For better or for worse, tying the merger knot after the courtship

To combine facilities, keep education programs, materials from both

Administrators often refer to a merger between two hospitals as a marriage, and for good reason. During a merger, separate facilities must become one.

The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations certainly surveys them as one. They are now one hospital with two buildings, says Ann Kobs, MS, RN, associate director in the department of standards for the Joint Commission.

"If the hospitals are teaching the same patient population, they would have to have standardized materials because now they are one place. Just as you wouldn’t have six approaches in one single hospital, you would not have different approaches in the newly created entity," explains Kobs.

Often the Joint Commission will set up a minisurvey to see if the hospital is working on compliance with its standards. This is done shortly after an organization notifies the Joint Commission of a merger if the actual survey is a few years away. However, hospitals cannot request the minisurvey.

Hospitals concerned about their progress as a merged entity can arrange for a mock survey from Oakbrook Terrace-based Quality Healthcare Resources, a subsidiary of the Joint Commission that provides consultations for a fee.

Grant Medical Center and Riverside Methodist Hospital arranged for a mock survey one year after the two hospitals in Columbus, OH, merged. The consultants determined that both facilities had strong education programs, but they were not the same.

"The surveyors told us we had good programs, but we needed to bring the best of both worlds together," says Mary Jo Fitzpatrick, MS, RN, CPHQ, quality improvement specialist in the Department of Nursing Administration at Grant/Riverside Methodist Hospitals. "That has become our operating motto. Instead of saying ‘Grant is best’ or ‘Riverside is best,’ we say what is the best of both and try to bring those together."

Make process orderly

With the hospital system set to be surveyed in July 1998, the blending process is in earnest. To make the process of blending patient education programs orderly, B.J. Hansen, BSN, patient education coordinator at both facilities listed every service at each hospital such as cardiac, oncology, and orthopedics. Then she prioritized the list by selecting the services that had the greatest patient volume or those departments that were ready to integrate.

To blend programs and materials for each department, Hansen assembles a group of unit experts from both campuses, usually case managers and other staff directly involved with patients.

Often, Hansen has to find creative ways to make materials consistent, yet unique to both hospitals. For example, each hospital has diagnostic cards for procedures, such as a stress test, that include instructions on where to go for the procedure. Groups are now working to make the information generic, and Hansen is creating 5x8 sheets, one with a map of Grant and the other with a map of Riverside and directions to the location. "The system difference will be on the 5x8 sheets," says Hansen.

At Fairview-University Medical Center, administrators took a slightly different approach and established a timeline for merging the departments at The University of Minnesota Hospital and Clinic and Fairview Riverside Hospital in Minneapolis. Teams work on blending materials as departments merge, or in some cases, create new materials if the procedure is different, explains Nancy Goldstein, MPH, patient education program manager at Fairview-University Medical Center. For example, the cardiology departments at each campus have different ways of doing procedures, so a team made up of representatives from each hospital will determine the best method for each procedure, and patient education materials will have to be revised accordingly.

Also, Goldstein has found that some materials can be gradually updated and combined. For example, there are two sets of medication cards, but rather than make revisions all at once, Goldstein is revising them as the supply for a particular card runs low. At this time, she sends copies of both cards to the pharmacy department and asks staff to review the material and create one card.

Scope of education becomes broader

Goldstein has found that mergers often take more work. The merger between Fairview and University hospitals expanded Goldstein’s scope of duties, since Fairview did not have a coordinated patient education system. With more people involved in the approval process, it takes longer to review or create patient education materials, she says.

Expanding responsibilities for patient education managers is not uncommon since there are at least two institutions to coordinate materials. More employees make inservicing on new patient education forms and teaching sheets more time-consuming. Also, some health care systems have clinics, long-term care facilities, home health, and wellness centers attached.

Following the merger of the Hospital of the University of Pennsylvania and Presbyterian Medical Center in Philadelphia, the patient education committees began to look beyond the hospitals to the continuum of care. Committee members hope to coordinate the materials passed out in the clinics with those distributed within the hospital, explains Dawn Stivale, MSN, RN, educator at the department of education for nursing and patient care services at the University of Pennsylvania Health System, Hospital of the University of Pennsylvania.

"You have to rethink your whole system for how you provide patient education materials and how you identify the need because education is much broader now, and not everyone can be creating their own materials," says Stivale.

It’s also difficult to distribute materials to outlying clinics. That’s why the health system is considering distributing as many patient education materials as possible via the Intranet. (For more information on distributing educational materials via the Intranet, see Patient Education Management, July 1997, pp. 81-83.)

To make materials more suitable for all areas of the system at Grant/Riverside Methodist Hospitals, whether inpatient or outpatient, Hansen uses a three-ring binder whenever possible so information can be added or deleted. For example, she recently had a team create an orthopedic notebook that contains core information on the surgery that is consistent throughout the system, yet physicians can change the discharge instructions.

"Because orthopedic surgery is 100% planned admission, the physician’s office can use our information and initiate the teaching. The patients bring the packets of information with them," says Hansen.

Coping with turf issues

Coordinating and blending education is not always easy. It is often difficult to get buy-in from everyone involved. When two hospitals, Bethesda North and Bethesda Oaks, in Cincinnati merged with a Good Samaritan in the same city to form TriHealth, the merged patient education committees struggled to create one documentation form for patient education.

"Each hospital system had different ways of doing things and had recently passed Joint Commission, so each thought their way was best," explains Joyce Fugate, RN, MS, supervisor of cardiac and pulmonary rehabilitation at Bethesda Hospital and co-chair of the patient education committee for TriHealth.

Staff at Good Samaritan documented patient education well on their form, but health care workers had to shuffle through six sheets of paper to find out what had been taught. Staff at Bethesda charted on computers, and the documentation of patient education was vague.

"Neither system provided a good functional process to deliver education to patient and family members by multidisciplines," says Fugate.

A committee tried to blend the methods, but each thought their way was superior. When negotiations broke down, the hospital hired an outside consultant to review the form.

"A consultant is helpful, for it is not one hospital saying ‘do it my way.’ An impartial party is explaining what is wrong with the form and how to make it better," says Fugate.

Earlier, to help the committee agree, Fugate asked one of the in-house facilitators to come to a committee meeting and speak about how to arrive at a consensus and remain committed once an agreement has been reached. The situation improved for awhile, then the same turf issues resurfaced. (For pre-merger strategies to smooth the way, see p. 131.)

While there are negative aspects to merging, the benefits far outweigh them, says Sharon Cure, director of patient and family services at Karmanos Cancer Institute, which encompasses the oncology departments of six hospitals in Detroit.

To coordinate the services at all six locations, a toll-free line was established so callers can quickly get information. Also, the institute was able to create a comprehensive community resource guide by pooling all the information from each health care facility. Best of all, patient satisfaction is skyrocketing.

"We are seeing an upward trend in patient satisfaction because more services are available," says Fugate.