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.

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.

Dynamics of distributed leadership during a hospital merger

Purpose Mergers have become an influential part of public hospital development, and the successful implementation of such mergers requires skillful management. Recent studies have pointed to the impact of the distribution of leadership tasks amongst employees for implementing planned radical changes, yet this lacks examination with regard to hospital mergers. The purpose of this paper is to investigate the emergence of distributed leadership and this leadership's influence on the implementation of a hospital merger. Design/methodology/approach The emergence of distributed leadership is examined through a qualitative case study of two Danish hospital units in the context of a large hospital merger. The data consist of 21 interviews and documents collected over a three-year period. Findings The findings suggest dynamics of widened and restricted distributed leadership being influenced by and influencing the merger at hospital and local-unit levels, respectively. Importantly, the perceived purpose of widened and restricted distributed leadership mediated the actual effects of widened and restricted distributed leadership on the implementation of a merger. Moreover, the findings show that mergers on both the hospital and local level lead to variations in top-down and bottom-up distributed leadership across pre-merger organizational boundaries. Practical implications Perceived purposeful widening and restriction of distributed leadership at various hospital levels enables merger integration and collaboration across organizational boundaries and hierarchies. Originality/value The paper addresses the need to understand the complex dynamics of widened and restricted leadership distribution in a merger context.

Motivational paradigms for the integration of a Belgian hospital network and merger presented in the printed press

Purpose

Legitimizing health-care networks over time is crucial to the survival of the networks, but studies providing insight into the motivational paradigms used to legitimize networks and mergers are missing. This study aims to contribute by analyzing which motivational paradigms, namely, transaction costs economics, resource dependency, stakeholder theory, organizational learning and institutional theory, are used over time to motivate the formation, integration and eventually merger of a health-care network.

Design/methodology/approach

The theoretical paradigms from the literature are matched with the motivational arguments that were found in the communication around the formation and evolution of a specific health-care network. Secondary data in the printed press were analyzed in three ways to obtain triangulation in method.

Findings

Five theoretical paradigms matched the communication during significant parts of the time-scope of the study, but not always equally strong. It, therefore, confirms the usefulness of an integrated and evolutionary perspective on the paradigms, not only during the formation but also during the life-span of the organization.

Originality/value

Insight into the motivational paradigms that dominate in the press during an integration and merger process allows for health-care managers and policy makers to manage the process of legitimizing. This might prevent network failure because of lack of legitimacy, misperceptions of the motivations, overemphasizing one motivation or inability to move to a next layer of motivation when the integration process evolves.

A Study of the Role of ‘Representative’ Leadership in Stimulating Organization Democracy

There has been a growing concern among commentators about the disconnection between the apparent increase in the plurality of society, and the relatively limited facets of democracy practised in the corporate work place. Specifically, models of distributed leadership appear at odds with the dominant bureaucratic and unitary model of organizing. In addressing the problem, this article offers a model of Representative Leadership (RL) derived from a political institutional discourse and suggests that in settings of contested plurality, the representation of different organizational constituencies, by a wide range of individuals is central to effective organizing. This model of leadership is explored in the context of data derived from 31 senior managers in five different commercial organizations. Observations are provided about the causal relationships between organization context, managerial cognitions of plurality, personal interest, authority and politics. The potential for RL behaviour to inform future discourse on democratic governance is considered.

The Power of 'Organizational Culture' as a Discursive Formation in Merger Integration

This paper argues that knowledge on ‘organizational culture’ has acquired authority and constitutes a ‘truth’ on mergers, a truth imbued with both enabling and constraining power effects. Taking a Foucauldian perspective, the paper theorizes ‘organizational culture’ as a discursive formation that is implicated in a regime of truth. This regime has involved a process of disciplinary normalization in merger integration with the result that ‘culture’ has become naturalized to ‘organization’. Drawing on ethnographic research into merger integration, these arguments are illustrated through two vignettes titled ‘surveillance’ and ‘sanctuary’. These represent the reproduction of, and resistance to, the truth effects of ‘organizational culture’. The implications of critically examining ‘organizational culture’ in this way are twofold: first, it opens up space for other merger discourses, and second, it enables positioning of merger accounts within cultural discourses in a way that forwards productive rather than divisive effects in theory and practice.

Why healthcare providers merge

In many OECD countries, healthcare sectors have become increasingly concentrated as a result of mergers. However, detailed empirical insight into why healthcare providers merge is lacking. Also, we know little about the influence of national healthcare policies on mergers. We fill this gap in the literature by conducting a survey study on mergers among 848 Dutch healthcare executives, of which 35% responded (resulting in a study sample of 239 executives). A total of 65% of the respondents was involved in at least one merger between 2005 and 2012. During this period, Dutch healthcare providers faced a number of policy changes, including increasing competition, more pressure from purchasers, growing financial risks, de-institutionalisation of long-term care and decentralisation of healthcare services to municipalities. Our empirical study shows that healthcare providers predominantly merge to improve the provision of healthcare services and to strengthen their market position. Also efficiency and financial reasons are important drivers of merger activity in healthcare. We find that motives for merger are related to changes in health policies, in particular to the increasing pressure from competitors, insurers and municipalities.

The Intertextual Production of International Relations in Mergers and Acquisitions

While studies on international management have focused on cultural differences and examined institutional specificities in various national business systems, conceptions of international relations have been left relatively underexplored. We argue that representations of international relations are relevant to international M&As and contend that intertextuality offers a novel approach to examine these relational features of international management. Our analysis focuses on Sino–US relations in the context of the acquisition of American IBM’s Personal Computer Division (PCD) by the Chinese company, Lenovo. We demonstrate the ways in which facets of international relations are produced in media accounts of this acquisition, and analyse the intertextual dynamics entwined with their production. The analysis consists of three sections: constitutive intertextuality, manifest intertextuality and intertextual ideological undercurrents. These illustrate the variation in producing international relations through discursive themes (threat to security/peaceful rise), emotion rhetoric (fear/cheer) and ideology (cold war/globalism). In summary, the paper elucidates the ways in which international M&As are immersed in a seascape of intertextual international relations.

Consultants as legitimizers: exploring their rhetoric

Purpose

The purpose of this paper is to explore how legitimizers invest in their approach to meet the suspicion of being a one‐sided advocate.

Design/methodology/approach

A multiple case study of four public sector decisions, based on a comparative argumentation analysis of two consulting reports in each case, one written by a legitimizer and one by a devil's advocate. The findings of the document analysis are triangulated with author interviews.

Findings

Consultants acting as legitimizers are often suspected of being political allies of a decision maker. To neutralize their reputation as hired guns, these consultants invest in being seen as impartial by making their research approaches transparent and their argumentation balanced to increase their credibility in the eyes of stakeholders, which is necessary to execute their central task: legitimizing a major decision.

Research limitations/implications

The number of four cases could limit the possible variation within the legitimizer role. Further research could therefore explore under what conditions consultants are willing to argue more one‐sidedly as “advocates”.

Practical implications

Practitioners, such as consultants or decision makers, can apply the approach used in this research to make their method more transparent and to balance their argumentation to get commitment from stakeholders, while legitimizing a decision.

Originality/value

The paper nuances the view on the legitimizer role of consultants in previous studies, by exploring how their arguments are more balanced and transparent than assumed and how they try to contribute to their clients' decision‐making process.

Dissemination of management into politics: Michael Porter and the political uses of management consulting

The article contributes to the literature on management dissemination by looking at how management fashions are diffused into and circulated in politics. The ideas of management have been increasingly disseminated into the realm of politics during recent decades. To illustrate how this takes place, this article examines the spread of Michael Porter’s ideas on national politics. Porter’s work is considered a management fashion that has been skilfully packaged; a new form of the 20th-century tradition of state-led social engineering which takes the form of management fashion-style packaging. For this he is seen as a global guru in national politics, and this development is regarded as a new form of consultocracy in the realm of democracies. In consultocracy, the ideas of management consulting are often adopted into politics as a common justifying rationality of power for the political elites. Thus we call for further research on the underlying dynamics of the power involved as management fashions are disseminated into the realm of politics.

A Reflection on the Significance of Numbers

This article reflects on what the author considers a curious absence of curiosity about, and research looking at the practices of, management development practitioners. Whilst appreciative of the breadth and depth of qualitative research presented in this journal over the course of the last 40 years the article suggests that we are far from having the measure of management learning as a practice and that it would now be helpful—perhaps even essential if the field is to be meaningful to academics, practitioners and policy makers—to establish the boundaries of the field with the help of quantitative data about the business of management learning.

Pulp and Paper Fiction: On the Discursive Legitimation of Global Industrial Restructuring

Despite the central role of legitimacy in social and organizational life, we know little of the subtle meaning-making processes through which organizational phenomena, such as industrial restructuring, are legitimated in contemporary society. Therefore, this paper examines the discursive legitimation strategies used when making sense of global industrial restructuring in the media. Based on a critical discourse analysis of extensive media coverage of a revolutionary pulp and paper sector merger, we distinguish and analyze five legitimation strategies: (1) normalization, (2) authorization, (3) rationalization, (4) moralization, and (5) narrativization. We argue that while these specific legitimation strategies appear in individual texts, their recurring use in the intertextual totality of the public discussion establishes the core elements of the emerging legitimating discourse.