Changes in Quality of Care after Hospital Mergers and Acquisitions.

BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).

Big Med's Spread.

Policy Points Hospital executives posit a number of rationales for system mergers which lack any basis in academic evidence. Decades of academic research question whether system combinations confer public benefits. Antitrust authorities need to continue to closely scrutinize these transactions. Recently, mergers of hospital systems that span different geographic markets are on the rise. Economists have alerted policymakers about the potential impacts such cross-market mergers may have on hospital prices. We suggest there are other reasons for concern that scholars have not often confonted. Cross-market mergers may be conducted for purely self-serving reasons of organizational growth that increases executive compensation. Combinations of sellers should have clear advantages to consumers. System executives and their boards should bear the burden of proof. Federal regulators and state attorney generals should be cognizant that rationales for cross-market systems advanced by merging parties are unlikely to be operative or dominant in merger decision making. Policymakers should be careful about passing legislation that encourages hospitals to consolidate. CONTEXT: There is a growing trend of combinations among hospital systems that operate in different geographic markets known as cross-market mergers. Economists have analyzed these broader systems in terms of their anticompetitive behavior and pricing power over insurers. This paper evaluates the benefits advanced by these new hospital systems that speak to a different set of issues not usually studied: increased efficiencies, new capabilities, operating synergies, and addressing health inequities. The paper thus "looks under the hood" of these emerging, cross-market systems to assess what value they might bestow and upon whom. METHODS: The paper examines recently announced cross-market mergers in terms of their supposed benefits, as expressed by the systems' executives as well as by industry consultants. These presumed benefits are then evaluated against existing evidence regarding hospital system outcomes. FINDINGS: Advocates of cross-market hospital mergers cite a host of benefits. Research suggests these benefits are nonexistent. Additional evidence suggests other motives may be at play in the formation of cross-market mergers that have nothing to do with efficiencies, synergies, or community benefits. Instead these mergers may be self-serving efforts by system chief executive officers (CEOs) to boost their compensation. CONCLUSIONS: Cross-market hospital mergers may yield no benefits to the hospitals involved or the communities in which they operate. The boards of hospital systems that engage in these cross-market mergers need to exercise greater diligence over the actions of their CEOs.

Nurses' work experiences 5 years after hospital merger in the province of Quebec/Canada-An exploratory qualitative study.

In recent years, healthcare organisations in North America have undergone major structural changes. In particular, the province of Quebec in Canada adopted a reform in 2015 which led to the merging of healthcare organisations into centralised regional administrations (the 'CISSS'). As research indicates negative impacts of mergers on patient outcomes and difficulties for the nursing work group in particular, the present paper aims to answer calls for more research about the long-term effects of major organisational changes on nurses' professional practice and well-being. We used an exploratory qualitative research design and report on data collected from 42 nursing professionals, ranging from clinical nurses, nurse practitioners, to head nurses and nursing advisors. Drawing on the job demands-resources model and the person-environment fit theory, our findings yield three main conclusions regarding the state of nursing practice 5 years after the 2015 reform: (1) emergence of a new demand for work harmonisation; (2) growing gaps in the nursing practice environment across departments; (3) evidence of a structural disempowerment of the nursing practice in healthcare organisations. There is hope that a vast project for practice harmonisation initiated and led by local senior nursing advisors will bring about positive outcomes for the nursing practice, and nurses' overall working conditions in the province.

Reasons for merging and collaborating in healthcare: Marriage or living apart together?

BACKGROUND: Across OECD countries, integration between healthcare organisations has become an indispensable part of contemporary healthcare provision. In recent years, inter-organisational collaboration has increasingly been encouraged in health and competition policy at the expense of mergers. Yet, understanding of whether healthcare organisations make an active choice between merging and collaborating is lacking. Hence, this study systematically examines (i) healthcare executives' motives for integration, (ii) their potential trade-offs between collaborating or merging, and (iii) the barriers to collaborating perceived by them. METHODS: Early 2019, an online questionnaire was conducted among a nationwide panel of 714 healthcare executives in the Netherlands. Because of their strategic position within healthcare organisations as end-responsible managers, healthcare executives are especially suited to provide broad and in-depth knowledge on the internal and external processes and decisions. Three hundred thirty-seven Dutch healthcare executives completed the questionnaire (response rate 47%). This study sample was representative of the largest healthcare sectors in the Netherlands. In total, 137 mergers and 235 inter-organisational collaborations were reported. Both closed questions and open-ended questions were systematically analysed. RESULTS: Improving or broadening healthcare provision is the foremost motive for mergers as well as inter-organisational collaborations. When considering both types, reducing governance complexity is one of the decisive reasons to opt for a merger, whereas aversion towards a full merger and lack of support base within the own organisation convinced healthcare executives to choose for a collaboration. When comparing specific healthcare sectors, the overlap in pursued motives and sub-motives indicates that inter-organisational collaborations and mergers are used for comparable objectives. Only a small minority of the responding executives switched between both types of integration. Institutional barriers, such as laws, regulations and financing regimes, appear to be the most restricting for healthcare executives to engage in inter-organisational collaborations. CONCLUSIONS: Our integral approach and systematic comparison across sectors could serve policymakers, regulators and healthcare providers in aligning organisational objectives and societal objectives in decision-making on collaborations and mergers. Future research is recommended to study multiple collaboration and merger cases qualitatively for a detailed examination of decision-making by healthcare executives, and develop an integral assessment framework for balancing collaborations and mergers based on their effects in the medium to long term.

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.

If you say so: A mixed-method study of hospital mergers and quality of care.

BACKGROUND: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. PURPOSE: We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design. METHODOLOGY: Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers. RESULTS: Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers' quality implications, resulting from scale and shock effects. CONCLUSION: The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy. PRACTICE IMPLICATIONS: Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects.

Integrating e-collections following the merger of two specialist hospital libraries: a case study.

BACKGROUND: Birmingham Women's and Children's NHS Foundation Trust was formed in February 2017 following an acquisition. The Library and Knowledge Services (LKS) merged while operating across two hospital sites. A priority for the merged Library and Knowledge Service was to integrate e-collections. A literature review identified six papers reporting health libraries that had merged and integrated e-collections. OBJECTIVES: A priority for the merged Library and Knowledge Service was to integrate e-collections. METHODS: To ensure equitable and cost-effective access to an extended collection, an audit of pre-existing e-collections was conducted. Electronic licence agreements enabling cross-site access were negotiated. A new OpenAthens ID was created. RESULTS: The integration of e-collections enabled Trust staff access to a greater number of e-journals and additional e-content, and an overall cost-saving was achieved. DISCUSSION: This case study supports existing literature stating that integrating collections increases the number of e-journals. It further identifies cost-difference in acquiring cross-site access to e-journals compared to databases providing full-text e-journals and additional e-content. CONCLUSION: Integrating e-collections enables equity of access and value. A national co-ordinated approach to procurement of e-collections will further support equity and best value throughout NHS LKS.

Developing senior hospital managers: does 'one size fit all'? - evidence from the evolving Chinese health system.

BACKGROUND: To improve the effectiveness and efficiency of health service provision in China, the National Health Commission has emphasised that training of all health service managers is essential. However, the implementation of that policy has proven challenging for various reasons, one of which is the lack of understanding of the competency requirements and gaps. The aims of the study were to develop an understanding of the characteristics and training experience of hospital managers in one major Chinese city, explore the difficulties they experience and relate them to their perceived importance of management competencies and the perceived level of their management competency. METHODS: A cross-sectional, descriptive study with a three-component survey including the use of a validated management competency assessment tool was conducted with three senior executive groups (n = 498) from three categories of hospital in Jinan, Shandong Province, China. RESULTS: The survey confirmed that formal and informal management training amongst participants before commencing their management positions was inadequate. The core competencies identified in the Australia context were applicable to the management roles in Chinese hospitals. In addition, the senior executives had low levels of confidence in their management competence. Furthermore, the data showed significant differences between hospital categories and management levels in terms of their commitment to formal and informal training and self-perceived management competence. CONCLUSIONS: The study suggests that management training and support should be provided using a systematic approach with specific consideration to hospital types and management levels and positions. Such an approach should include clear competency requirements to guide management position recruitment and performance management.

Capital Expenditures Increased at Rural Hospitals That Merged Between 2012 and 2015.

EXECUTIVE SUMMARY: The number of rural hospital mergers has increased substantially in recent years. A commonly reported reason for merging is to increase access to capital. However, no empirical evidence exists to show whether capital expenditures increased at rural hospitals after a merger. We used a difference-in-differences approach to determine whether total capital expenditures changed at rural hospitals after a merger. The comparison group (rural hospitals that did not merge during the 2012 through 2015 study period) was weighted using inverse probability of treatment weights. The key outcome measure was logged total capital expenditures.Merging resulted in a 26% increase in capital expenditures and also was associated with a significant improvement in plant age. The postmerger improvement in plant age may have been partially attributable to merger-related accounting changes and partially attributable to increased capital expenses, possibly on long-term asset renovations and replacement.These findings suggest that through mergers, rural hospital board members and executives who have accepted or are considering a merger may improve a hospital's ability to increase capital expenditures. Further, increased capital investments in rural hospitals may be an important signal to the community that the acquirer intends to keep the rural hospital open and continue providing some volume and level of services within the community. Future research should determine how capital is spent after a merger.

Better Together? An Examination of the Relationship Between Acute Care Hospital Mergers and Patient Experience.

EXECUTIVE SUMMARY: The United States is experiencing another wave of hospital mergers. Whether patients benefit from these mergers, however, remains an open issue for many interested stakeholders. One measure of the potential benefit of hospital mergers is how they affect patient experience. This study used a quasi-experimental design to examine the relationship between hospital mergers and four different Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings (i.e., overall, physician communication, nurse communication, and staff responsiveness). The study findings showed an association between hospitals that experienced a merger and slower growth in HCAHPS scores for two of the four HCAHPS domains (overall and nurse communication) when compared to matching hospitals that did not merge. Findings from this study can guide and inform hospital administrators, health system boards, state and federal government regulators and policymakers, and others across the spectrum of healthcare stakeholders.

Intradisciplinary Nursing Communication Post Hospital Merger: A Quality Improvement Project Using Online Communities of Practice in the Intensive Care Unit.

After hospital mergers, unit work environments are at risk of being unhealthy due to poor intradisciplinary two-way communication in times of change. This quality improvement project explored the impact a 4-week, social-media-based, intradisciplinary communication strategy had on a postmerger intensive care unit work environment. The sample (N = 14) included 11 bedside nurses and three administrative nurses working in a 22-bed southwestern US ICU. The participants took part in a Facebook closed-group community of practice called Nurse to Nurse, with a total of 25.9% participation rate. Eleven participants completed the pre-Nurse to Nurse survey, a 20.4% completion rate, while eight participants completed the post-Nurse to Nurse survey, a 14.8% completion rate. After the conclusion of Nurse to Nurse, the overall mean skilled communication survey score increased to 3.79, a 1.6% improvement. Question 14, which measured zero-tolerance behavior perception, exhibited a mean of 2.3% improvement, boosting this metric to excellent status. Utilization data revealed 68 comments posted within Nurse to Nurse implementation, with 56 showing horizontal communication (73.5%) and 24 displaying vertical communication (26.5%). A total of 217 bedside nurse views (81.3%) and 50 administrative nurse views (18.7%) were noted. Nurse to Nurse, an online communication-focused community of practice, enhanced communication among bedside and administrative nurses working in a postmerger intensive care unit setting.

Merging Cultures: Organizational Culture and Leadership in a Health System Merger.

EXECUTIVE SUMMARY: Health system mergers and acquisitions have increased exponentially in recent years as an apparent result of the Affordable Care Act. Mergers and acquisitions are seen as a way to control interdependencies within the market, control costs, leverage debt, and negotiate better rates among health insurers. Regardless of the impetus for a merger, the largest predictor of its success or failure lies within the organizational culture. The purpose of this research was to assess the current organizational culture and preferred organizational culture of two competing health organizations prior to a planned merger, and then to determine whether there were significant differences between the premerger cultures and the postmerger preferred organizational culture using the Competing Values Framework (CVF). Current culture is defined as the premerger culture as measured by the CVF, and preferred culture is defined as the self-identified preferred traits and characteristics of the postmerger culture as measured by the CVF. The study findings indicated a statistically significant difference between the premerger cultures of the health systems. However, respondents from both health systems preferred a postmerger organizational culture that was statistically the same. A review of the results along with best practices for health system leaders follows.

A Post-Merger Value Realization Framework for a Large Community Hospital.

To capture the value of the Scarborough Health Network amalgamation, a value realization framework (VRF) was developed, based on three themes and nine goals. Each goal was mapped to key strategies and indicators that signalled our delivery of value to the community. Value was achieved when indicators moved in the desired direction. The VRF acknowledged that integration is a journey and identified value in the short, medium and long term. Four quarterly VRF progress reports were completed, illustrating a positive story of the post-merger period. The VRF provided a standardized framework for tracking and monitoring strategies for a successful organizational transition.

Playing Well With Others: The Challenge of Academic and Community Radiology Practice Integration.

OBJECTIVE. In this article, we review models for clinical integration across the full spectrum of radiologic services in merged health systems that include both academic and community practice components. We also discuss the issues involved in the integration of disparate practice models and reward systems for both the community radiology group and the academic faculty practice group. CONCLUSION. Although we see advantages to the current trends in mergers and acquisitions within academic radiology, it remains to be seen whether academic and community practice radiology groups can truly work and play well together.

Price effects of a hospital merger: Heterogeneity across health insurers, hospital products, and hospital locations.

In most studies on hospital merger effects, the unit of observation is the merged hospital, whereas the observed price is the weighted average across hospital products and across payers. However, little is known about whether price effects vary between hospital locations, products, and payers. We expand existing bargaining models to allow for heterogeneous price effects and use a difference-in-differences model in which price changes at the merging hospitals are compared with price changes at comparison hospitals. We find evidence of heterogeneous price effects across health insurers, hospital products and hospital locations. These findings have implications for ex ante merger scrutiny.

The ethnographer as health service leader: An insider's view of organisational change.

PURPOSE: The conceptual presentation of a detailed case study of structural reorganisation in the English NHS illustrates what factors lead to productive or unproductive organisational change. FINDINGS: This autoethnography of a NHS Trust chair provides an account of two reorganisations over an 8-year period. The paper is based on diaries that allow for the presentation of examples that highlight different processes and outcomes. The various actors in the two reorganisations gave complex and multilayered meanings to structural changes and their impact. Two theoretical frameworks helped to analyse the dynamics of productive and unproductive changes. CONCLUSION: It is argued that structural change rarely delivers and that working through people and paying due attention to their motivations and moral imperatives will more likely produce benefits to organisations, staff, and patients.

Hospital library closures and consolidations: a case series.

BACKGROUND: Health sciences libraries are being closed or are under threat of closure, but little is published that looks at context and causes or alternative library service delivery models such as affiliations or consolidations. There is also very little research about the effect of these changes on health care provider satisfaction, patient care, or hospital quality indicators. Preventing library closures is not always possible, but understanding some of the circumstances leading to the decision and implementation of a closure or consolidation could inform best practice management. CASE PRESENTATIONS: At a recent Medical Library Association joint chapter meeting, a panel of six librarians presented their cases of navigating a library closure or reorganization. Background information was given to highlight reasons that the decisions to reorganize or close were made. Following the case presentations, participants took part in discussion with audience members. Cases and discussion points were recorded for further research, publication, and advocacy. CONCLUSIONS: Several points from the cases are highlighted in the discussion section of the paper. An accurate reporting of US health sciences libraries and librarian staffing is needed. More needs to be written about new library service models and best practices for centralizing and maintaining library services. After a consolidation, remaining librarians will be expected to manage the effects of staff loss and site closures and so should be involved in planning and implementing these decisions. It remains to be determined how hospitals with librarians compare in patient care and other quality indicators against hospitals without librarians.

The LOTUS: A Journey to Value-Based, Patient-Centered Care.

In response to the merger of our 248-bed community hospital with a new health system, a multidisciplinary team began a journey of holistic transformation via the evolution of a new rounding process called Leadership, Ownership, Transformation, Unity, and Sustainability (LOTUS) in the 20-bed ICU. Morphing from a hierarchical practice structure with limited engagement of multidisciplinary members, the LOTUS initiative (named for the blossom whose petals surround its core, the patient) afforded each discipline (petal) an equal voice and allowed a once-fragmented team to work cohesively, collaboratively, and at the highest level of the scope of practice for each discipline, thus affording expert guidance during care planning while providing a method to collect quality metrics. LOTUS allows us to view our patients in a new way as we refocused goal determination on patients and their families. The restructuring and evolution into a high-functioning team was targeted with the goal of enhancing quality critical care for patients, which, in the literature, has correlated with improved patient safety and decreased mortality and ICU length of stay.