Impact of hospital mergers: a systematic review focusing on healthcare quality measures.

BACKGROUND: Despite mergers have increasingly affected hospitals in the recent decades, literature on the impact of hospitals mergers on healthcare quality measures (HQM) is still lacking. Our research aimed to systematically review evidence regarding the impact of hospital mergers on HQM focusing especially on process indicators and clinical outcomes. METHODS: The search was carried out until January 2020 using the Population, Intervention, Comparison and Outcome model, querying electronic databases (MEDLINE, Scopus, Web Of Science) and refining the search with hand search. Studies that assessed HQM of hospitals that have undergone a merger were included. HQMs were analyzed through a narrative synthesis and a strength of the evidence analysis based on the quality of the studies and the consistency of the findings. RESULTS: The 16 articles, included in the narrative synthesis, reported inconsistent findings and few statistically significant results. All indicators analyzed showed an insufficient strength of evidence to achieve conclusive results. However, a tendency in the decrease of the number of beds, hospital staff and inpatient admissions and an increase in both mortality and readmission rate for acute myocardial infarction and stroke emerged in our analysis. CONCLUSIONS: In our study, there is no strong evidence of improvement or worsening of HQM in hospital mergers. Since a limited amount of studies currently exists, additional studies are needed. In the meanwhile, hospital managers involved in mergers should adopt a clear evaluation framework with indicators that help to periodically and systematically assess HQM ascertaining that mergers ensure and primarily do not reduce the quality of care.

The bigger, the better? A systematic review on the impact of mergers on primary care organizations.

BACKGROUND: Primary care services are the first point of contact in a healthcare system; in the last years, many mergers and reconfigurations have taken place in this setting. The aim of this study is to summarize the literature evidence on the relationship between the increase in the size of these organizations and their performance. METHODS: A systematic review of the literature was carried out querying EMBASE, MEDLINE and Web of Science databases, from their inception to January 2020. Articles which quantitatively assessed outcomes and process indicators of merger/structural reorganization of primary care organizations and qualitative articles that assessed staff perception and satisfaction were included in the review. RESULTS: A total of 3626 articles was identified and another study was retrieved through snowball search; 11 studies were included in the systematic review. Studies about lipid profile evaluation and emergency admissions for chronic conditions showed moderate evidence in supporting the merging of primary care organizations; conversely, clinical outcome studies did not reach a sufficient level of evidence to support merging actions. A moderate evidence of a negative effect on patient's perspective was found. CONCLUSION: Actually, there is no strong evidence in favour or against merging of primary care organizations without equivocation. This review supports the possibility to identify indicators for evaluating a merging process of primary care organizations and for adopting eventual remedies during this process. Further efforts should be made to identify additional indicators to assess merge actions among primary care organizations.

[Impact of merging healthcare organizations: a review of the literature]. / L'impatto degli accorpamenti di organizzazioni sanitarie: una revisione di letteratura.

Over the last two decades, the healthcare sector of different Countries has been involved in a wave of mergers. This wave first started in the US and in the UK and, later, has involved Italy. Despite these activities are still pursued, little attention is paid to the assessment of their impact. The aim of this study is to summarize, through a review of the literature, evidence on the impact of these mergers. The main results are divided into four areas: the impact of mergers on clinical outcome, processes and use of resources; the association between population size and performance of primary care organizations; the analysis of the main drivers; and eventually, staff perception and satisfaction. Evidence is conflicting and small number of indicators of clinical outcome, processes and use of resources show a significant improvement. The performance of the Primary care Organizations does not seem significantly related to the size of the population served but to numerous factors, among others the function of the organization itself. Drivers that lead the pursuing of merging can be distinguished in stated and unstated drivers the first ones originating from public consultation document, the second ones from staff interview. Concerns about mergers derive from responses of personnel interview, in particular about the cultural differences and the distance perceived from top managers. Evidence shows that these processes do not necessarily lead to the expected benefits. It is important, therefore, to periodically and systematically assess the impact of mergers in a continuous quality improvement cycle that makes professionist, recipients and policy maker accountable. These latter, in particular are responsible for protecting the health of the community.

[A proposed organizational model for health districts of the Lazio Region (Italy)]. / Proposta di un modello organizzativo per i Distretti della Regione Lazio.

In the Lazio Region (Italy), health districts were established with Regional Law n. 18 of 1994. In the absence of specific regional recommendations, this was done by taking into account local situations and the needs of individual local health authorities, resulting in a network of markedly heterogeneous health districts. This serious situation has never been dealt with in a concrete manner and no measures have been undertaken over the years to correct it. The Regional Association of healthcare directors, managers and workers, established in 2001, has performed a number of studies to compare corporate acts and healthcare services provided by individual health units; these have confirmed the existence of varied organizational structures. The proposal of a single organizational model for all health districts is particularly important today, following the approval of a commissarial decree (N.373 of 30.7.2015) that states that resources should be used efficiently, health care services should be offered in a homogeneous manner and in compliance with the basic levels of care, and that the number of healthcare units in Rome must be diminished through a process of merging and revision of territorial areas. This reorganization will necessarily face critical issues because of the presence of very different organizational models in the merged healthcare units, making it necessary to develop and implement new homogeneous models in the entire region.

[Survey to assess educational needs of personnel working at Departments of Prevention, Health Districts and Hospital Directions in Italy: questionnaire validation and preliminary results]. / Indagine conoscitiva sulla rilevazione dei bisogni formativi del personale in servizio presso Dipartimenti di prevenzione, Distretti sanitari e Direzioni degli Ospedali: validazione del questionario e risultati preliminari.

AIM: The aim was of this pilot study was to validate a questionnaire to collect information on the number of health professionals, doctors and veterinarians working in the Departments of Prevention, Health Districts and Hospital Directions, their sociodemographic characteristics and cultural-background, define their educational needs, and subsequently extending the study to the maximum number of professionals in the classified services under study. METHODS: The survey was conducted through the use of a questionnaire, designed and prepared by the working group and subsequently reported on-line. Internal consistency of the questionnaire was measured by Cronbach's alpha. RESULTS: Overall, 128 health professionals were enrolled in the study. Their mean age was 57.5 years; 83.6% have a medical degree and 6.3% a degree in veterinary medicine. Most participants (64.8%) are employed by a Health District, 21.1% work in a Department of Prevention and 2.3% are part of a hospital clinical management staff. 32.3% are specialists in only one area, and, in particular, 22% of the sample is a Public Health specialist, 4% respectively are specialists in Occupational Medicine and Forensic Medicine. The alpha values for each section were, for Section A, 0.914; Section B, 0.963; Section C, 0.802; and Section D, 0.945. CONCLUSION: The questionnaire was shown to have good internal reliability. Identifying the educational needs of public health professionals, and the innovative and emerging issues that impact public health is essential to allow for National Health Service staff to be able to respond to the rapid cultural changes that characterize the current global health context.

Job Satisfaction Among Employees After a Merger: A Cross-Sectional Survey in the Local Health Unit of Sardinia Region, Italy.

Job satisfaction plays an important role in healthcare organization and management; it is critical for maintaining and improving staff efficiency and consequently the quality of care provided. Organizational restructuring processes, including mergers, are likely to affect job satisfaction levels, but evidence of the impact they have is surprisingly scarce. The aim of the study was to describe a methodology used to measure job satisfaction of the employees at a Local Health Unit (LHU) in Italy immediately after a merger and to assess the determinants associated with any reduction in worker satisfaction. The study was conducted among employees of the LHU of the Sardinia Region in July 2018, after a merger of eight subregional LHUs had taken place. The entire staff was enrolled, of which a total of 1,737 employees were surveyed. We used a questionnaire exploring socio-demographic and working characteristics of the employees, the various areas related to job satisfaction and interviewee opinions on the merger process. Multivariable stepwise backward logistic regression models were built to identify factors independently associated with lower job satisfaction. The results of a multivariable analysis showed that lower job satisfaction was more likely in employees with an administrative role (aOR: 2.34, 95% CI: 1.37-4.00) or a career demotion (aOR: 1.84, 95%CI: 1.11-3.03). High levels of mental stress were strongly associated with lower job satisfaction (aOR: 5.64, 95%CI: 4.16-7.64). "More equity of employee rewards" was the only example of a set of responder suggestions found to be associated with lower job satisfaction (aOR: 2.30, 95%CI: 1.51-3.47). Generally, responders showed a good level of job satisfaction-and this was also the case following the merger-but some job profile determinants were strongly associated with low employee satisfaction. The results of the study highlighted several challenging areas and critical issues relating to working conditions. Further surveys are required to confirm these results and to monitor their evolution over time.