etter patient care” is the reason hospital and health systems usually give when they merge or acquire one another. Our research suggests that mergers and affiliations might, paradoxically, increase the risk of harm to patients in the short run. Improving the safety of patient care is possible during mergers and affiliations, but requires intentional efforts.
What happens after a merger or acquisition matters keenly to patients, and tens of millions of them are affected by such deals each year. There have been more than 100 hospital or health system mergers and acquisitions each year since 2014, with a high of 115 in 2017, and that pace is likely to continue. No part of the country has been spared. Although much is known about the financial impact of hospital and health system mergers and acquisitions, we know almost nothing about how they affect patient care or patient safety.
When hospitals or health systems begin talking about mergers or acquisitions, network development leaders — whose training is usually in business, not medicine — tend to be at the forefront of the discussions. Clinicians often aren’t included, especially early in the process, although this is beginning to change. It’s usually not until after the deal has been completed that they are asked to work out the necessary arrangements to fill gaps and coordinate and standardize clinical care. That’s too late.
Over the past few years, Harvard-affiliated hospital systems have expanded, much like their counterparts in other parts of the country. The leadership of these systems identified mergers and affiliations as an emerging area of risk. They asked their malpractice carrier, CRICO/Risk Management Foundation, to support a process to better understand the nature of the risk caused by the variation in how care is provided in the different hospitals and to propose solutions. CRICO partnered with Ariadne Labs to do this.
To get a better sense of the clinical landscape after a merger or acquisition, we started simply: polling physicians in our research group whose practices had been involved in one. Each had one or more stories of incidents in which patients had been put at risk following a merger or acquisition.
To understand if risks to safety occur because of system expansion, where they might come from, and what could be done to reduce them, we interviewed more than 70 clinicians (mostly physicians) as well as business staff involved in network development. We also convened large, multidisciplinary discussion groups.
The stories we heard shaped our understanding of the sources of risk to patient safety. They also guided the development of tools we built (more about that in a minute) to address the risks. Here are just a few examples:
- A surgeon described being called to assist in a code when a patient’s heart stopped beating. The patient was in a rehabilitation unit in a separate building that was accessible only by a connecting bridge. Because of a poor orientation process, the surgeon got lost trying to locate the patient she was trying to help.
- An anesthesiologist found himself late at night in the basement of a hospital that had merged with the one where he usually worked. Again, because of poor orientation, he had trouble finding the room in the radiology suite where a patient had stopped breathing and needed a breathing tube inserted immediately.
- A pediatrician covering the emergency department in a hospital that was seeing more pediatric patients as a result of a new affiliation inadvertently gave a child double the dose of an anti-seizure medicine. That happened because medication doses for children are based on their weight in kilograms and this emergency department, not used to treating children, didn’t have a reliable system for converting pounds to kilograms.
- An emergency medicine physician was assigned to cover a 24-hour urgent care center with just 30 minutes of orientation. With only three nurses to assist, he suddenly found himself faced with multiple ambulances arriving with patients from a car crash. He had not been briefed on how to obtain backup help in such an unexpected emergency, and care was delayed for all but the most critically injured patients.
As we wrote in a Viewpoint article in the Journal of the American Medical Association, from these and other stories we identified three key sources of risk:
New patient populations. After an expansion, a health care institution’s patient population may change. The institution may experience a general increase in volume, a change in the demographic characteristics of its patients, or increases in patients with certain conditions. Even if more providers and support staff are hired, staff members who interact with and care for these patients elsewhere in the hospital or health system may need new knowledge and support.
Unfamiliar infrastructure. Institutions often intentionally standardize supplies, processes, equipment, and protocols during a system expansion as a way to meet fiscal goals. When faced with unfamiliar tools, clinicians must pay extra attention to using them correctly, attention that is taken away from talking to and examining their patients. Failing to connect with patients and understand their problems can lead to medical errors. Errors can also arise from using equipment incorrectly or prescribing a medication incorrectly based on new formulary.
New settings for physicians. System expansion can result in clinicians having to travel to practice at another institution, intermittently and often temporarily, under a professional services agreement. They often receive little systematic orientation to their new setting. As a result, they can be faced with infrastructure, responsibilities, team members, and a clinical culture that can vary significantly — and unexpectedly — from those at their home institution.
To further address these areas of risk, CRICO and Ariadne Labs convened meetings of clinical and network development leaders across the Harvard clinical system. Our team took what we learned from the stories we had gathered and from these meetings and developed several free toolkits. One is a guide meant to be used before affiliation to help clinicians identify important variations in practice between institutions. We believe that such variations arise normally and are not in themselves a problem. But they can become a problem when they are not surfaced and addressed before physicians are assigned to new settings. To leverage the new relationships and information flows that develop after an affiliation, we also created a guide for clinical and nonclinical leaders to ensure that problems identified during pre-affiliation discussions are focused on after it begins.
Two issues emerged in this work that we plan to focus on next. First, we need to create tools to support clinicians when they are deployed to new institutions. There is a widespread assumption that a clinician who knows how to practice in one setting can do so in a different one. One of the most poignant and telling quotes from all of our interviews was from a physician who said, “I know the medicine. I just don’t know how to get things done around here, and especially how to get them done fast.”
Second, a particular challenge of affiliations that became evident during our work was the difficulty transferring patients between hospitals within a network when the patient’s condition changes. No guidelines exist for what should trigger a transfer and many institutions lack protocols to guide safe and timely transfers.
There are no signs that the pace of hospital and health system mergers and acquisitions will slow. Clinicians and leaders of the Harvard institutions shared their experiences to develop a broad understanding of the sources of risk to patient safety during system expansion and solutions for them. Many have already incorporated these tools — which are generalizable to hospitals and health systems across the country — into their work. Incorporating early, clinician-led evaluation of the potential patient safety risks from system expansion is a practice every health care system should incorporate into its planning process.
Susan Haas, M.D., is co-principal investigator for Ariadne Labs’ CRICO-funded work on reducing the risks to patient safety of health care system expansion. William Berry, M.D., is associate director and senior adviser at Ariadne Labs. Mark E. Reynolds is president and CEO of CRICO/Risk Management Foundation.