similar to the March 7 meeting happening among every medical staff at every hospital in the country. He said a generation ago, many doctors owned hospitals and now 40 percent of them are employed by – or "owned" – by a hospital.
“We’re in a completely different world now,” he said. “Medical staffs everywhere are struggling with this loss of autonomy. This is a national struggle. The situation here is not worse than anywhere else. I am optimistic from the standpoint that we have gotten the attention from leaders and commitment from them to get doctors involved. The old days are gone, and everyone recognizes that it’s time for us to stand up and time for administrators to let us re-engage.”
Seagraves said that he wouldn’t characterize the March 7 “no confidence” vote as unanimous, since no roll call was taken and not everyone voted. He also said that a title change like the one Dombrouski got is less important than how the administrators manage leadership and how much authority they have.
“Since that meeting, there has been a willingness on the part of the administration to meet with us to work on a complete redesign of the medical staff to address the deficiencies,” he said. “That points to a competent, capable leadership structure.”
Seagraves said he hadn’t spoken to Maxwell or Knapp about their frustrations or reasons for resignation.
“The vast majority of docs here are busy going about their practice,” he said. “They see the world around them changing. They see the lack of control, which is imposed not by (Providence) but is imposed by practicing health care circa 2017. It’s a completely different game. The rate of change and the declination of autonomy is steepening, and that’s where a lot of unhappiness among medical staffs is coming from.”
Seagraves said that the medical staff at St. Pat’s is giving great health care and it’s still a “fabulous” place to work.
“At the same time, the burdens that practitioners have to deal with now, versus 10 or 20 years ago, are staggering and maddening,” he said. “They are not necessarily burdens that improve patient care and some people have a hard time dealing with the current world order and are pushing back.”
The bright spot, he said, is the March 7 meeting “fired up” the medical staff to “re-engage.”
Knapp, for his part, feels a tinge of sadness at having to resign with a level of unhappiness directed toward his workplace after over 30 years.
“It’s an extraordinary business,” he said. “(Administrators) have to keep balance sheets going and keep the hospital above board and all the requirements. But the fundamental issue we deal with is personal interactions on a day-to-day basis by an extraordinary team of nurses and physicians. They need to be supported. And that has been sorely lacking in the recent past.”