Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals.

Importance: Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. Objectives: To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. Design, Setting, and Participants: In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. Exposures: Hospital mergers. Main Outcomes and Measures: The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. Results: A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04). Conclusions and Relevance: These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.

Using safety culture results to guide the merger of four general practices in the UK.

BACKGROUND: The rapid merger in a crisis of three GP practices to incorporate the patients from a neighbouring closing surgery, led to the redesign of primary care provision. A deliberate focus on patient safety and staff engagement was maintained throughout this challenging transition to working at scale in an innovative, integrated and collaborative GP model. METHOD: 3 cycles of a staff culture tool (Safety, Communication, Organizational Reliability, Physician & Employee burn-out and Engagement) were performed at intervals of 9-12 months with structured feedback and engagement with staff after each round. The impact of different styles of feedback, the effect of specific interventions, and overall changes in safety climate and culture domains were observed in detail throughout this time period. RESULTS: Strong themes demonstrated were that: there was a general improvement in all culture domains; specific focus on teams that expressed they were struggling created the most effective outcomes; an initial lack of trust of the management structure improved; adapting and tailoring the styles of feedback was most efficacious; and burn-out scores dropped progressively. A unique observation of the rate at which different modalities of safety climate and culture change with time is demonstrated. CONCLUSION: With limited time, resources and energy, especially at times of crisis or change, the rapid and accurate identification of which domains of 'culture' and which teams required the most input at each stage of the journey is invaluable. Using this tool and prioritising patient safety, enables rapid and effective positive change to the culture and shape of expanding practices. It affirms that new models of working at scale in GP can be positively embraced with improvements in safety culture, if this is deliberately focused on and included in the transition process.

Executing on Integration: The Key to Success in Mergers and Acquisitions.

Health care mergers and acquisitions require a clearly stated vision and exquisite planning of integration activities to provide the best possible conditions for a successful transaction. During the due diligence process, key steps can be taken to create a shared vision and a plan to inspire confidence and build enthusiasm for all stakeholders. Integration planning should include a defined structure, roles and responsibilities, as well as a method for evaluation.

Multi-level model of missed nursing care in the context of hospital merger.

The aim of this study was to delineate the multi-level relationships of individual registered nurse (RN) and nursing unit factors on missed nursing care. This was a quantitative model-building study using a descriptive, cross-sectional design. Surveys (N = 553) and administrative unit records from nurses in one hospital system undergoing merger were included. The results showed that 36% of the variation in missed nursing care is due to the unit context, with a corresponding 64% due to individual nurse differences. At the unit level, workload, skill mix, and critical unit type affected the amount of missed nursing care. At the individual nurse level, more experience, supplies problems, communication problems, and involvement in errors of commission all increased the perception of the amount of missed nursing care. Education level was not related to the amount of missed nursing care. The findings highlight the importance of unit- and individual-level interventions to redesign hospital nursing care.

Health care mergers and acquisitions: implications of robbers cave realistic conflict theory and prisoner's dilemma game theory.

Many health care mergers and acquisitions have proven highly successful because of the geographic proximity of the institutions, coalignment strategies, complementary services, and improved financial performance. Other health care mergers and acquisitions, however, have been dismal failures. This article seeks to explain a primary cause of less successful mergers or acquisitions through the prism of a multiscale, iterative prisoner's dilemma that occurs between department managers. Aspects of "Coping Theory," "Resource (Conservation) Theory," and "Social Comparison Theory" are used to analyze the experience of employees charged with making mergers or acquisitions successful. Lastly, this article suggests possible culture clash remedies drawn from the realistic conflict experiment conducted by Muzafer Sherif near Robbers Cave State Park in Oklahoma.

Welfare standards in hospital mergers.

There is a broad literature on the consequences of applying different welfare standards in merger control. Total welfare is usually defined as the sum of consumer and provider surplus, i.e., potential external effects are not considered. The general result is then that consumer welfare is a more restrictive standard than total welfare, which is advantageous in certain situations. This relationship between the two standards is not necessarily true when the merger has significant external effects. We model mergers on hospital markets and allow for not-profit-maximizing behavior of providers and mandatory health insurance. Mandatory health insurance detaches the financial and consumption side of health care markets, and the concept consumer in merger control becomes non-evident. Patients not visiting the merging hospitals still are affected by price changes through their insurance premiums. External financial effects emerge on not directly affected consumers. We show that applying a restricted interpretation of consumer (neglecting externality) in health care merger control can reverse the relation between the two standards; consumer welfare standard can be weaker than total welfare. Consequently, applying the wrong standard can lead to both clearing socially undesirable and to blocking socially desirable mergers. The possible negative consequences of applying a simple consumer welfare standard in merger control can be even stronger when hospitals maximize quality and put less weight on financial considerations. We also investigate the implications of these results for the practice of merger control.