Ballad staffers cite issues with morale, leadership post-merger

This the final installment in a four-part series examining how competing truths over consolidation impact a health system and its community.

JOHNSON CITY, TENN.—Morale is low at Ballad Health’s hospitals since the merger became official in 2018, according to several current and former nurses and doctors. They say they’ve watched many colleagues leave, fed up with being overworked, with management that doesn’t listen and changes to pay and benefits.

“I just felt like the direction that everything was going was unsafe and that we were completely marginalized from the decision-making process,” said Dr. John Keeley Jr., a trauma surgeon at Ballad’s Holston Valley Medical Center in Kingsport, who resigned from his position after the merger. Ballad is downgrading that hospital’s trauma center.

System executives say that’s not true, that the health system is weathering the same nursing shortage as the rest of the country. They say nurse turnover here is no different than before the merger.

“To attribute that to the merger is intellectually dishonest,” said Alan Levine, Ballad’s CEO. “The nursing shortage began before the merger and it's continued and it's going to get worse. I think you'll hear that from anybody who's out in the field right now.”

Johnson City, Tenn.-based Ballad was formed through a controversial maneuver that allowed it to avoid a federal lawsuit, even though the Federal Trade Commission opposed the deal. The not-for-profit health system covers a largely poor and rural 21-county region in northeast Tennessee and southwest Virginia, where it’s the only hospital provider.

But current and former nurses, doctors—some of whom spoke off the record—and patients say the departures have led to logjams at some Ballad hospitals. Patients sounded off about long waits in emergency rooms at a February public hearing, and said it wasn’t due to a lack of beds, it was because there wasn’t enough providers to treat patients.

“The outflow of nursing talent has been tremendous,” said Dr. Ken Smith, a neurosurgeon with level 1 trauma experience in Kingsport who has performed surgeries at Holston Valley in Kingsport for the past 30 years. “Some days I go up and I don’t know anyone on the floor.”

It’s not possible to know whether there is truly a staffing problem since Ballad declined to share pre-merger registered nurse turnover rates.

The two systems that joined to form Ballad calculated turnover differently, so Ballad can’t do an apples-to-apples comparison of current turnover and pre-merger turnover, said Debbie Dover, Ballad’s chief human resources officer and senior vice president of talent engagement. For example, they may have had different takes on whether to count people moving from full- to part-time positions or those who retired, she said.

As of June 30, registered nurse turnover was 17.2% Ballad-wide, which is on par with the national average, according to data shared by Ballad. On July 1, 2018, that was 21.6%, according to Ballad. Levine, who was the CEO of one of the legacy systems, Mountain States Health Alliance, said that organization's turnover was 25% and growing before the merger.

Dover said at the beginning of Ballad’s fiscal 2019, which would have been in July 2018, she started asking consulting firms if nurse turnover typically increased after health system mergers, but wasn’t able to find data on the subject. In July 2019, she attended a conference where she asked other health systems if they saw increased nurse turnover post-merger. The answer was yes.

“I wanted to make sure we weren’t really experiencing something different from what others across are experiencing across the nation,” she said.

At Ballad’s biggest hospital, Johnson City Medical Center, nurse turnover increased between July 2018 and June 2019, said Ballad spokeswoman Teresa Hicks. She declined to share specific numbers. Turnover decreased at Holston Valley during that time, she said, citing no numbers.

Ballad released a report that showed the Johnson City facility saw a decline on eight of 17 quality measures as of February 2019 compared with a 2017 baseline. There were no specific ties to issues related to staffing, however. Holston Valley improved on all but three of those same measures.

And Levine contends The Joint Commission has conducted at least 10 surveys of Ballad in the past 18 months and none turned up staffing issues, including a visit to Holston Valley and a cancer center in Kingsport.

Providers cited a variety of reasons nurses are leaving, but most commonly that they feel overworked and are made to take on too many patients. Others say they’re upset with management or changes to compensation.

Some nurses are unhappy over what they characterize as Ballad’s “mandatory overtime” policy, which requires nurses considered full-time to work seven 12-hour shifts per pay period instead of the usual six in units with significant vacancy, including all medical-surgical, critical care and emergency departments.

Lisa Smithgall, the system’s chief nursing executive, said the policy, which she does not consider mandatory overtime “in the true sense of the word,” (which is when a nurse can't leave at the end of a shift because there aren't enough staff) is effective at Holston Valley and Bristol Regional Medical Center.

“That’s a national practice that nurses have to be available for additional patient care requirements for the hospital as patient volumes fluctuate,” she said. “We’ve done that same thing and just said instead of being on call we’re just going to go ahead and schedule you.”

One former Ballad nurse said working there felt like drunk driving—constant, mandatory overtime and being made to take on a patient load that felt unsafe.

“I was tired of putting my license at risk,” that nurse said. A current Ballad nurse said the fear of missing some aspect of patient care is constant.

The merger involved melding the different retirement and other human resources policies of the two legacy organizations, resulting in changes to some people’s pay and benefits. Each employee received a personalized letter detailing how their compensation would change when the two health systems merged, but Dover received feedback that some details were still unclear. She said Ballad encouraged staffers to talk to them if they were concerned about the changes.

“Pay stubs can be confusing,” Hicks said.

Some nurses told Modern Healthcare in off-the-record interviews they feel Ballad’s management is demeaning to nurses.

Ballad said it rolls the higher wage for working nights and weekends into nurses’ base pay, so they’re ultimately paid the same amount, despite the fact that their hourly wage doesn’t change when they work on a night or weekend. Still, some nurses believe they’re making less.

Some of Ballad’s experienced nurses said they feel undervalued by some of Ballad’s pay practices, including giving them annual lump-sum bonuses once they hit a certain pay grade instead of annual increases to their base pay.

A nurse who spoke out about that pay practice at a public hearing in February was fired in April. Sabrina Gray, formerly associate clinical leader in Holston Valley’s cardiovascular surgery department, said she had also written a letter to management about the issue and met with human resource executives on behalf of herself and at least six other employees to discuss it.

Gray, 57, said she said she felt the practice discriminated against longtime employees.

“I fought,” she said. “I said, ‘I will give you the money back. I want an hourly rate increase every year.’ They said, ‘We’ll see what we can do,’ but nothing ever came of it.”

Ballad declined to share its top-out range, but said the practice existed before the merger and is standard nationwide. The American Nurses Association had no data to determine whether that's true or not.

Cheryl Peterson, vice president of nursing programs for the ANA, said the bigger question is whether nurses are satisfied with it.

“If the nurses are satisfied with it, then whether or not it is uniformly used across the industry or not really doesn’t matter,” she said. “If it isn’t satisfactory to the nurses and they are not retaining nurses because they’re using this practice, then I think that’s the more important question that needs to be explored.”

Ballad touts the fact that it made a $10 million investment in wage increases for some of its front-line nurses and support staff in June. Starting salaries for new hires in those positions also went up. Levine said the starting wages for nurses in Ballad’s region used to be $18 an hour, compared with close to $25 in Asheville, North Carolina an hour and a half south. Now, he said Ballad’s nurses start north of $20 per hour.

Ballad reported a more than $30 million decline in its salary, wage and benefit spending in fiscal 2019, before the nursing wage increase took effect. Hicks said that was due to using less contract labor and volume declines. In February 2018, Ballad eliminated about 200 mostly administrative positions, 150 of which were occupied, Hicks said.

Staffing shortages appear to have affected at least one of Ballad’s nursing homes. A staff member at Laughlin Health Care Center, a Ballad nursing home in Greeneville, Tenn., told a CMS inspector “staffing is horrible right now” and that residents have to wait for care. One resident turned on a call light for help using the restroom and waited 43 minutes, according to an October 2018 inspection report. That facility has one out of five stars on CMS’ Nursing Home Compare website.

Hicks wrote in an email that facility staffs at or above required levels. She said the standards were met the day of that inspection, but an error in communication led to a delay for that resident. The facility has not been cited on staffing since.

Dr. Keeley said he resigned because he worried service changes were being made without input from staff who would be left behind to care for patients perhaps with fewer resources. Keeley felt left out of the decision to downgrade Holston Valley’s trauma center from a Level 1 to a Level 3. Level 3 trauma centers can rely on general surgeons rather than trauma surgeons to take trauma cases.

“We’re the experts of the community in trauma and trauma care,” he said, “and some hospital administrator without consultation or discussion with any of us to any degree which I can appreciate comes and makes these broad, sweeping decrees.” Levine contends Ballad’s physicians were consulted on the trauma downgrade, and even had a board committee that included physicians, that provided input.

Keeley said he has agreed to stick around until the end of September, but may ultimately stay longer.

Around the time of the merger, Keeley said nurses started leaving, saying they didn’t feel supported and were being asked to do more with less.

“We’ve certainly lost huge access to the experienced nurses that have been pillars of the system for years and years,” he said.

Several nurses who spoke to Modern Healthcare asked to remain anonymous out of fear they would be fired if they publicly criticized Ballad. With Ballad being the only hospital game in the 21-county region, they’d have to move far away to keep working in hospitals.

“They were told specifically not to talk about Ballad in any way, shape or form,” said Wayne Baxter, a registered nurse and paramedic, whose daughter, a nurse, recently quit her job at Ballad.

Dover said Ballad would “absolutely, positively not” fire someone for speaking out. In the same interview, Smithgall added that if an employee shared inaccurate information, Ballad would determine his or her motivation for doing so. If someone was “deliberately negligent or inappropriate” it would trigger corrective action, she said.

“If policies were completely ignored, then yes, we would terminate based on how that does not align with the policy,” Smithgall said.

Gray was told she was fired over statements she made in private phone call that had been secretly recorded by a coworker. She never got to hear the alleged recording because, she was told, “It’s property of Ballad.” She had been warned a month earlier for leaving an inappropriate voicemail on a coworker’s phone.

Gray said she’s a dedicated employee, and guesses she missed three days of work in her five years there. One absence came after a car wreck. She now lives temporarily in Arlington, Virginia, where she works as a traveling nurse. She’s considering legal action.

Other nurses blame the people protesting Ballad, both on social media and outside the Holston Valley hospital, for casting a negative pall over their work environment.

Ashliann Norton, a nurse in Holston Valley’s pediatrics department, said she’s trying to stay positive. But the criticism has created a “chaotic environment” and has divided her colleagues.

“I want to be part of making all of this work,” Norton said. “We can’t be just sitting around waiting and watching for our community to fail. We’ve got to come together and make everything a success.”

Norton said she’s never been warned against speaking out.

Stephanie Cook, a nurse who serves as director of patient care services at Ballad’s Franklin Woods Community Hospital in Johnson City, said the critics and social media posts hurt the reputations of people who work for Ballad and might discourage new people from applying.

“We still are here because we love our area,” said Cook, District 5 president of the Tennessee Nurses Association. “We’re the same people who have been here for years and years and years. It really is unfortunate that we are portrayed in such a negative light. I think all of us are starting to feel that.”

This story has been updated to correctly characterize Ballad nurse Sandra Gray's account of her termination.