Managing clinical integration: a comparative case study in a merged university hospital.

PURPOSE: This paper seeks to explore critical factors that may obstruct or advance integration efforts initiated by the clinical management following a hospital merger. The aim is to increase the understanding of why clinical integration succeeds or fails. DESIGN/METHODOLOGY/APPROACH: The authors compare two cases of clinical integration efforts following the Karolinska University Hospital merger in Sweden. Each case represents two merged clinical departments of the same specialty from each hospital site. In total, 53 interviews were conducted with individuals representing various staff categories and documents were collected to check data consistency. FINDINGS: The study identifies three critical factors that seem to be instrumental for the process and outcome of integration efforts and these are clinical management's interpretation of the mandate; design of the management constellation; and approach to integration. Obstructive factors are: a sole focus on the formal assignment from the top; individual leadership; and the use of a classic, planned, top-down management approach. Supportive factors are: paying attention to multiple stakeholders; shared leadership; and the use of an emergent, bottom-up management approach within planned boundaries. These findings are basically consistent with the literature's prescriptions for managing professional organisations. PRACTICAL IMPLICATIONS: Managers need to understand that public healthcare organisations are based on competing institutional logics that need to be handled in a balanced way if clinical integration is to be achieved--especially the tension between managerialism and professionalism. ORIGINALITY/VALUE: By focusing on the merger consequences for clinical units, this paper addresses an important gap in the healthcare merger literature.

Logics of pre-merger decision-making processes: the case of Karolinska University Hospital.

PURPOSE: The purpose of this paper is to examine how and why a decision to merge two university hospitals in a public context might occur by using an in-depth case study of the pre-merger process of Karolinska University Hospital. DESIGN/METHODOLOGY/APPROACH: Based on extensive document analysis and 35 key informant interviews the paper reconstructed the pre-merger process, searched for empirical patterns, and interpreted those by applying neo-institutional theory. FINDINGS: Spanning nearly a decade, the pre-merger process goes from idea generation through transition to decision, and took place on two arenas, political, and scientific. Both research excellence and economic efficiency are stated merger motives. By applying a neo-institutional perspective, the paper finds that the two initial phases are driven by decision rationality, which is typical for political organizations and that the final phase demonstrated action rationality, which is typical for private firms. Critical factors behind this radical change of decision logic are means convergence, uniting key stakeholder groups, and an economic and political crisis, triggering critical incidents, which ultimately legitimized the formal decision. It is evident from the paper that merger decisions in the public sector might not necessarily result from stated and/or economic drivers only. PRACTICAL IMPLICATIONS: This paper suggests that a change of decision logic from decision to action rationality might promote effective decision making on large and complex issues in a public context. ORIGINALITY/VALUE: This is the first systematic in-depth study of a university hospital merger employing a decision-making perspective.