Viewpoint: Why hospital mergers raise patient safety problems

Although hospitals and health systems often cite the pursuit of "better patient care" as reason for mergers or acquisitions with one another, research shows partnerships and transactions might put patients at a higher risk for harm in the short term, three authors write in an op-ed published by STAT.

Hospitals can improve patient safety during mergers and affiliations, but they must make intentional efforts to ensure patients receive the best care in a deal's aftermath, the authors argue.

Here are six insights from the op-ed, written by Susan Haas, MD, co-principal investigator for Boston-based healthcare solutions firm Ariadne Labs' work on reducing patient safety risks with health system expansion, and William Berry, MD, associate director and senior adviser at Ariadne Labs and Mark Reynolds, president and CEO of CRICO/Risk Management Foundation:

1. Since 2014, there have been over 100 hospital or health system mergers and acquisitions across the U.S., with a high of 115 M&As in 2017. "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," the authors write.

2. The authors note how merger talks often start with network development leaders opposed to leaders with a background in medicine, and clinicians are rarely included in the process early on. "It's usually not until after the deal has been completed that [clinicians] are asked to work out the necessary arrangements to fill gaps and coordinate and standardize clinical care," the authors write. "That's too late."

3. As part of their ongoing research, the authors polled physicians in their research group whose practices were involved in a merger or acquisition. They interviewed more than 70 clinicians (mostly physicians) and business staff involved in network development to assess whether patient safety risks happen due to system expansion.

4. After hearing several stories involving risks to patient safety, the authors identified three key sources of risk: 

  • New patient populations. A health system's patient population may change after an expansion, the authors write. "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. To meet financial goals, institutions may intentionally standardize supplies, processes, equipment and protocols during a system expansion. These operational changes can contribute to delays, oversights or confusion on behalf of the medical staff. "Failing to connect with patients and understand their problems can lead to medical errors," the authors write. "Errors can also arise from using equipment incorrectly or prescribing a medication incorrectly based on new formulary."

  • New settings for physicians. Clinicians may have to travel to practice at another institution after a system expansion. "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." For example, one surgeon told researchers she got lost trying to find a patient she was trying to help due to an issue with accessing the correct building. In another instance, a surgeon had trouble locating the room in a radiology suite where a patient had stopped breathing and needed a breathing tube inserted immediately.

5. The authors have developed several free toolkits and created a guide for clinical and nonclinical leaders. "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," the authors write.

6. The authors now plan to focus on developing tools to (a) support clinicians when they are deployed to new institutions and (b) help minimize difficulties transferring patients between hospitals within a network when the patient's condition changes.

"There are no signs that the pace of hospital and health system mergers and acquisitions will slow," the authors write. "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."

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