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Community Health Programs: An agency in turmoil, doctors say

Their concern, doctors say, is that the quality of patient care at CHP’s health centers is at risk in a climate where physicians’ voices are ignored or marginalized, where staff members who raise concerns are bullied to the point where they eventually leave or are fired.

Great Barrington — Six Community Health Programs (CHP) physicians are in open revolt against the non-profit organization’s administration, its Board of Directors and Chief Executive Officer Bryan Ayars, citing a host of issues such as staffing shortages and a “toxic environment” that, if allowed to persist, they say may eventually affect the quality of patient care.

Community Health Programs CEO Bryan Ayars.
Community Health Programs CEO Bryan Ayars.

Four doctors who are medical leaders at three of CHP’s health centers — one a former Medical Director — sent a letter this week to the Health Resources and Services Administration (HRSA) — a division of the U.S. Department of Health and Human Services — which provides funding and oversight for CHP and all federally designated health centers across the country. The physicians declined to use their names for this story over concerns about contract stipulations that forbid them to cast the organization in a bad light. In the letter to HRSA they expressed their “grave concern about current leadership,” and “request additional oversight…because CHP’s Board of Directors is not fulfilling their role in overseeing the organization. We have NO CONFIDENCE in CHP’s CEO nor the Board…”

Their concern, they say, is that the quality of patient care at CHP’s health centers is at risk in a climate where physicians’ voices are ignored or marginalized, where staff members who raise concerns are bullied to the point where they eventually leave or are fired, where allegations of sexual harassment are disregarded, and where a wall stands between doctors and the board, preventing regular communication.

Pediatrician John Horan, who works part of each month as interim Medical Director at the Blood and Marrow Transplant Program at AFLAC Cancer Center at Emory University and Children’s Healthcare of Atlanta, was so fed up he resigned two weeks ago, writing to The Edge that he had “completely lost trust in the administration and confidence in the board.” One reason for his resignation, he wrote, were “lies perpetrated to cover things up” after the former Human Resources Director was fired when the administration learned she was about to speak out over allegations of sexual harassment. Horan said he gave three months notice as his contract requires.

Pediatrician Dr. John Horan who resigned from CHP two weeks ago.
Pediatrician Dr. John Horan who resigned from CHP two weeks ago.

That former HR Director filed a discrimination lawsuit two weeks ago against Ayars and CHP with the Massachusetts Commission Against Discrimination. MCAD, however, will not disclose case details until after adjudication. Upon her attorney’s advice, she declined to use her name in part because she is looking for another job. Attorney Michael Aleo of Northampton’s Lesser, Newman & Nasser LLP, said that his client was fired “unlawfully” for doing her job after getting “several complaints of workplace harassment from employees.”

Aleo said he and his client are not yet ready to make details of the claims public.

“Under both state and federal law, as well as under the organization’s own personnel manual,” Aleo said in an email, his client “was obligated to take adequate steps to address and remedy sexual harassment in the workplace.”

The doctors’ letter to HRSA mentions the allegation, saying “she was let go the next morning” after a private conversation in which she revealed “Mr. Ayars was conducting an inappropriate sexual relationship with a subordinate.”

Doctors further wrote to HRSA that her departure left the human resources department limping at time when “there are serious staffing shortages in two of CHP’s largest health centers,” the Great Barrington and Pittsfield clinics.

During an interview at CHP offices on Stockbridge Road in Great Barrington, Ayars, CHP’s Board President Jodi Rathbun-Briggs, and Vice President Lynn Carlotto spoke to The Edge about the letter to HRSA, but they deny the allegations made in the lawsuit and declined further comment on that matter.

Horan and his wife, part-time CHP ophthalmologist Diane Singer, said they have watched the situation unravel amid deteriorating conditions over the past year as staffers left and departures squeezed the Great Barrington center into functioning with a skeleton crew. They laid the blame squarely on Ayars, whose actions and inaction, they say, may compromise physicians’ ability to deliver high quality care, and threaten Berkshire County’s most critical rural public health resource, one that also prevents patients with state insurance from having to travel long distances for care that is covered.

CHP’s Board President Jodi Rathbun-Briggs.
CHP’s Board President Jodi Rathbun-Briggs.

Horan said the board is not functioning as it should. “The board has denied us any means of sharing our concerns with them other than by channeling them through the CEO,” he wrote.

CHP was founded by pediatrician Thomas Whitfield in 1975 to address a lack of access to medical care for rural children living in poverty. It has seen dramatic growth, from several thousand patients in 2003 to more than 14,000 today, and now has a annual budget of $12 million. All of its programs combined serve around 16,000 people in Berkshire County. The organization got a federal designation in 2000, expanding to serve adults and seniors, and takes MassHealth, unlike most private practices in the area. It also gives free care to anyone who needs it, and prides itself on giving the same care to those who can pay and those who can’t. The organization has a mobile medical van that travels to provide free services. CHP is funded with large federal grants every year to run two health centers and a dental office in Great Barrington, health centers in Pittsfield and Lee, and numerous other programs for families and children. It has 140 employees, 25 of which are physicians. In December CHP will open clinics in Adams and North Adams to add care lost by the closing of North Adams Regional Hospital last year. CHP is a public health provider in an area with a high poverty rate and an increasing elderly population.

In their letter to HRSA, the physicians wrote that they had a “heavy heart” over having to go to the agency with their concerns about an organization that takes care of “the neediest and most at risk patients in this county.”

“We are increasingly troubled by an organizational culture that demands complete acquiescence and silences questions, shames those who speak out, and that consistently disrespects medical advice,” they wrote. They had tried, they said, to address it with the board in September 2014. The board responded, they said, by interviewing CHP’s administrative and medical leaders, who the physicians’ say, “agreed with most of our concerns about Mr. Bryan Ayars, but “made inadequate efforts” to address them. In the HRSA letter, they cited a “lack of informed effective leadership” in certain areas, and “increasingly serious repercussions on patient care.”

“The culture at CHP is one of separation and isolation,” Horan said, explaining that Ayars is positioned between the medical staff and board — which presently has no doctor sitting on it — so that doctors must go through Ayars in order to voice ideas, concerns or other issues. Many of the concerns, Horan says, have to do with Ayars himself, complaints ranging from dismissiveness and hostility, to what Horan and Singer say is problem with “strong women,” particularly female physicians.

“The board spent a long time looking at provider concerns,” Ayars said. He admitted to “communication difficulties,” something he says was improved upon when the board decided to reorganize and cut the Chief Operating Officer (COO) position, “streamlining” so that he was the only one between the board and the doctors.

In the HRSA letter the doctors say eliminating the COO position “transferred more power and responsibility” to Ayars, even though, they said, he is unqualified to run the operational aspects of a health center. As a result, the physicians say, “The practice managers have full responsibility but no authority and [Ayars] has all the authority but no responsibility.” This reorganization, they added, “empowered him and sent a strong message that to ask questions about his leadership is a risky business.”

In a prepared statement Rathbun-Briggs said CHP, now in its 40th anniversary year, “will continue to undergo a series of important organizational changes that will position us for even stronger growth in the future.” She also said that decisions would be made for the “best interests of the entire organization,” despite what “some of our stakeholders, including some of our own physicians, may want…”

CHP ophthalmologist Dr. Diane Singer.
CHP ophthalmologist Dr. Diane Singer.

A consultant’s report noted a “culture of silence” at CHP, Horan said, adding that a September site visit by HRSA indicated that 9 out of 19 elements investigated were “unmet,” though that report has not yet been distributed. Ayars told The Edge that the term “culture of silence,” was simply a description by some physicians, and that the consultant used Survey Monkey for those results. He also said that the HRSA site evaluation is not a “gotcha,” but a way to bring consistency into the organization and improve things. He said at the evaluation exit interview, HRSA representatives told CHP that it is “short-staffed at the senior management level, and over-staffed at the clinical level given productivity (how many patients are seen per hour).”

Horan and his colleagues who wrote to HRSA noted the “shrinking leadership team.” But clinical understaffing last summer was another complaint in the letter, and one of Horan’s as well.

“[Ayars] doesn’t listen or engage with the providers,” said Horan. “We went to him about help last summer and he didn’t help.”

The events of last summer at the Great Barrington location, Horan says, were the final straw for him, especially since it is the only health center with pediatricians on staff. Two nurses left and a pediatrician, the former Chief Medical Officer, went on sabbatical, giving at least three months notice. Both the letter and Horan claim that Ayars knew he had to hire replacements but never did, and all summer providers, which includes doctors and nurse practitioners, were doing extra workload on top of their own, and using extra vigilance to ensure no mistakes were made. With so few pediatricians, another physician had to cover not only her job, but all CHP patient hospital cases and deliveries, and all pediatric work at Fairview Hospital. The nursing shortage, Horan said, caused problems, too.

“I had to send parents home and tell them to come back for vaccines,” he said.

The letter to HRSA stated that “Ayars had done nothing to initiate the search for locums to ensure adequate coverage for patients…he only responded when it was an impending crisis and when the hospital-owned pediatric practice that shares the call responsibility contacted him to say this was not acceptable. Even then, his actions were slow and ineffective…repeatedly, issues that land on Mr. Ayars’ desk are left to wither.”

Ayars explained the challenges of recruiting doctors to work in the Berkshires. He acknowledged the “emotional stress” the staff felt when the physician left for sabbatical during summer, especially with staff trying to take vacations. He said he and interim Chief Medical Officer Thomas Irwin were not aware of people being turned away for immunizations. “That was news to me,” Ayars said, adding that after the nurses left, he brought in nurses from other health centers. And he denied that the summer was a problem. “[Doctors] were busier but they weren’t swamped,” he said. “They still had spaces in their schedules.”

Horan also said long-time physician Charles Wohl, who founded CHP’s Neighborhood Health Center in Pittsfield, retired two years ago and still hasn’t been replaced, short-staffing that center and compromising care. The letter to HRSA also raises this concern. Ayars denied there is a crisis there, explaining that Wohl worked part-time in the few years before his retirement, and over time, assigned his patients to new doctors. “By the time he retired we had absorbed all of his patients,” Ayars said, adding that soon a physician will return there from maternity leave. While they are still trying to find another physician, they have interim help to take on new patients, and a steady rotation of internal medicine residents from University of Massachusetts in concert with Berkshire Health Systems.

The service area reached by Community Health Programs, with percentage of clients by zip code.
The service area reached by Community Health Programs, showing percentage of clients by Zip Code.

Without HRSA knowing, CHP did not have a top “medical leader,” known as the Chief Medical Officer (CMO), for 6 months, the physicians say, after the CMO went on sabbatical, giving her required notice. At that point, all the medical leaders gave “unanimous support” to an existing physician from CHP’s Lee Family Practice to be an interim CMO while a national search was conducted for a replacement. The physicians wrote that Ayars told this medical director in a public forum, “under no terms would I ever agree to work with you,” and that it was better not to have “medical knowledge in senior leadership.”

Thomas Irwin became interim CMO in September of this year.

The letter says there is currently no “medical expertise” in CHP’s senior leadership. The only board member with medical expertise, physician Adrian Elliot, recently left. Rathbun-Briggs and Carlotto said there is a nominating committee vetting possible new members, some of whom “have medical backgrounds.” They said it is a challenge for doctors to be on the board given the unpredictability of their work. They said their board composition is complex and full of requirements by HRSA, which does not mandate the inclusion of a physician. HRSA does, however, insist that half of a board’s members are CHP patients. “This keeps things honest,” Ayars said. “I get great suggestions for improvements.”

“A shrinking leadership team” along with “staff departures,” the physician’s wrote to HRSA, is weakening the organization. The partial cause, they say, are several retaliatory firings and some departures.

“The Director of Marketing filed a hostile workplace complaint against Mr. Ayars; although there were other issues with her performance, she was fired,” the physicians wrote.

Former CHP grant writer Ruth Dinerman recently resigned, giving six weeks notice before she wrote an emailed resignation letter to board members that said the administration’s operational strategy is “dangerous” to the organization. “It burns out physicians, destroys morale, and thus leaves CHP vulnerable to providers leaving. Each time one does, CHP takes a financial hit…administrative resources are tapped out. Providers are worn thin.”

Diane Singer said losing staff, particularly physicians, is risky business in an area where doctors are not easily replaced. “How many lives are changed because one person is running unchecked?” she said. “People are leaving in dribs and drabs. It’s an empty shell.”

The physicians’ letter to HRSA claims that the former Chief Medical Officer’s tenure was not renewed by the board because “she was being punished for raising questions about senior leadership.” This is what caused Dinerman, who had brought in more than $2 million in funding in 2015, to quit.

Dinerman said this may take a toll on funding. “More than once recently, CHP has not met the requirements of a grant it has received because existing staff can barely handle the ongoing work on their plate.” This runs the risk, she added, of making CHP “less attractive” for grants.

CHP operate a mobile health care clinic serving the rural Berkshires.
CHP operates a mobile health care clinic serving the rural Berkshires.

Dinerman goes on to say that Ayars has also “alienated large donors” and other long-time supporters who could help fundraise, adding that CHP is “in a worse situation now in terms of individual fundraising than it was when I arrived in 2012, bringing in steadily less money every year…The organization is more fragile than it should be.”

Dinerman said she “got an immediate reply from Rathbun-Briggs thanking me for my concerns and saying we all had CHP’s best interests in mind.” Dinerman included CHP’s attorney in the email list for her resignation letter. He called her and asked questions, she said. “I never heard another thing from the board.”

Dinerman was mystified when her supervisor told her a “hard copy of the letter” would be considered “insubordination.”

Ayars dismissed Dinerman as “harboring ill will” because of her relationships with several of the physicians. He also says the HRSA letter is “retaliation” from a group of doctors who feel “disenfranchised.”

“We need to be working with them and them with us,” Ayars said. “Ninety-five percent of their concerns are shared by the leadership and board — it’s just how we get to [fix] them.”

Ayars went on to say that being a doctor comes with frustrations over “changes in healthcare, where providers are no longer feeling like they’re in touch with their patients.” Technology is one reason, he said. Payment structures, less pay and more work and record keeping and reporting is all taking its toll, he added. “The national perspective is that they’re no longer in control. It’s no longer health and wellness, it’s a business. We want providers to be more involved but within limits.”

Rathbun-Briggs said “decisions that are made to uphold our mission aren’t always popular. They are made for the greater good and not for promoting individual ideas.” She said the board has a “remarkable skill set” and are “active and engaged.” She “vehemently disagrees” with the assertions made in the discrimination lawsuit. She said physicians may sometimes want changes to happen at a pace that isn’t always possible.

Carlotto said she takes her role on the board “very seriously” and finds the allegations “sad.” She has passion for the organization, she said, since Dr. Whitfield, CHP’s founder, was her pediatrician. “We’re listening and we’re very attentive to any issues we see…Bryan has to report to us on a continuous basis.”

A 2015 Employee Satisfaction Survey sent by Ayars to The Edge showed morale in Ayars department “better now than last year.  Fifty-six percent say it is improving. Almost 90 percent of employees report that they are treated very respectfully or extremely respectfully by their supervisor; 89 percent of employees report being proud to be CHP employees; 85 percent feel CHP is moving in the right direction.”

“The only reason something bad hasn’t happened yet,” said one CHP physician, who insisted on anonymity, “is that providers are working overtime and double checking others to make sure mistakes aren’t being made.” She added that “none of us have raised any concerns about our compensation.”

In an email to The Edge, Horan said CHP was in serious trouble. “The administration and board have managed to conceal [problems] from the public,” he added. “[Physicians] have held off divulging our problems to the press for fear that it might tarnish CHP’s reputation. As things deteriorate further at CHP, however, we’re thinking it may be time to get the word out.”

Horan says that by contrast, at his other job at Emory, “no substantive decisions are made without being vetted over and over again with the [doctors].” He said that even though he is 900 miles away, he is constantly connected to the administration and other physicians there.

“Even though [Ayars’] office is probably less than 100 feet from mine,” Horan added, “I often go months without any contact from him other than his periodic group wide emails.”

Another former physician, also insisting on anonymity, says she left CHP in part because of Ayars’ “militaristic” leadership style.

“It’s basically: ‘shut up’, ” she said.


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