The divide at Rochester General

Newly unionized Rochester General Hospital nurses held a press conference last week, their first since kicking off contract negotiations last summer.

The event, carefully staged on a Portland Avenue sidewalk to stay just outside of the RGH property line, was meant to dramatize dire conditions the nurses say are hurting patient care and to spur what union members see as the glacial pace of negotiations.

Chief among ills the unionized nurses want addressed is chronic understaffing that leaves key hospital units with nursing staff vacancy rates that are often higher than 50 percent.

A union handout cites an 89 percent vacancy rate for an RGH cardiac care unit and a 56 percent vacancy rate for the hospital’s operating rooms.

Citing an overall 20 percent vacancy rate that includes its own employed and agency nurses, the hospital says it disagrees with the union’s per-unit vacancy-rate computations.

The nurses say deficits in RGH’s regularly employed nursing staff are largely made up by hiring travel nurses, agency temps who typically are paid triple or higher staff nurses’ hourly pay. The high cost of travel nurses, the union maintains, creates a loop that only makes it harder for RGH to attract and retain regular staff, while chronically low staffing makes for unsafe conditions on many hospital units.

“Unfortunately, (it’s) likely that the union will present individual stories and claim patient care is suffering due to RGH’s actions or inaction. This is truly regrettable since it undermines the public’s confidence in RGH and the amazing work that all of you do,” stated Jennifer Eslinger, Rochester Regional Health chief operating officer and interim RGH president, in an internal memo sent to RGH staff two hours before the union’s Jan. 26 press event.

Long-standing problems

The nurses’ union—the Rochester Union of Nurses and Allied Professionals, or RUNAP—is the first nurses union to successfully form in Rochester. A union drive at the more than 800-bed Strong Memorial, a teaching institution and the region’s largest hospital, failed more than a decade ago.

So far, RUNAP represents some 900 registered nurses at the 538-bed Rochester General, a tertiary care facility and the region’s second-largest hospital.

The newly minted union’s bylaws leave open the possibility of creating bargaining units to represent other RGH health care workers like nurse practitioners, physician assistants and nurse’s aides as well units representing workers at other RRH hospitals or hospitals not in its system, an ambition union officials say they hope to realize.

The union’s birth in July came as the global pandemic that had strained Rochester-area hospitals and virtually all U.S. health care providers to their limits marched toward its third year.

But COVID-19, the RUNAP nurses maintain, was only a tipping point that exposed and exacerbated long-existing shortcomings in RGH’s operations, most of them related to nursing-staff shortages. For them, the hospital was like an already leaky ship that collided with iceberg. In RUNAP nurses’ telling, already bad conditions are only getting worse.

“COVID threw a lot of things into an accelerated light,” says RGH nurse Nate Ontiveros.

Hospital officials acknowledge strains bearing down on nursing staff, but say they are working hard to overcome difficult conditions.

Ontiveros is an eight-year veteran as an RGH nurse and a member of RUNAP’s bargaining committee. He works in the hospital’s Medical Step-Down Unit, which treats patients discharged from RGH’s intensive care unit and those whose conditions are critical but not serious enough to warrant ICU treatment.

Ontiveros worked for several years as an RGH nurse’s aide before earning a nursing degree from St. John Fisher University. Before going into health care, he’d worked as a paralegal. He says disillusionment with the legal profession combined with an idealistic desire to contribute more motivated his career switch. The past few years have sorely tested his ideals.

Slow pace of negotiations

RUNAP members think the union’s first-contract negotiations with the hospital have moved at a snail’s pace, says Ontiveros.

Of 35 proposals submitted at the talks’ start, management negotiators have responded to only a handful and have so far not dealt with any that nurses see as most substantive, says bargaining committee member Colleen Shields, a nurse in RGH’s neonatal intensive care unit and a nearly two-decade veteran of the hospital.

Talks resumed Jan. 20 after a seven-week break for a fifth bargaining session.

“We were hoping they would come back with comprehensive responses to our contract proposals, but they came back with only seven responses. We were unable to reach any tentative agreements today,” states an update posted on RUNAP’s website.

RUNAP’s on-staff organizer, Patrick Coyle, personally believes any agreement could be six to seven months away, an opinion he bases on past similar negotiations between hospitals and nurse’s labor organizations, which, Coyle says, typically take a year to conclude. It is not, he adds, RUNAP’s position.

RGH’s Eslinger sees talks taking longer. Hospital first-contract negotiations typically take 465 days to conclude, “so while the union may be frustrated (that) they don’t already have a contract the negotiations are proceeding no more slowly than is typical,” she states in the Jan. 26 memo.

Challenging times

In the meantime, the unionized nurses maintain, their working conditions and patient safety are suffering.

RGH’s rates of hospital-acquired infections are far above averages, as high as 87 percent for central line infections and 14 percent for C-diff, a bacterial infection that can cause life-threatening bouts of diarrhea, according to figures posted on the union’s website.

RGH disputes the union’s infection numbers. To arrive at the rates it states, the hospital conjectures, RUNAP is likely “misinterpreting” data published by the Center for Medicare and Medicaid Services and other sources, which in order to control for differences among institutions is not stated as rates of infection.  

While hospital-acquired infections occurred at higher rates at the pandemic’s peak, they have since been declining, RGH says, adding that it takes pains to report all hospital-acquired infections to appropriate regulatory agencies.

Though COVID put new strains on Rochester-area hospitals and on health care institutions across the country, U.S. hospitals for years have been struggling with nursing staffs’ declining ranks. Health care experts had long warned that shortfalls in nursing staffs would reach critical levels.

“Creation of new jobs in combination with large numbers of retirements from an aging nurse workforce is expected to produce a substantial nurse shortage in the next decade. Estimates of the shortage vary from between 300,000 to more than a million by 2020–2025,” authors of 2009 study published then in Health Affairs predicted.

At RGH, the nurse staffing crisis long preceded COVID, Ontiveros says. The pandemic has made a bad situation much worse.

In response to the Rochester Beacon’s interview request, RGH submitted a prepared statement noting among other points that there is a long, ongoing national nursing shortage and detailing the hospital’s nurse-recruitment efforts.

According to the hospital’s statement, RGH last year hired “631 team members within nursing and critical patient-facing roles (including) 150 Registered Nurses, 44 Licensed Practical Nurses and 10 Nurse Leaders.”

In the first month of this year, the statement adds, 112 RNs and 19 LPNs have agreed to take jobs at RGH.

“We are dedicated to making sure Rochester General Hospital is and remains a great place to work, that values our nursing employees and has them staying with us for a long time to come,” RGH states. “We fully recognize that more work needs to be done and we are committed to the work to recruit and retain nurses and other healthcare employees in this very challenging recruiting environment.”

Shields does not believe the hires will have much lasting impact unless conditions at the hospital improve.

“We train nurses who then turn around and quit for travel nursing jobs or go to Strong Memorial where the pay and benefits are better,” Shields contends.

Nurse turnover at Strong stands at 17 percent, says Karen Keady, UR Medicine chief nursing executive. For Strong, which is not currently known to be facing an organizing drive, conditions are still less than ideal but moving the right direction, Keady believes. Nurse movement between Strong and RGH is less of a problem than desertion of experienced staff from both hospitals for travel nursing jobs, she says.

Staffing issues

As the Rochester Beacon reported last year, local hospitals including RGH have struggled to deal with declining ranks of nursing staff as pandemic fatigue culled nurses who quit or retired, while legions of overworked staff nurses left for nurse-staffing agencies where they could as much as triple their hourly wages as travel nurses.

“For some nurses, the draw of working as an agency nurse is compelling,” RGH concedes in its prepared statement.

“However,” the statement adds, “we are dedicated to making sure Rochester General Hospital is and remains a great place to work, that values our nursing employees and has them staying with us for a long time to come.”

The statement concludes: “We fully recognize that more work needs to be done.”

Despite the recruiting successes detailed in the hospital’s statement, RGH currently reports its overall nursing staff vacancy rate stands at 20 percent, “on par with the average 18.3 percent vacancy rate at the state’s other hospitals.”

For RUNAP, staffing remains “the crux of the issue,” Ontiveros says.

Shields is a 19-year veteran of RGH’s nursing staff. She currently works in the hospital’s neonatal intensive care unit. While a relatively low patient census has somewhat eased NICU pressures in recent weeks, two months ago the unit was habitually understaffed, leading to 60-hour weeks for staff nurses, she says.

While ideal nurse-to-patient ratios are in the neighborhood of five patients per nurse, units typically run ratios as high as one nurse to eight or 10 patients, Shields and Ontiveros say. Both , also say that nurses are too often pulled away from their assigned units to fill holes in other understaffed units. Travel nurses continue to fill yawning gaps in regular nurse staffing. Both practices make continuity of care hard to maintain.

RGH nurses are only scheduled to have eight patients in very specific circumstances and then are supported by a licensed practical nurse, the hospital counters. Efforts are made to keep times that units are understaffed to four hours or less. A single RN is only rarely responsible for a higher patient volume than usual. And in such situations, RGH says, it brings in RNs from similar departments to balance the assignments.

Both Shields and Ontiveros see wage and benefit increases the union seeks more as inducements to help stem staff desertions and attract new permanent nursing staff than as an end in themselves.

Wage and benefits

RGH says it is working hard under challenging conditions to make sure pay and benefits are as adequate as possible.

“RGH healthcare premiums remain flat for the past two years and this year RGH added an additional healthcare plan option for employees with lower premium rates,” the hospital’s statement notes.

Premium rates are only part of the health insurance story, Shields counters. High deductibles required by the hospital’s health plans induced her to quit the RGH offering and sign on to her husband’s policy. She also complains that in order to meet a new state staffing-level requirement, RGH took away an extra week of vacation time it had previously granted to long-term employees, a move she feels is grossly unfair.

The hospital points to systemwide pay raises its parent, RRH, has recently granted and tight finances as greatly constraining its ability to go much further.

In one negotiating session, says Ontiveros, RRH controller Howard Glastonbury put up a pie chart to show how RGH revenues were carved up and presumably to demonstrate financial barriers to meeting RUNAP’s wage and benefit demands.

“Why don’t they just give us a bigger piece of the pie?” wonders Ontiveros, citing millions paid to top administrators.

As a nonprofit, RGH is required to file annual financial statements with the Internal Revenue Service. In its most recently filed Form 990, RGH reported paying its four most highly compensated administrators a total of $3.6 million in 2020.

Three of the four, former RRH CEO Eric Bieber M.D. , CFO Thomas Crilly and chief administrative officer Hugh Thomas, have or had systemwide responsibilities. Bieber’s 2020 compensation totaled $1.4 million. Thomas’ totaled $617,129. Crilly made $523,904. Former RGH president Kevin Casey earned $1.1 million.

Shields wonders if some of the dollars RGH and its parent are spending to build new clinics and other facilities might better be redirected to investments to retain and recruit RGH nurses.

RGH states that it and RRH lost money in 2022, a first for the hospital and health system with expenses last year outpacing revenue by more than $100 million.

Despite that grim financial picture, the hospital says, RRH implemented a 4.5 percent wage increase for all employees in late 2022, bringing the average total wage increases given to nursing employees over the past year to 10 percent. Nurses’ pay averages $39.26 an hour, with a minimum hourly wage of $31 and a maximum of $58.23.

Whether the hospital will be able boost nurse pay and benefits enough to stabilize working conditions to RUNAP’s satisfaction remains to be seen.

Bigger forces at play

David Nash M.D. is a longtime advocate for U.S. health care reform. Author of the recently published “How Covid Crashed the System, a Guide to Fixing U.S. Health Care,” Nash is a 1981 graduate of UR’s School of Medicine and Dentistry. While not commenting specifically on the RGH-RUNAP negotiations, he sees larger forces at play in any such talks.

The founding dean emeritus of the Jefferson College of Population Health at Thomas Jefferson College in Philadelphia, where he has worked and taught for some three decades, Nash is no particular fan of health care worker unions. Asked whether the 10-hospital Jefferson Health system is unionized, he replied: “No, thank goodness.”

Still, Nash sees nurses like RUNAP’s members and the hospitals that employ them as equally skewered by the nation’s wildly dysfunctional method for reimbursing medical providers.

Nash says that payment method, known as fee for service, puts doctors, hospitals and other medical providers on a “hamster wheel” that requires them to cram as many procedures, consultations and scans as possible into each workday. While demanding volume, he says, fee for service only lets providers to at best secondarily focus on outcomes.

Under fee for service, U.S. commercial insurers largely run employer-sponsored plans that account for a major slice of Americans’ health coverage. As a rule, such plans pay medical providers a set amount for each office visit, operation, scan or procedure.

Nash advocates for replacing that piecework approach with a so-called capitated system that pays providers a set amount per month. Freed from the economic necessity of delivering high-volume care, he believes, providers would be better able to put quality and patient first.

Under fee for service, Nash says, the bottom line for hospitals is that patients compute to revenue while staff computes to an expense. Whatever a hospital’s idealistic goals might be, its economic incentives, especially when it is under financial strain, are to maximize revenue and minimize expenses, a situation not especially conducive to a meeting of the minds between hard-pressed administrators and restive nursing staffs.

Rochester’s dominant commercial health insurer, Excellus, which controls most of the local market, several years ago introduced so-called value-based contracts with area hospitals. Such contracts reward institutions for delivering quality care by paying extra amounts to hospitals that show positive health outcomes for patients and meet other quality metrics. However, fee-for-service reimbursement remains the basis for most of the insurance payments area hospitals and doctors rely on to pay the bills.

As long as fee for service remains the dominant method for reimbursing U.S. hospitals and medical providers, Nash predicts, “you’re going to see more nurses unions and probably doctors unions too.”

Will Astor is Rochester Beacon senior writer. The Beacon welcomes comments and letters from readers who adhere to our comment policy including use of their full, real name. Submissions to the Letters page should be sent to [email protected].