By Rebecca Robbins, Katie Thomas and Jessica Silver-Greenberg

• Published by The New York Times,  Dec. 15, 2022

At a hospital in a Chicago suburb last winter, there were so few nurses that psychiatric patients with Covid were left waiting a full day for beds, and a single aide was on hand to assist with 32 infected patients. Nurses were so distraught about the inadequate staffing that they banded together to file formal complaints every day for more than a month.

About 300 miles away, at a hospital outside Flint, Mich., similar scenes were unfolding. Chronic understaffing meant that patients languished in dried feces, while robots replaced nursing assistants who would normally sit with mentally impaired patients.

Both hospitals are owned by one of the country’s largest health systems, Ascension. It spent years reducing its staffing levels in an effort to improve profitability, even though the chain is a nonprofit organization with nearly $18 billion of cash reserves.

Since the start of the pandemic, nurses have been leaving hospitals in droves. The exodus stems from many factors, with the hospital industry blaming Covid, staff burnout and tight labor markets for acute shortages of staff.

But a New York Times investigation has found that hospitals helped lay the groundwork for the labor crisis long before the arrival of the coronavirus. Looking to bolster their bottom lines, hospitals sought to wring more work out of fewer employees. When the pandemic swamped hospitals with critically ill patients, their lean staffing went from a financial strength to a glaring weakness.

More than half of the roughly 5,000 hospitals in the United States are nonprofits. In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities.

But The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions.

Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas.

And many have cut staff to skeletal levels, often at the expense of patient safety.

At a single hospital in Northern California, the sprawling nonprofit hospital chain Providence laid off dozens of medical staff in 2017 and 2018, resulting in long waits for crucial care. At a Washington State hospital that is part of CommonSpirit Health, another giant nonprofit chain, years of belt-tightening reached a breaking point in October when an overwhelmed nurse called 911 dispatchers, who sent the fire department to help care for patients.

Ascension, which runs 139 hospitals, among the most of any chain in the United States, is emblematic of the industrywide movement to keep labor costs low.

As recently as 2019, Ascension was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric. At one point, executives boasted to their peers about how they had slashed $500 million from the chain’s labor costs. In the years before the pandemic, they routinely refused requests to hire more medical workers or fill open jobs, according to current and former hospital administrators and employees.

The yearslong effort — a combination of widespread layoffs and attrition — rarely attracted public attention. But it left Ascension flat-footed for Covid.

During surges in the coronavirus, Ascension repeatedly reduced its capacity by more than 500 beds nationwide because it did not have enough workers. In Michigan alone late last year, the chain had 1,100 nursing vacancies. The head of an Ascension hospital in Baltimore last year blamed staffing shortages for the emergency room being dangerously overcrowded.

To understand how Ascension’s strategies affected patients, The Times focused on two hospitals, St. Joseph in Illinois and Genesys in Michigan, where nurses belonged to unions that tracked staffing cuts and kept detailed logs of what they said were unsafe conditions. The Times reviewed more than 3,000 pages of those logs and interviewed 70 current and former nurses, executives and other employees at Ascension hospitals.

Nurses said that Ascension’s downsizing had stark consequences.

Nurses at Ascension hospitals filed formal complaints warning about inadequate staffing.

Patients lingered for hours on gurneys with serious, time-sensitive problems. Surgeries were delayed. Other patients developed bed sores — gaping wounds that for frail patients can be deadly — because they were not repositioned often enough.

“You feel awful because you know you’re not turning these patients,” said Jillian Wahlfors, a nurse at Genesys. “You know they’re getting their meds late. You don’t have time to listen to them. They’re having accidents, because you can’t get in fast enough to take them to the bathroom.”

Nick Ragone, an Ascension spokesman, denied that cost-cutting contributed to staffing shortages during the pandemic. Such a claim, he said, “is fundamentally misguided, misleading and demonstrates a lack of understanding of the impact of Covid-19 on the health care work force.” He also said Ascension offers superior care that “has been improving over time” and that the hospital provides free treatment for many low-income patients.

Unlike some rivals, Ascension avoided layoffs early in the pandemic, and Mr. Ragone said the chain has more employees relative to patients than many of its peers. From December 2015 to June 2021, he said, Ascension’s ratio of bedside nursing capacity to its discharged patients has increased by 64 percent, with staff increasing and discharges holding roughly steady.

Academics who study hospital workforces cautioned that the metric makes Ascension’s staffing conditions seem better than they are. For example, the ratio’s increasing number of nurses over time at least partly reflects Ascension having added about 17 hospitals, while the data on discharges does not include outpatients, even though nurses are spending more and more time caring for them.

Because it is difficult for outsiders to verify such industry-supplied data, hospitals can use it to serve their own purposes.

“The complexity and the lack of transparency, all of these things make it impossible to try and figure out exactly what’s going on,” said Linda Aiken, a professor at the University of Pennsylvania School of Nursing, who has conducted large surveys of hospital staff. “That’s why we ask nurses.”

A Ministry, Not a Business

Ascension was created in 1999 through the merger of two networks of hospitals, many founded in the 1800s by nuns who ministered to the poor.

The combined hospital system swiftly became a juggernaut, its profits soaring sixfold in its first decade. (As a nonprofit, Ascension describes this figure as “excess of revenues and gains over expenses and losses.”) By 2010, Ascension’s $15 billion in revenue rivaled that of companies like General Mills and Gap.

Today, Ascension operates in 19 states, mostly in the South and the Midwest. It serves about six million patients.

By many measures, Ascension is rich.

In addition to its billions in cash, it runs an investment company that manages more than $41 billion. Last year it paid its chief executive, Joseph Impicciche, $13 million.

Because of its nonprofit status, Ascension avoids more than $1 billion a year in federal, state and local taxes, according to the Lown Institute, a health care think tank. Until the pandemic, Ascension was consistently profitable, earning hundreds of millions a year. The past year was a rare exception: Because of the stock market downturn and soaring labor costs, Ascension lost $1.8 billion.

Ascension and its executives have powerful incentives to be as profitable as possible. The more money the chain makes, the more its executives get paid. (Mr. Ragone said that a larger proportion of executives’ pay is based on other factors, like delivering high-quality care.) And stronger financial metrics allow the chain to borrow money at lower interest rates, enabling it to buy new hospitals and add services.

Executives have described their profit-seeking strategies as key to the hospital system’s stability and its mission of serving the poor and vulnerable.

“We are a ministry,” Anthony Tersigni, Ascension’s previous chief executive, said in 2007. “We’re not a business.” (Mr. Tersigni now leads Ascension’s investment arm, a job that paid him $11 million his first year.)

Four former executives who joined Ascension from other nonprofit hospital systems said the profit-driven culture surprised them. There were few conversations, they recalled, about how profits could be used to advance Ascension’s charitable mission. The pressure to reach financial targets struck them as more befitting a for-profit company.

“Their whole approach to the finances was right out of the Wall Street playbook,” said William Weeks, who until his retirement in 2019 was the chief operating officer of a five-hospital chain that Ascension owns in Oklahoma.

For example, Ascension charged its hospitals management fees, which covered the cost of centralized services like human resources, that were so high that they sometimes drove hospitals into financial peril.

In Washington, Ascension charged tens of millions of dollars in fees to Providence Hospital, which largely served poor, Black patients. The district’s attorney general investigated whether Ascension’s fees were excessive. In response, the chain in 2018 agreed to forgive $130 million of debt owed by the struggling hospital, which by then was being downsized into an urgent care center.

But the heart of Ascension’s business strategy was cutting costs.

A Late-Night Phone Call

In 2010, Dr. Michael Schatzlein, who had spent years at a for-profit hospital chain, was hired to run a handful of Ascension hospitals in Tennessee and Alabama.

“The idea was to bring what I’d learned about containing costs through improving efficiencies to a mission-driven organization,” he said.

It was a tumultuous time in the health care industry. The federal government was reducing the amounts that Medicare paid hospitals to care for older patients. Plus, the coming rollout of the Affordable Care Act created deep uncertainty about hospitals’ financial prospects.

Around 2013, Ascension executives made a series of projections that showed that, over the next five years, their costs were expected to outpace their revenue by more than $5 billion.

To close that anticipated gap, Ascension turned to its biggest expense: labor. That year, the chain laid off thousands of workers, including medical staff.

Dr. Schatzlein, who by then had been promoted to run more than a dozen hospitals, was asleep at the JW Marriott in Indianapolis, where he was attending an industry conference with other Ascension executives. A phone call woke him. He was asked to come to a meeting downstairs, where executives decided they had to lay off thousands of workers across Ascension.

For Dr. Schatzlein, that meant axing about 3 percent of the staff, or about 1,000 nurses and other employees, in his hospitals. “I felt horrible about it,” he said. “My entire career was based on avoiding across-the-board layoffs.”

Across its network of hospitals, Ascension set individual financial targets, and executives whose hospitals did not achieve their goals would not get bonuses, according to three former executives. Keeping staffing low was one of the easiest ways to get paid, since labor costs make up about half of a hospital’s expenses.

Ascension also closely tracked the number of nurses on duty relative to how many patients were treated in each hospital unit. Managers felt pressure to require fewer nurses to handle more patients. Some had to show they were hitting productivity targets before they could hire more workers, according to current and former Ascension employees.

Ascension began showcasing its initiatives to cut labor costs. At a 2015 industry conference, two Ascension executives gave a presentation titled “Successful Labor Optimization Efforts” that detailed their tactics, which they said had saved nearly $500 million in just three years.

In Michigan and Illinois, Ascension lobbied against legislation that would have required minimum nurse-to-patient ratios. The measures never became law. In the following years, staffing levels at Ascension hospitals in those states were routinely below what the bills would have required, according to nurses at those hospitals.

Ascension’s fears about looming financial shortfalls never came to pass. Over the five years in which Ascension executives had projected the $5.2 billion loss, the system instead earned $2.7 billion in profits.

Even so, it continued to cut workers.

Running for Supplies

When the pandemic hit, nurses at St. Joseph, the only hospital in Joliet, Ill., were overwhelmed and feared for the safety of patients, according to state inspection records and thousands of pages of formal complaints that nurses filed with the hospital warning about unsafe conditions.

“Every day it’s unsafe staffing!!!” one nurse wrote in June 2020, underlining “every day” four times.

Nurses said they had been finding themselves in such situations more and more since 2018, when Ascension took over St. Joseph.

Shortly after the acquisition, St. Joseph employed 791 nurses. That number has since dropped by 23 percent, according to the Illinois Nurses Association, which represents the hospital’s nurses and has clashed with Ascension’s management over pay and other issues.

The staff reductions were largely the result of nurses leaving to pursue better pay and working conditions elsewhere. Ascension then left many vacant jobs open, though some slots were filled by nurses on short-term contracts, employees said. Nurses at St. Joseph generally make between $29 and $52 an hour and can earn multiples more working for medical staffing companies.

Mr. Ragone said that St. Joseph’s number of employees per occupied bed went up 6 percent between 2018 and 2021. But that figure partly reflects Ascension having reduced its capacity. The data also includes many employees who do not treat patients. Mr. Ragone would not provide data specific to nurses.

Some of the nurses’ grievances have been substantiated by state authorities.

In April 2021, Illinois health inspectors cited St. Joseph for failing to care for patients who needed to be regularly repositioned. The inspectors found that some patients developed bed sores after they were not moved for as much as 20 hours, despite doctors’ orders that they be shifted often.

Since then, the problems have intensified.

In January 2022, as the Omicron wave pummeled the Chicago area, groups of nurses signed the formal complaints on more than 130 occasions.

At the beginning of the month, an entire shift of eight nurses in one unit signed a complaint that there was only one nurses’ aide available for 32 patients with Covid, most of them on oxygen. The complaint said a supervisor told the nurses that the entire hospital was short-staffed.

At the end of the month, no one showed up to staff the surgical supply room. When two patients needed emergency surgery, nurses were left to gather instruments themselves. One surgery was delayed, and a nurse had to abandon a 100-year-old patient to run for supplies.

One night in October, nurses in St. Joseph’s intensive care unit learned that they would have to care for four patients each — double the industry standard. The hospital had to divert ambulances from delivering patients until more nurses arrived.

Four nights later, nurses in the emergency room refused to clock in because they were being asked to care for 11 patients each, instead of the recommended four.

“It was inevitable,” said Jillian Moffett, who was among the nurses who protested the staffing levels. “One of these days someone was going to put their foot down and say, ‘I’m not taking this anymore.’”

The Rise of the Robots

In 2019, Ascension received an award from a company called AvaSure. The “AvaPrize” was bestowed upon the hospital chain because of its embrace of a new cost-cutting innovation: robots.

Traditionally, Ascension, like other hospitals, sent nurses’ aides into the rooms of patients who needed close supervision. Left untended, these patients, many with dementia or psychiatric illnesses, might get out of bed and hurt themselves.

But in the years before the pandemic, some Ascension hospitals switched course. Going forward, they would generally assign nurses’ aides only to patients who were deemed at high risk of dying by suicide.

For other patients, aides would be replaced by AvaSure’s “TeleSitters.” By 2019, Ascension had installed 450 of the robots in more than 50 of its hospitals. The devices — essentially a video camera mounted on a metal pole — send live footage to an off-site command center, where workers talk to patients through speakers in the machine.

In marketing materials, AvaSure boasts that the TeleSitter — which is used by about 1,000 hospitals nationwide — allows workers to monitor the movements of up to 16 patients at once.

Its website features the testimonial of a top nurse at a Texas hospital that started using AvaSure devices during the pandemic. He said they would enable someone like him to “do three shifts in the E.R. and then do a shift at home using this.”

AvaSure cites research showing its robots reduce dangerous falls. And some Ascension officials said the TeleSitters were invaluable during the pandemic. “Somebody had eyes on those patients,” Maureen Chadwick, an Ascension executive, said at an event this year.

But at Ascension’s Genesys hospital in Michigan, nurses said patients, many of them already disoriented, were confused by the disembodied voices coming from TeleSitters. There were sometimes not enough robots — which nurses derided as “sitters on a stick” — to go around.

And when workers at the command center 80 miles away called the hospital about wayward patients, there were often no secretaries at Genesys available to answer the phones.

Ascension had cut those jobs.

16-Hour Shifts

Patients enter Genesys through a four-story atrium decorated with greenery and rock pools. Inside, the 400-bed hospital is reeling from years of downsizing.

In 2018, Ascension had laid off workers, including at least 500 in Michigan — even as the chain that year reported profits of $2.2 billion. Genesys, one of a handful of unionized Ascension hospitals, avoided those layoffs. Instead, administrators froze hiring.

That freeze eventually thawed. Even then, vacant positions were rarely advertised online.

Since the hiring freeze was imposed, the number of permanent nurses working at Genesys has fallen by roughly 30 percent, according to the Teamsters union that represents the nurses.

Ascension partially filled that gap by hiring temporary nurses, and Mr. Ragone said Genesys’s employees per occupied bed increased 12 percent between 2018 and 2021. (Like St. Joseph, Genesys reduced its patient capacity, which contributed to the rise in the staffing ratio, and Mr. Ragone would not provide data about the hospital’s nursing staff.)

Yet nurses said that to keep things running, Genesys demanded they work 16-hour shifts, threatening to fire some who refused because of exhaustion or child-care commitments. Hospitals commonly require nurses to work past their scheduled shifts as an emergency stopgap, such as during a blizzard. But at Genesys, nurses said, the tactic is used to make up for chronic understaffing.

Stephanie Bates, a Genesys nurse who works a 12-hour shift ending at 11:30 p.m., said that multiple times a week, she is ordered to work until 3:30 a.m. She said that she refuses so that she can care for her young children early in the morning. Other nurses echoed her experience.

On at least four occasions this year, managers have written in nurses’ employment files that refusing to work 16-hour shifts “is not in line with our value of dedication,” according to internal disciplinary records reviewed by The Times.

Nurses in nearly every unit at the hospital said in interviews that they were regularly required to care for more patients than allowed under their contract — restrictions that are supposed to ensure the safety of patients. “You just try to do damage control your whole shift,” said Stephanie Atchley, a Genesys nurse. “It just all snowballs into very poor care.”

Dr. Dale Hanson, a physician who treats patients at Genesys, said that most days, there are not enough nurses, resulting in prolonged hospital stays for his patients. Some get marooned in the emergency room because of nursing shortages in other parts of the hospital.

Dr. Hanson blamed Ascension’s aggressive cost-cutting, which he said has resulted in “miserable” conditions for patients and staff.

‘Someone Is Going to Die’

Jill Bruff, an I.C.U. nurse at Genesys, said she regularly finds patients lying in dried feces.Credit…Dieu-Nalio Chéry for The New York Times

Even as the pandemic has waned, nurses at St. Joseph and Genesys said, there remained so many unfilled positions that they felt like they were working in a perpetual crisis.

As of this month, 24 of the 52 night-shift positions in Genesys’s medical and surgical intensive-care units were listed as unfilled, and 17 of the open jobs had yet to be advertised, according to the hospital’s internal tally, which The Times reviewed.

Jill Bruff, a nurse who works in those I.C.U.s, said that about once a week, she arrives for her night shift to find patients who had been lying in their own feces for so long that the excrement had dried. On one recent occasion, Ms. Bruff said, the nurse working before her cried when she explained that she had not had time to clean up a soiled patient.

“That patient shouldn’t ever had to sit for that long, and that nurse shouldn’t have had to cry because she felt so awful,” Ms. Bruff said. Four other nurses said their patients have had similar experiences as a result of understaffing.

Mr. Ragone said that “the publication of an assertion from an unsubstantiated claim that our dedicated nursing staff would allow a patient in the I.C.U. to be left improperly unattended, without evidence, is irresponsible.”

Nurses at St. Joseph in Illinois also were at their breaking point.

“MAKE THIS BETTER ASCENSION. SHAME ON YOU!!!” one nurse wrote in a formal complaint in June. The nurse described a chaotic scene in the emergency room where there were not enough nurses or beds for seriously ill patients.

“Someone is going to die if this continues,” another nurse wrote in July, “and there is no indication that anyone is concerned.”

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