St. Luke's Health System

National Labor Relations Board - Board Decisions

Nov 28, 2003

340 N.L.R.B. 1171 (N.L.R.B. 2003)

ST. LUKE’S HEALTH SYSTEM, INC. 1171
St. Luke’s Health System, Inc. and United Food and
Commercial Workers Local Union 222. Case
18–RC–16937
November 28, 2003
DECISION ON REVIEW AND ORDER
BY CHAIRMAN BATTISTA AND MEMBERS
SCHAUMBER
AND WALSH
On February 14, 2002, the Regional Director for Re-
gion 18 issued a Decision and Direction of Election find-
ing that a unit of professional employees, excluding phy-
sicians, at the Employer’s Sunnybrook facility in Sioux
City, Iowa, is appropriate.1 Thereafter, in accordance
with Section 102.67 of the National Labor Relations
Board’s Rules and Regulations, the Employer filed a
timely request for review arguing that the smallest ap-
propriate unit consists of all professional employees,
other than physicians, at the Employer’s network of clin-
ics in the Sioux City area.2 The Petitioner filed an oppo-
sition to the Employer’s request for review. By Order
dated March 13, 2002, the Board granted the Employer’s
request for review.
The National Labor Relations Board has delegated its
authority in this proceeding to a three-member panel.
Having carefully considered the entire record, includ-
ing the parties’ briefs on review, we find, contrary to the
Regional Director, that the petitioned-for single-facility
unit is inappropriate. As explained below, we find that
the Employer has rebutted the single-facility presump-
tion.
I. FACTS
The Employer operates a health care system in the
Sioux City area that includes a network of 21 clinics
(also referred to as “profit centers”) operating out of 16
locations.3 The clinics, which are not separately li-
censed, provide nonacute health care-related services in
family practice, rehabilitation, and specialty areas.4 The
Employer’s system also includes an acute care hospital, a

1 The Petitioner sought to represent a unit of only registered nurses
at the Sunnybrook facility but did not file a request for review of the
Regional Director’s inclusion of all other professionals (nurse practitio-
ners and physician assistants), except physicians, at the facility or of his
direction that the medical technologist vote under challenge.
2 The Employer’s clinics are located in an area that is commonly re-
ferred to as “Siouxland,” which is comprised of North Sioux City,
South Dakota; Sioux City, Iowa; and South Sioux City, Nebraska.
Siouxland is generally regarded as one community.
3 The Regional Director mistakenly stated in his decision that the
Employer operates 15 clinics.
4 Specialty clinics include a surgical clinic, internal medicine, ortho-
pedics and sports medicine. Physical therapy and occupational health
services are offered in the rehabilitation clinics.
college offering nursing and medical technology courses,
and a nursing home. The Employer concedes that these
latter facilities may be excluded from any unit encom-
passing the clinics.
The petitioned for unit at Sunnybrook family practice
clinic—one of 11 such clinics—employs nine RNs, one
medical technologist, one nurse practitioner, and one
physician assistant. The Employer’s proposed unit
would include approximately 121 employees in 11 pro-
fessions (84 RNs, 9 medical technologists, 7 nurse practi-
tioners, 6 physician assistants, 2 occupational therapists,
10 physical therapists, and 2 speech pathologists). All of
the clinics are located in Siouxland. Eleven of the 16
clinic locations, including Sunnybrook, are within 10
miles of each other in metropolitan Sioux City. The re-
maining clinics are located between 15 and 55 miles
from downtown Sioux City.
There is common management of the Employer’s
Siouxland clinics. Three directors oversee the clinics’
operations and are responsible for different functional
areas. Rita Collins is the director of the 11 family prac-
tice clinics; Wendy VanHatten is the director of the 6
specialty clinics; and Maxine Kilstrom is the director of
the 4 rehabilitation clinics. Among other duties, these
directors determine the appropriateness of new or vacant
positions as suggested by clinic managers via job requisi-
tions, assist with hiring, confer with clinic managers re-
garding final hiring decisions, authorize suspensions or
terminations recommended by clinic managers, approve
permanent transfers, and organize and conduct quarterly
employee meetings.
Collins and VanHatten report to a vice president, and
Kilstrom reports to the chief nursing director. The vice
president and chief nursing director in turn report to the
chief operating officer (COO), who is in charge of all
clinic operations.
Each clinic has an onsite clinic manager, who reports
to Collins, VanHatten, or Kilstrom, as appropriate. Some
clinics are multipurpose and include more than one de-
partment. For example, the Morningside clinic offers
both family practice and rehabilitation services. Multi-
purpose clinics are typically supervised by a separate
manager for each department, and some of these manag-
ers service more than one clinic. Single-purpose clinics,
like Sunnybrook, are each supervised by one clinic man-
ager.
The Employer’s clinics all operate under the auspices
of the human resources (HR) department, headed by Di-
rector Gary Johnson. Human resources administers all
employee benefit and compensation programs, as well as
the Employer’s grievance procedure, which may culmi-
nate in a hearing before a peer review board. Human
340 NLRB No. 139
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD 1172
resources also directs the clinic managers regarding dis-
ciplinary matters and employee hiring and recruitment.
When disciplinary issues arise, clinic managers may ver-
bally warn the employee, and also memorialize the warn-
ing. However, in cases involving suspensions or termi-
nations, clinic managers must coordinate with HR so that
there is consistency among the clinics. If HR determines
that the clinic manager has not followed the appropriate
disciplinary procedures or provided enough evidence,
HR may veto the request to terminate or suspend the em-
ployee.
Regarding hiring, HR compiles a weekly list of sys-
temwide openings that is distributed to each clinic, pro-
viding all employees with the opportunity to apply for
different positions or locations. Current employees fill
out a transfer request and submit it to HR. After the di-
rector approves the transfer, the clinic manager inter-
views the employee and coordinates with HR as to the
final hiring decision. For outside hires, HR advertises
the position, collects and screens all applications, con-
ducts initial interviews, and performs background and
reference checks. Human resources compiles a final list
of promising candidates, who then interview with the
clinic manager. Although the clinic manager decides
which candidate to hire, HR possesses the authority to
reverse a hiring decision or rescind a job offer. Finally,
HR—not the clinic manager—determines the salary to be
paid to the new hire. In sum, contrary to our dissenting
colleague, we find that HR exercises significant control
over the hiring process.
Regardless of which clinic they are assigned to, all of
the professional employees share the same skills depend-
ing on their particular job classification. All new em-
ployees attend the same 1-day orientation program, held
in a central location. Many of the Employer’s educa-
tional and training programs are provided to all employ-
ees, such as an annual benefit fair and general policy
training. Employees from any clinic may attend the
more specialized programs, such as those dealing with
professional licensure and continuing education. The
Employer also holds quarterly nurse meetings in which at
least one nurse from each facility is present. All clinic
employees are paid on the same wage scale, which the
Employer bases on local, regional, or national market
surveys. Employees also receive the same employee
handbook and fringe benefits. Most of the clinics are
open only during weekly daytime hours, but two have
evening hours and one is open on Saturdays. All em-
ployees keep track of their time by dialing into a com-
mon phone number and entering their specific identifica-
tion number each time they start and end a shift or take a
break.
Permanent transfers among the clinics occur with some
frequency through the clinic-wide job posting procedure
and the relatively close proximity of the clinics to one
another. In 2000, 13 employees transferred from one
location to another, including one RN, one occupational
health nurse, one nurse practitioner, one physical thera-
pist, and one occupational therapist. In 2001, the number
of transferred employees increased to 16, which included
3 RNs, 2 medical technologists, and 4 radiology techni-
cians.
Regarding temporary transfers, up to 20 percent of all
job classifications within the clinic work force “floats” to
other locations in any given year. For example, RNs
float from clinic to clinic when additional assistance is
needed and may substitute for vacationing RNs. Also,
nurse practitioners and physician assistants may be
pulled from their regularly assigned clinics to assist at
another clinic that is shortstaffed. The occupational
health nurses, who usually work in the school system, fill
in at various family practice clinics so that those nurses
may take vacations. The medical technologists float to
all of the clinics that have labs; thus, their workplace
varies on a weekly, and even daily, basis. The occupa-
tional therapists, though headquartered at one clinic, of-
ten travel to other locations in order to serve patients
across the network. Physical therapists temporarily
transfer to other clinics upon patient demand. Sunny-
brook is the designated “home base” for floaters. Al-
though not every floater is physically present at the facil-
ity, management has designated Sunnybrook as the cen-
tralized floater location to ensure that they all consis-
tently receive company bulletins, directives, and the like.
II. ANALYSIS
Although a single-facility unit in the health care indus-
try is presumptively appropriate,5 that presumption can
be rebutted. To determine whether the single-facility
presumption has been rebutted, the Board examines such
factors as geographic proximity, employee interchange
and transfer, functional integration, administrative cen-
tralization, common supervision, and bargaining history.6
West Jersey Health System, 293 NLRB 749, 751 (1989).
Contrary to the Regional Director, we find that, analyz-
ing these factors, the Employer has rebutted the single-
facility presumption.
The Employer has demonstrated that the clinics oper-
ate as a single network and are functionally integrated
both as to the services provided and as to the employees
who provide them. Thus, patients are able to transition
out of acute care and receive a full range of health-

5 Manor Healthcare Corp., 285 NLRB 224 (1987).
6 We note that there is no bargaining history concerning these clinics.
ST. LUKE’S HEALTH SYSTEM, INC. 1173
related services at the various clinics. Similarly, as to
employees, virtually all of the clinics’ administrative
operations are centralized in that they utilize: uniform job
applications, position descriptions, and applicant screen-
ing; the same operational systems, such as patient infor-
mation, computer, purchasing, billing, receivables, pay-
roll, and time and attendance; and identical marketing
initiatives and materials. All clinic employees are sub-
ject to identical work hours and wage scales, policies and
procedures, and fringe benefits. The job skills and duties
of the various classifications at all of the clinics are iden-
tical. Finally, the clinics are small and employ on aver-
age only six professional employees per facility, and
workers from all of the clinics jointly attend various
meetings as well as educational and orientation pro-
grams.
The frequency of temporary and permanent transfers
throughout the clinics also establishes the high level of
functional integration among all of the clinics. Because
job openings are posted at all clinic locations, permanent
transfers of employees occur with ease. For example, in
the past 2 years, 29 employees (unit and nonunit) have
permanently transferred throughout the system.7
Our dissenting colleague contends that the record evi-
dence regarding permanent transfers that are specific to
Sunnybrook is insufficient to rebut the single-facility
presumption because permanent transfers are generally a
less important indication of interchange than temporary
transfers. The Board, however, has long held that no one
factor is determinative in analyzing whether the single-
facility presumption has been overcome. See West Jer-
sey Health System, supra at 751. Here, the network ex-
perienced increased permanent transfers during a 2-year
period—13 in 2000 and 16 in 2001. We recognize that
only four of these transfers involved Sunnybrook, and
two of the four did not involve transfers into unit posi-
tions. However, the issue concerning these transfers is
not to be viewed in isolation. It must be viewed in the
context of other transfers. These other transfers include
the systemwide floating discussed above. Sunnybrook is
the home base for all of the floaters within the Em-
ployer’s system.
In addition, approximately 15 to 20 percent of employ-
ees within all network job classifications were temporar-
ily assigned to other facilities, thus demonstrating the
regularity of temporary transfers. For example, RNs
float to other clinics to offer additional assistance or sub-
stitute for vacationing RNs; nurse practitioners and phy-
sician assistants temporarily aid shortstaffed clinics;

7 In 2000, 13 employees permanently transferred, including 4 unit
employees. In 2001, there were 16 permanent transfers, 6 of whom
were unit employees.
school-based occupational health nurses fill in at family
practice clinics in the summer months; medical tech-
nologists travel to all of the clinics with labs and there-
fore have no “home” base; and occupational and physical
therapists move around to various clinics based on pa-
tient demand.
In finding the single-facility unit appropriate, our dis-
senting colleague relies heavily on the absence of tempo-
rary interchange directly involving Sunnybrook. We find
this reliance unwarranted. First, the record is replete
with examples of temporary transfers occurring among
other Siouxland clinics and clinics involving all job clas-
sifications within the network. Second, due to ever-
changing medical and staffing needs, floating has be-
come commonplace among the various clinics. Again,
although these temporary transfers may involve other
clinics, Sunnybrook is the home base for the entire float-
ing system.
Further, the Employer accords little autonomy to the
individual onsite clinic managers. Concededly, clinic
managers exercise administrative authority on such pro
forma matters as developing inclement weather direc-
tives and smoking policies. They schedule employees,
make “time off” determinations, and perform annual
evaluations, which may be used as the basis for merit
increases. However, the merit increases themselves are
not decided by clinic managers but by HR. The three
offsite directors bear ultimate supervisory responsibility
for the clinics, and HR directs the labor relations func-
tions for all clinic employees, such as screening and per-
forming the initial interviews of all outside applicants, as
well as determining new hires’ salaries; independently
investigating and authorizing terminations and suspen-
sions; administering the Employer’s grievance proce-
dure; and issuing personnel policies and procedures.
In finding that the Sunnybrook clinic manager has sub-
stantial autonomy, our dissenting colleague relies on the
fact that the clinic manager decides whether to hire an
applicant and can initiate discipline. However, it is HR
that decides whether an applicant is suitable for consid-
eration by an individual clinic, and which can reverse a
clinic manager’s hiring decision or rescind a job offer if
HR determines that the applicant was unsuitable. Fur-
ther, although HR Director Johnson testified that he
would defer to a clinic manager’s recommendation for
suspension or termination, he also testified that he has
“veto power” on a clinic manager’s recommendation to
suspend or terminate an employee if it is not properly
documented and, if it is necessary to further pursue the
matter, it is ultimately resolved at the vice president
level. In these circumstances, we find, contrary to our
dissenting colleague, that the Employer has a heavily
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD 1174
centralized hiring and disciplinary system which under-
mines the appropriateness of a separate Sunnybrook unit.
Finally, the Employer’s clinics are all located in the
Sioux City area. Eleven of the clinics are located in the
Sioux City metropolitan area and are less than a 10-
minute drive from each other. The remaining clinics are
located between 15 and 55 miles from downtown Sioux
City. See West Jersey, supra (finding single-facility units
inappropriate where the distances between the four facili-
ties ranged from 2-1/2 to 20 miles). Indeed, the prox-
imity of the clinics has facilitated permanent and tempo-
rary transfers and joint meetings and educational and
training programs.
In sum, when all of the relevant evidence is examined,
we find that it establishes that a single-facility unit is
inappropriate here. Indeed, we find that the interests of
the petitioned-for employees have been effectively
merged into a more comprehensive unit, such that the
petitioned-for clinic is not a separate appropriate unit.
We conclude, therefore, that the Employer has rebutted
the presumptive appropriateness of the petitioned-for
single-facility unit.
ORDER
The Regional Director’s Decision and Direction of
Election is reversed. This proceeding is remanded to the
Regional Director for further appropriate action consis-
tent with the decision.

MEMBER WALSH, dissenting.
Contrary to my colleagues, I agree with the Regional
Director that a single-facility unit of professional em-
ployees at the Employer’s Sunnybrook clinic is appropri-
ate. As my colleagues acknowledge, a single-facility
unit in the health care industry is presumptively appro-
priate. Manor Healthcare, 285 NLRB 224 (1987). A
party may rebut that presumption by proving that the
single facility is so effectively merged into a more com-
prehensive unit, or so functionally integrated, that it has
lost its separate identity. D&L Transportation, 324
NLRB 160 (1997). To determine whether the presump-
tion has been rebutted, the Board examines such factors
as geographic proximity, employee interchange and
transfer, functional integration, administrative centraliza-
tion, common supervision, and bargaining history. West
Jersey Health System, 293 NLRB 749, 751 (1989). Em-
ployee interchange and common supervision are particu-
larly important factors. Heritage Park Health Care Cen-
ter, 324 NLRB 447, 452 (1997), enfd. 159 F.3d 1346 (2d
Cir. 1998). In the present case, because the record shows
separate supervision and an absence of employee inter-
change at Sunnybrook, I would find that the Employer
has failed to rebut the single-facility presumption.
I. SEPARATE SUPERVISION
The Sunnybrook clinic, like each of the Employer’s
other clinics, is supervised by its own onsite clinic man-
ager. Contrary to my colleagues, I would find that the
clinic manager has substantial autonomy in supervising
the clinic’s employees and managing the clinic’s day-to-
day labor relations.
First, the clinic manager is largely responsible for hir-
ing. Although my colleagues note that the Employer’s
human resources (HR) department screens applications
and conducts an initial interview, it is the clinic manager
who conducts the final interview and makes the decision
on whether to hire an applicant. Second, the clinic man-
ager schedules employees for work, grants time off, and
issues annual performance evaluations. Third, although
there is a companywide grievance procedure, the Em-
ployer encourages the clinic manager to resolve griev-
ances on his or her own, and the HR director testified
that the majority of grievances are resolved without HR
getting involved. Fourth, the clinic manager initiates
discipline. He or she has authority to issue verbal or
written warnings without further review. As my col-
leagues emphasize, a clinic manager’s recommendation
for suspension or termination will be reviewed by HR.
However, the HR director testified that he will defer to
the clinic manager’s recommendation if there is evidence
of prior warnings and the recommendation is adequately
documented. For all of these reasons, I would agree with
the Regional Director that the Sunnybrook clinic man-
ager’s substantial autonomy strongly favors a single-
facility unit.
II. LACK OF EMPLOYEE INTERCHANGE
Although my colleagues find that both permanent and
temporary interchange occurred within the Employer’s
system, the record shows almost a complete absence of
interchange affecting Sunnybrook.
My colleagues note that there were 13 permanent
transfers throughout the Employer’s system in 2000, and
16 in 2001. Those statistics, however, include transfers
of clerical employees and managers, who are not in-
cluded in the proposed unit. Furthermore, of those 29
permanent transfers, only 4 involved Sunnybrook. Of
those four, only two involved employees who arguably
would be included in the proposed unit.
Even if those two transfers were deemed significant in
number, the Board has stated that permanent transfers are
generally a less important indication of interchange than
temporary transfers. See Deaconess Medical Center,
314 NLRB 677 fn. 1 (1994). There is no record evidence
of temporary transfers affecting the Sunnybrook clinic.
My colleagues find that about 25 employees have
ST. LUKE’S HEALTH SYSTEM, INC. 1175
“floated” to other locations in the past 2 years. However,
they observe that this floating particularly occurs among
the Employer’s rehabilitation clinics. Sunnybrook is not
a rehabilitation clinic. My colleagues also state that the
Employer’s therapists and occupational health nurses
move around to different clinics. Interchange among
these employees, however, does not affect Sunnybrook,
because these positions do not exist at Sunnybrook. In
addition, my colleagues find that nurse practitioners and
physician assistants “float” to other clinics to offer tem-
porary assistance. Again, there is no evidence of such
interchange to or from the Sunnybrook facility. In sum,
while there is general evidence that temporary inter-
change occurs among certain of the Employer’s facilities,
there is no evidence specific to Sunnybrook. To the ex-
tent the Employer relies on temporary interchange to
rebut the single-facility presumption, the Employer has
the burden to produce relevant, affirmative evidence on
that issue. See J&L Plate, Inc., 310 NLRB 429 (1993).
By failing to produce any evidence of temporary inter-
change at Sunnybrook, it has failed to carry that burden.
Without citing any precedent, my colleagues assert
that the permanent and temporary interchange at the
other facilities is relevant because Sunnybrook has been
designated as the “home base for all of the floaters within
the Employer’s system.” The Board has held, however,
that interchange is relevant to whether or not the em-
ployees in the particular unit at issue have a separate
community of interest from employees at other facilities,
and thus the only relevant evidence is evidence of inter-
change involving unit employees in the petitioned-for
facility. See D&L Transportation, Inc., 324 NLRB 160,
161 (1997) (“That locations other than Shelton may have
a higher or significant level of interchange with each
other to accommodate the Employer’s daily operations
does not negate the separate community of interest
shared by the Shelton drivers, who rarely interchange for
this purpose. Moreover, there have been only two per-
manent transfers of drivers from Shelton to other loca-
tions.”).
III. OTHER FACTORS
My colleagues observe that the Employer’s administra-
tive operations are centralized, and that employees are
paid on the same scale and share the same benefits.
However, I would find these factors insufficient to de-
stroy the separate identity of the Sunnybrook clinic, in
light of the substantial autonomy and lack of interchange.
See New Britain Transportation Co., 330 NLRB 397
(1999) (“Centralized control over personnel and labor
relations alone . . . is not sufficient to rebut the single-
location presumption where the evidence demonstrates
significant local autonomy over labor relations.”).
In my view, the Employer has failed to prove that the
Sunnybrook facility has been so effectively merged into
a more comprehensive unit that it has lost its separate
identity. Accordingly, I would affirm the Regional Di-
rector’s decision that a single-facility unit of professional
employees at Sunnybrook is appropriate.