Dr. Cobbs Letter November 4, 2016 Mr. Anthony Armada Dear Tony, I want to thank you lor needing my call to sit down With the neurosurgeons of Swedish Neuroscience Institute (SNI) last weekend to hear our universal concerns regarding the direction ol the institute. The SNI has been regarded lor over a decade as one of the finest healthcare tacilities in the world, leading the neurological field in exceptional care, state-ol-the art innovation, and groundbreaking research let by top clinicians and researchers in the nation. In the last two years, we have lost 62 team members lrom this campus. Our current lunctionality as a surgical institute is severely limited by decreased ability to stall and support our operating rooms, provide effective and sate care in our ICU/floor, and demonstrate excellence to our patients in the clinical setting. This in turn, has led to a iinancial downturn lor the institute and system, The common thread linking these events is the leadership and management style at Dr. Johnny Delashaw. Fundamental issues including respect for others, patient safety, appropriate surgery, and quality of care have been rebulted by the leadership, in particularly Dr. Delashaw. Referral patterns once flourishing and trending upward, were eliminated through decimation of a prior relerral distribution inlrastructure with personal sequestering of cases tor his own volumes. Relationships with outside reterring institutes and providers have been probably irreversibly damaged due to their interactions with Dr. Deiashaw. further damaging the SNI reputation lor excellence. Providers and start who have attempted to address these concerns have been met with threats and reprisals. This toxic, repressive environment has already negatively impacted the ability at the SNI community to provide the quality care our patients that they deserve, These issues have led to active lawsuits against Swedish, ongoing investigations by The Seattle Times and Department or Health/MOAC, and ultimately advertise that our institution is unable to police itself and advocate tor patient safety. 11 When I was recruited to Swedish to run the Ben and Catherine Ivy Center forAdvanced Brain Tumor Treatment by my late friend and colleague Dr. Greg Foltz, I made a personal commitment to honor his legacy. That legacy was founded above all else on morals, ethics, and integrity, and ?doing the right thing? for every single patient, every time. Under Dr. Delashaw, my own ability to be a patient advocate has been challenged by thinly veiled threats and innuendo. I personally feel threatened for my job security if I speak up at patient quality conferences for fear of retaliation. I know for a fact that many individuals who work at SNI also fear for their careers because of Dr. Delashaw?s relentless vindictiveness, as they have witnessed the forced departure of dozens of their physician, administrator, nursing and OR staff colleagues who challenged him. They feel that as a condition of their continued employment, they must endure this intimidating and hostile environment. Swedish values above all the culture of safety, where all of those working with patients feel free to speak up and address issues of safety and quality. This culture has been egregioust damaged over the course of 2 years as evidenced by massive staff turnover, abusive repression of safety and quality concerns, and loss of many surgeons, administrators, and nursing staff who put safety as their top priority. The neurosurgeons, neurologists, and staff of SNI place patient care and safety as our top priority. lf Swedish and Providence value preservation of this culture, our requests as outlined in the minutes from our meeting on October 30 (attached) must be taken seriously. We only want the best for Swedish and we feel that a culture of safety, a pillar of the Swedish values, is now at risk. Sincerely, Charles S. Cobbs, MD Meeting Minutes October 30, 2016 Ad hoc meeting SNI surgeons and Swedish Administration: Present: Administration: T. Armada, Altaras, A. Cosentino Surgeons: JR Chapman, Cobbs, Litvak, McDougalI, Monteith, Oskouian, A Patel By call-in: Hart, Loh Absent: Backous, David, Hanscom, McMenomey Excused: Delashaw, Mayberg Based on invitation by the CEO Swedish Medical Centers and VP of the PHS Western Region Armada, the above-mentioned surgeons met with administrative leadership to discuss current problems at SNI. The meeting was held under the premise of the 5 Swedish Bests: - Best Place to Work and Practice - Best Customer Experience - Best Quality and Safety - Best Health Outcomes - Best Use of Resource 12 The group collectively identified a number of gains over the last 2 years: Recruitment of outstanding colleagues (CM, ZL, RH, SM), SSF success, SCI project, robust M&M/Quality process, strong reapplication for residency, publication output, conferences The surgeons group unanimously identified serious concerns in three domains. While there are many external challenges (changes in Health care reimbursements, Group Health Integration, financial constraints) many problems are directly associated with SNI Neurosurgery leadership activities, most if not all very directly with Dr. Delashaw?s decisions or (in) actions. The group pointed out that there have been multiple concerns expressed by a great number of Swedish employees to the administration and HR concerning patient safety, including surgeons, anesthesiologists, ICU staff, nursing staff, and OR staff. Many of these concerns were met with inaction, and in some cases intimidation and fear of retribution. Many physicians and nurses who have voiced concerns have been essentially marginalized, intimidated and have had to leave. We stated that because of rampant loss of SNI staff, the Seattle Times has been calling former and current SNI employees and wishing to write and article about Dr. Delashaw and the lack of the administration to act on multiple issues related to patient safety, toxic work environment and fear of retribution by hospital staff for discussing existing issues. We fear that if the current issues are not immediately addressed that some former SNI employees will expose this issue and SNI/Swedish will be subjected to further bad publicity that would harm all parties involved. The group stated that Dr. Delashaw has overseen the direct interference of patient referrals and has used direct intimidation and retaliation to interfere with long-standing referral patterns. Our group will not tolerate having Dr. Delashaw unilaterally demand that patient referrals be rerouted from individual surgeons in the group to his practice. This highly unorthodox strategy has been aimed at undermining the practices and incomes of existing SNI surgeons. The group stated that at the current time, there is unanimous lack of confidence and trust in the leadership of Dr. Delashaw, and that we essentially feel zero confidence in his ability to self- correct and return to a position of trust amongst the group. We stated that his record of destruction at OHSU and UC Irvine indicates that he is unable to be rehabilitated with respect to his patterns of behavior. When asked by Mr. Armada what our plan is, we stated that we had spoken to the CMO, Dr. Vassal, who told us to figure it out amongst ourselves. Based on that recommendation, our group expressed the desire to have Dr. Delashaw resign immediately, and that our group will form a plan to self-govern with central overall leadership of Dr. Gwinn and then leadership of centers of excellence by appropriate SNI staff. External domain - Loss of referrals from Alaska, Spokane, Group Health - Lack of program and practice building and recruitment of new collaboration opportunities and referral sources - Disjointed fundraising 13 Internal Domain: - Serious S-CH OR disruption - Centralization of referral streams through Dr. Delashaw to the detriment of established and competent SNI surgeons. - Poor relationship building with GH Neurosurgery - Poor relationship with SNI-Neurology - Lack of MSK RPM integration - Degradation of Neuro ICU coverage - Dissolution of Swedish Spine Center identity - Undermining clinical and scientific activities of the Ivy Cancer Center - Degradation of Transfer center - Lack of hospitalist engagement with transfers - Profound loss of quality staff and surgeons (see Encl.1) - Degradation of institutional knowledge Interpersonal communications (JD specific): - Culture of intimidation, threats and retaliation - Derogatory communication about others - Attempts at interference with committee - Unprofessional inappropriate expressions A detailed discussion about complaints was had with brief or more detailed discussions about the following complaints (see Encl. 2). The profound nature of disappointment in Dr. Delashaw?s leadership style, actions was shared by all present faculty. The current development threaten the very health of SNI and are in clear conflict with The 5 Swedish Best. Resolutions: The undersigned surgeons identified the following three needs to assure rapid return to SNI program health and compliance with the 5 Swedish Best: 1. Appointment of Interim Clinical Operations Director (COD) This surgeon colleague will oversee all clinical operations, is clinic referrals, program implementations, subspecialty clinical activities and operating room activities. This colleague will appoint such colleagues to aid in the execution of these tasks as necessary. The surgeons have selected Dr. Ryder Gwinn to assume this role of COD. For now Drs. Chapman and Litvak have agreed to serve as surgeon representatives of the Ad Hoc OR management committee under the previously established premise of governance. Dr. Litvak will continue in his role as Program Director for educational activities. De Chapman will continue in his role as Clinical Research Director. Dr. Rod Oskouian will assume the role of External Relations Director. Dr. McDougalI has agreed to assume the role of committee Chair in lieu of Dr. All of these appointments will function under the premise that Dr. Delashaw has no administrative authority over these colleagues beyond that of an advisory colleague. 2. Interpersonal conduct Administration will take effective actions to prevent Dr. Delashaw from unprofessional conduct such as speaking in derogatory fashion, or acting in intimidating, threatening or retaliatory fashion of colleagues, administrators, staff. Surgeons and staff will not 14 3. Future meetings As a new SNI governance structure and actionable items will need to be developed and addressed, the SNI surgeons, administrators and others as needed will meet on a regular basis on short-term notice. ENCLOSURE 1 Swedish/SSF Providers Dismissed, Resigned, Reassigned or Position Eliminated No longer working at Swedish Neuroscience Institute lCherry Hill I. Physicians Physician Assistants John Henson, MD Past Vice President for Medical Affairs; Swedish Cherry Hill Campus Lily Jung Henson, MD Past Vice President for Medical Affairs; Swedish Ballard Campus David Newell, MD Past Co-Executive Director, Swedish Neuroscience Institute - Marc Mayberg, MD Past Co-Executive Director, Swedish Neuroscience Institute Frances Broyles, MD Previous Director Swedish Pituitary Program; (Terminated by SMG) Peter Nora, MD Previous Chief of Neurosurgery John Hsiang, MD Past Director of SNI Spine Sarah Fouke, MD Past Staff Neurosurgeon; Swedish Neuroscience Institute Joe Eskridge, MD Past Swedish Staff Interventional Neuroradiologist - Arthur Lam, MD - Past Director Cherry Hill Neuro ICU - Doug Backous, MD Previous Director of SNI Neuro-Otology Alan Velander, MD Previous Staff Neurocritical Care, Swedish Neuroscience Institute Stanley Lue, MD Previous Staff Neurocritical Care Intensivist, Swedish Neuroscience Institute Kristin DeGroot, PA-C -Previous Neurosurgery Physician SNI Martha Wilkes, PA-C Previous Neurosurgery Physician Assistant-SNI Pamela Radamaker, ARNP Previous Neurosurgery/Neuro-Oncology Nurse Practitioner II . O.R. Nursing Leadership (over 30 OR. staff nurses have resigned) Mary Fearon, RN Past Swedish Cherry Hill Director Perioperative Services Niki Ellington, RN Swedish Cherry Hill Cranial OR Nursing Manager Caroline Dufault, Swedish Cherry Hill Spine OR Nursing Manager Elizabeth Hendershott, RN Swedish Cherry Hill OR Nurse Bernedette Haskins, Swedish Cherry Hill OR Nurse Ill. Program Managers - Christie Morrison, RN Head Nurse, Outpatient Services. Swedish Neuroscience Institute Mary Caverly Previous Program Coordinator; Swedish Neuroscience Institute Laura Jacob Previous Director of Medical Education; Swedish Neuroscience Institute Davita Pennington Previous Program Manager, SNI Ivy Brain Tumor Center Peggy Shortt, ARNP Previous Program Manager; SNI Deep Brain Stimulation Program Luwanna LaPole Previous Director of Operations; SNI Neurology Tammy Lindblad Previous Manager of Clinical Operations; SNI Spine 15 ENCLOSURE 2 Concerns about Johnny Delashaw, MD. in his role as Chair of SNI - Loss of staff (OR, Clinical, and Physicians) 0 Variety of documented reasons with regards to Dr. Delashaw: - Concerns of patient safety - Ethical concerns regarding manipulation of referrals, patient surgical cases, and human life - Hostile work environment generating a fear of being fired (documented threat to staff) - Harassment and bullying insisting his surgical cases proceed despite concern for room/ staff/patient) that ultimately led to mental and physical stress to staff members - Stealing referrals - Manipulation of indirect referrals as direct referrals to his practice - Intimidation/Direct communication to referring providers to funnel referrals through his practice only - Loss of referral base peninsula, Olympia, Alaska) due to intimidating correspondence with Dr. Delashaw (mandating all referrals come through his practice) and poor post-surgical outcomes/follow-up This has damaged Spine, the Ivy Center, and the CV Center - Damaged relationship with referring providers refusing to have their patients see Dr. Delashaw AAlflatooni, Conway) 0 Many have been open in their fear he will intercept their referral or they will suffer his harassment if not sent directly to him. - Botched relationship with ANMC including all referrals being directed through his practice as well as open frustration from referring surgeons at ANMC Bumping junior surgeons with urgent cases - Relationship with neurology - Spine Institute - Strained relationship with Group Health due to intimidation of surgeons with regards to cases, OR space, and their industry choices - Documented interference with the GI process (per staff report and through trackable means with the QVFI system) - Hiring of multiple surgeons who are personal friends without group buy in and with little consideration for referral dispersal, lack of OR space for additional surgeons, lack of clinical space, and lack of support staff at this time - Decimation of ICU infrastructure with removal of world-renown anesthesiologist from leadership role and failure to adequately staff the unit with trained providers - Purchasing of OR equipment not wanted by team members Orbic c-arm, Brainlab Arrow CT) and pursuing the purchase of additional equipment (O-arm) with failure to get partners input (which is notably against the acquisition of an O-arm) . - Documented attempts to control quality review on Cherry Hill with removal from First Hil interdisciplinary review as dictated by Med Staff Threatening committee for presenting repeated cases of his that posed patient safety concerns 16 - DOH investigation with regards to OH incidences including verbal threats to nursing staff and throwing ol equipment at staff - MQAC investigation into behavior Complaints to Human Resources of harassment and Hostile in the work environment (i both OR and clinic and lloor/ICU) Threatening and bullying behavior 0 Multiple threats to get people lired noted by both clinic and OR stafl Inappropriate language in the work environment lrequeni use of curse words] 0 Harasses team members (both provider, ancillary stafl, and administration) - Documented inadequate care for patients by Dr Delashaw (i e, discharge ol patient with documented hardware lailure/malposition) Poor documentation with regards to clinical care and surgical planning - Lack ol accountability for post op complications blames others or disregards complications) I Blatant disregard lor other attendings' patients OR space and clinic space) - Failure to develop a visionary plan for since start cl employmenti succeeding in decimating previous infrastructure Without establishing a positive and productive system and nor securing any resources tor the Institutes lulure maintenance and growth DRAFT Vs 1 2 SNI Surgeon ConcernsPage 1 Oct 30' 2016 Charles S. Cobbs, MD