Layoffs at Ascension Health hospitals in Michigan have intensified this week and spread to more of the company's 14 hospitals in Michigan, according to employees, nurses and doctors.

Ascension officials have not commented on the layoffs or how many jobs it plans to cut. Crain's has learned from multiple sources that St. John Hospital and Medical Center in Detroit, Ascension's flagship hospital in Southeast Michigan, is planning a layoff of more than 250 employees as early as Friday.

Ascension Health owns five hospitals in Southeast Michigan under the St. John Providence banner. It is the nation's largest nonprofit health system, with 140 hospitals. The St. Louis-based system has reported a 78 percent decline in operating income so far this year and is said to be taking steps to shore up its profit margins.

Since late January, there have been layoffs of dozens of nurses, medical therapists and technicians, unit clerks and other support service employees. More are expected in the coming days or weeks, according to six sources familiar with aspects of the plans who requested anonymity.

In Michigan, Crain's has confirmed there have been layoffs at Providence-Providence Park hospitals in Southfield and Novi, St. John Macomb-Oakland Hospital in Plymouth and Warren, Borgess Medical Center in Kalamazoo and the St. John Detroit hospital.

A physician leader who requested anonymity was told by a manager at Providence Park Hospital that at least 1,000 employees at Ascension Michigan hospitals will be laid off or outsourced to contract management companies, one being Touchpoint Support Services.

Ascension Michigan spokesman Brian Taylor has told Crain's several times that the Catholic system would not be making any public announcements of personnel changes at its hospitals.

"We continually review staffing models to ensure efficiency of our resources, while providing the highest quality and most compassionate care as is consistent with our mission," Taylor said last week and repeated in a statement Thursday. "At this time, we have no information to share regarding personnel matters."

Two laid-off employees have told Crain's that they had been warned against speaking publicly about the layoffs and that their severance pay was contingent on not speaking with the media. One laid-off employee said he feared losing that pay, but he said he felt strongly that the public should know that the layoffs have hurt employee morale and will affect patient care.

The St. John physician leader said the manager told him the layoffs would be rolled out in stages to limit the public perception that it would affect quality and safety.

At Borgess, two nurses who are union leaders talked to Crain's Wednesday about the bulk of the layoffs they say management told them will occur March 4. The Borgess employees are planning an informational picket in front of the hospital from noon to 2 p.m. March 5 to express their concerns over patient safety.

Emily Fredericksen and Jamie Brown, two longtime employed nurses at Borgess, said they were told the nursing and other support staff cuts were necessary to increase productivity of workers. They estimated 60 to 70 nurses would be laid off based on their calculations of staffing ratio goals they were given by managers.

Many hospitals nationwide are experiencing declining profit margins because of lower reimbursements from government and commercial payers, rising uncompensated care and fewer people covered by health insurance based on federal decisions to limit financial support for the Affordable Care Act, or Obamacare.

At Ascension Health, which also is Borgess's parent, employees believe the drop in profit margins to about 0.7 percent during the first six months of 2018 from 3.3 percent the same period in 2017 has led to the expense reduction and downsizing plan.

Fredericksen said she was told by a nursing executive at Borgess that what is happening at Borgess and other Michigan and Indiana Ascension hospitals is a companywide plan to reduce costs and increase productivity.

"This was explained to us that the decisions came from the top in St. Louis. This is an Ascension idea," said Fredericksen, a pre-operative nurse at Borgess and vice chair of the hospital's nurses union. The Borgess Staff Nurse Council is part of the Michigan Nurses Association.

The St. John physician leader said doctors were told that there would also be "significant" layoffs in the administrative ranks, but that the number would be decided by Ascension's corporate office in St. Louis.

One laid-off St. John Detroit patient care technician told Crain's last week that she and her co-workers were called into a meeting by managers, who told them their duties would be picked up by intensive-care nurses. The source said the HR director and nursing director cited studies that showed nurses were more efficient. Twenty-eight staffers in the ICU were laid off, she said.

Patient care technician duties include moving and turning around patients, cleaning patients, filling up medicine boxes, taking blood pressure and temperatures. In addition, by removing unit clerks, nurses will be responsible for additional paperwork, the PCT employee said.

The PCT employee said workers were told they would receive severance pay and could reapply for open positions using St. John's online job application system.

But now other St. John employees have told Crain's that PCT workers across multiple departments will be laid off.

Here are some of the decisions St. John and Borgess have made so far and plans still in the works, according to multiple sources: