Wisconsin nurses pushed to the limit as hospitals cut costs

MADISON, Wis. (AP) — Dr. Robert Golden, chairman of the University of Wisconsin Hospitals and Clinics Authority Board, sat in front of a sea of fed-up nurses as he tried to wrap up an agenda item at a board meeting in Madison.

“We have gone beyond the allotted time,” he said, prompting shouts from the crowd.

“If a nurse can stand a 16-hour shift without a break, can’t you do a special meeting?” someone yelled, triggering applause across the auditorium at the UW School of Medicine and Public Health.

The Feb. 27 board meeting was the third in a row in which UW Health nurses asked the board to recognize their new union — thus far to no avail amid a dispute over how to interpret a 2011 Wisconsin law that severely weakened collective bargaining rights.

The nurses’ motivation: cost-cutting that has left them “concerned about our licenses” and “concerned about patients,” said nurse Shari Signer, a veteran of 17 years at UW Hospital.

The tensions offer a glimpse into a nationwide pattern of labor unrest. Thousands of U.S. nurses and other hospital workers walked off the job in the past year in at least five states — Arizona, California, Florida, Illinois and Washington. Elsewhere, including at SSM Health St. Mary’s Hospital in Madison, nurses are more quietly fretting that cost-cutting is pushing staff to the limit.

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The nonprofit news outlet Wisconsin Watch provided this article to The Associated Press through a collaboration with Institute for Nonprofit News.

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Hospital executives increasingly rely on manufacturing models — born out of companies including Toyota and Boeing — to bolster productivity. Outside consulting firms are introducing algorithms aimed at eliminating “waste,” including nurses with down time.

Executives want to slow rising labor costs, which they consider the biggest financial threat to hospitals. But critics contend that viewing staff and patients as data points leaves out nurses’ voices as frontline caregivers.

“We are in the midst of a grand social experiment where we’re literally willing to gamble our lives,” said Michelle Mahon, assistant director of nursing practice at National Nurses United, the largest U.S. nurses union.

At St. Mary’s, a new Intensive Care Unit sits unused for lack of staff, three nurses said. They were among more than a dozen current and former St. Mary’s employees interviewed for this story. All described their hospital units as understaffed. Most asked not to be named, fearing reprisals from managers.

Elizabeth O’Brien, a former St. Mary’s X-ray technician who now works as a traveling technician, said she saw St. Mary’s plummet from the best hospital in Madison when she started in 2002 to a hospital where patients were sometimes left to lie in their feces and urine. She said St. Mary’s fired her in December for “insubordination,” after handing K-Y Jelly to hospital administrators in protest of being “screwed” over cuts.

Another technician said she could not take a 15-minute break for a month, fearing leaving short-staffed coworker’s in a lurch.

Most of the employees say they noticed major changes beginning several years ago after the hospital worked with North Carolina-based consultant Premier Inc. Nurses say a Premier tool sets daily staffing levels for each hospital unit. Those levels fluctuate based upon how many patients the hospital serves and the severity of their conditions, they said.

“We feel we are always working understaffed and yet the numbers don’t say we are,” one nurse said.

A labor and delivery nurse said the hospital previously assigned extra nurses to her unit, offering flexibility in case of a sudden influx of patients. Much like the emergency department, most of these patients do not make appointments — they walk through the door. But the hospital has since cut the extra positions, considering them “unproductive,” the nurse said.

Premier says thousands of hospitals use its services to pinpoint cost savings and improve the quality and safety of health care. The company touts one of the largest datasets in U.S. health care.

SSM Health, a Catholic-run health system of 23 Midwest hospitals, signed a $7 million contract with Premier in 2005 to help cut labor costs and analyze productivity at more than a dozen of its hospitals.

Premier and St. Mary’s declined to respond to questions about the tool, staffing and the specific concerns expressed by staff.

“The details around specific internal operations and HR-related policies and practices are considered proprietary,” St. Mary’s spokeswoman Kim Sveum wrote in an email.

She said the hospital’s staffing procedures meet patient needs “across all our ministries — at all times.”

Sveum also pointed to the hospital’s American Nurses Credentialing Center “Magnet Designation,” which the credentialing group calls “steadfast proof of a hard-earned commitment to excellence in health care, with contented nurses at its heart.”

Wisconsin Hospital Association data show no clear increase in major falls or pressure ulcers at St. Mary’s since 2014.

But short-term data are not likely to show clear trend lines “at one hospital over a short period of time,” said Jack Needleman, professor in the Department of Health Policy and Management at the University of California Los Angeles School of Public Health.

Research shows that as nurses spend less time with patients, health outcomes worsen, leading to longer hospital stays and more “adverse events” like falls and pressure ulcers, Needleman said.

St. Mary’s nurses say new hires are increasingly arriving fresh out of school, finding themselves immediately tossed into the fray while veteran nurses have little time to offer guidance.

In the Medical Surgical Unit, one nurse said she saw this firsthand while taking over for an inexperienced nurse at the end of a night shift a year ago. Two of that nurse’s six patients appeared confused, one with garbled speech. They both had been coherent the day before, the nurse recalled.

“Both of those patients had a stroke overnight, and no one caught it,” the nurse said.

At UW Health, CEO Dr. Alan Kaplan shared his cost concerns in a 2017 message to system employees.

“We cannot stand by and watch our financial security decline,” the message read.

With help from Prism Healthcare Partners, a Chicago-based consulting group, UW Health aimed to save $80 million over 18 months.

UW Health would reduce paid working hours of its staff “through managing overtime, reducing onboarding costs, eliminating management positions and not filling open positions,” said Tom Russell, a UW Health spokesman. “But we did not eliminate any currently employed nurses.”

By December 2018, the system employed 284 fewer nurses than it did a year earlier. The quality of some medical supplies declined, nurses say, such as plastic urine collection bottles that now feature sharp edges that cut male patients.

But as nurses do more with less, they question whether hospital executives are showing the same restraint. Kaplan’s compensation increased to $1.5 million in 2018 from $900,000 the previous year. And UW Health in 2018 announced plans to build a $255 million clinic in Madison.

Kaplan, who was not available to be interviewed for this story, cited several challenges in a 2017 Wisconsin State Journal article, including taking on more Medicare and Medicaid patients and a “skyrocketing acceleration of costs in pharmaceuticals and medical supplies.”

Russell says UW Health exceeded its $80 million savings target, reaching $105 million in savings since 2017.

UW Health and Prism have since touted the health system’s cost savings to other health care executives, including in an August 2018 webinar.

A plunge in staffing costs was “led and really role modeled by our nursing departments,” Wayne Frangesch, then-UW Health’s chief human resources officer, said during the webinar. UW Health developed a productivity tool — similar in spirit to what St. Mary’s uses — to track the hours spent on each patient, comparing those figures to targets.

Nurses say they felt more strain.

Nurse Mariah Clark said her emergency department sometimes gets a couple of more nurses than the UW model prescribes. But those nurses are quickly sent home, increasing the stress on those who remain.

Russell said non-physician staffing at UW Health has returned to pre-2017 levels. Still, the volume of inpatient discharges at University Hospital has increased year over year since at least 2014, according to American Hospital Directory data. Data were not available for American Family Children’s Hospital.

Mahon of National Nurses United describes a shift from a “caregiving model” of health care to a “manufacturing model.”

One such popular manufacturing model is called “lean,” modeled on how Toyota produces cars.

UW Health in 2018 contracted with Virginia Mason Institute, known as a leader in applying lean principles to health care. The Cap Times, Wisconsin Public Radio and Wisconsin Watch obtained that contract through a public records request, but UW officials redacted key sections, including how much the system paid Virginia Mason, and specific services provided. SSM Health, which is not subject to state open records laws, has also embraced lean.

In an interview, Lean Global Network Chairman John Shook said lean emphasizes creating value while minimizing waste, “providing the customer with what they really need — nothing more, but nothing less.”

Lean is credited with helping some hospitals reduce ER wait times, reorganize surgical supply closets and encourage new mothers to show up for postpartum checkups.

Dr. John Toussaint, founder of Appleton, Wisconsin-based Catalysis, which teaches lean to hospitals, said many hospitals have misapplied the model. Some hospitals will use it to free up nurses’ time — and then cut them for being unproductive.

“If the staff are not engaged, and they’re mad at it, you’re not doing (lean) right. You’re doing something else,” Toussaint said.

Shook also acknowledges that hospitals do not always apply lean correctly, burdening nurses.

As UW Health nurses push executives to recognize their union, St. Mary’s staff say their shortage is only worsening. Two nurses point to a recent weekend in the labor and delivery unit to illustrate the rising stress.

A woman in active labor was calling for pain medication, only to be left alone for an hour as her nurse assisted with an emergency elsewhere.

“You go home so worn it's a chore to eat,” said one of the nurses. “We try our damndest to give them the care they deserve and keep them safe. A lot of us are burned out — you can't pour from an empty cup.”