Hospital mergers are on the minds of many nurse leaders — and for good reason. The volume of hospital M&As grew significantly in 2024, marking a historic number of transactions. As the scale of mergers increases, so too do the integration challenges.
By all accounts, 2024 will have been a record-breaking year in terms of hospital mergers and acquisitions (M&As). Against that backdrop, Wolters Kluwer joined the American Organization for Nursing Leadership in facilitating a dialogue of nurse leaders to exchange ideas on best practices and lessons learned in bringing nursing staff together postmerger, in influencing broader decisions, and in leading teams well beyond nursing. We covered a range of topics, and although all the participants were tackling their integrations in different ways, common themes emerged from our conversation. The theme that united them? All said they were on a multiyear journey and that with M&As predicted to continue, that journey was expected to continue far into the future.
Having been both a chief nursing officer (CNO) and a clinical executive, I’ve observed firsthand the nuanced strategies needed to achieve alignment and successfully navigate integrations. I understand the challenges the participants faced. And I found the participants’ comments insightful and the strategies they were using to be exactly right.
5 themes emerged from the M&A discussion
1. Adopting the power of system thinking
When healthcare systems merge, one of the first questions that usually comes up in the executive suite is: how close an alignment do we really want? Understanding the enormity of total alignment, some newly formed organizations opt instead for a partial approach. They may choose to have some areas in the new organization tightly conform systemwide, leaving other areas with more autonomy. In my experience, though, that tactic can cause substantial inequities among facilities. For instance, smaller hospitals with fewer resources can be left behind, leading to disparities in patient care, less staff engagement, and fewer opportunities for professional development. And that affects all of the hospitals in the new organization.
The participants agreed that a shared vision and a shared policy framework across an organization are foundational. Shared vision and a common enterprise-wide policy framework really constitute the glue that holds a system together and guides the way the operational infrastructure will support the combined entities. Strong systemwide alignment reduces confusion among nursing staff and ensures equitable access to resources.
2. Creating system roles to drive integration
Establishing system-level roles is a crucial step in integrating systems. From a nursing perspective, roles would likely include a chief nursing executive (CNE) and other key support roles such as director of professional practice. The CNE makes sure that nursing practice, culture, and operations are consistent across the system. In my experience, the CNE’s role is particularly vital. A CNE doesn’t necessarily oversee every CNO but instead, as a key member of the executive team, sets the tone for nursing culture, establishes practice, and has a seat at the executive system table to ensure nursing is part of the decision-making.
Having that central leadership in place is essential to a successful merger. After working with organizations that have chosen not to prioritize those key roles initially, I have learned that their entity leaders lacked alignment, that communication gaps and confusion usually appeared, and that the gaps and confusions inevitably trickled down to managers and staff and, ultimately, negatively affect patient care. I believe it is a big mistake to not invest in this and other system-based roles.
During our executive discussion, one of the speakers presented what I see as a best practice. The speaker said that during the organizational transition, she played a pivotal role in establishing a comprehensive system structure that successfully unified nursing practices across multiple entities. Central to that achievement was creation of the system nurse executive role, a position designed specifically to oversee and align nursing policies, practices, and culture throughout the organization. The CNE acted as the central figure, who set strategic direction for nursing across all hospitals within the system. And even though individual CNOs at each hospital retained executive authority and reported to local executive leadership at their respective entities, they operated within a matrixed structure by reporting to their local hospital leadership but ensuring a unified approach to nursing practice and leadership.
To support such system-level oversight, the speaker’s organization also introduced specialized roles such as system director of clinical practice, system director of nursing policies and procedures, and system director of professional practice. Those roles provided focused leadership in key areas, which ensured that clinical practices, professional development, and operational policies were implemented consistently across all facilities. Together the system-level roles formed the backbone of a collaborative leadership structure that bridged the gap between centralized governance and local autonomy.
3. Ensuring equity across facilities
During a merger, disparities will inevitably arise among the hospitals. The same system may comprise both larger, better-resourced hospitals and smaller, sometimes rural hospitals with fewer resources — a situation that can create a sense of haves and have-nots. Also, morale can become negatively affected by the inequities and manifest via poor staff engagement, turnover, and patient care that suffers.
What can be done to correct the inequity? One strategy I’ve seen work well is to actively identify best practices at smaller hospitals and then take steps to ensure the smaller hospitals’ voices are represented in systemwide decision-making. Bigger is not always better, as was illustrated by one merger that came up during our conversation: in that merger, smaller hospitals actually had better outcomes in specific clinical areas than the larger ones in their system. Celebrating those kinds of successes helps build a culture of mutual respect and collaboration.
A system can demonstrate commitment to equity by investing in resource-limited facilities. The investments can be in the form of training, professional development, or infrastructure upgrades. The results would be not only that smaller hospitals get brought up to par with larger ones but also that recruitment and retention improve because staff feel valued.
4. Aligning culture with operations
As important as leadership and equity are, culture plays an outsized role in the success of a merger. Peter Drucker famously said, “Culture eats strategy for breakfast,” and I’ve found that to be especially true in healthcare.
Culture isn’t an abstract concept; it’s reflected in an organization’s policies, practices, and everyday interactions. In other words, an inspiring mission statement or a great merger tagline isn’t enough. Culture is where the rubber meets the road: via systems and workflows that enable everyone to adhere to the same principles and operate with the same resources.
As one of the participants pointed out, fostering a unifying culture during the integration of multiple healthcare entities is a crucial first step. Drawing from experience, the participant highlighted the fact that the notion of culture — defined as, how we do things around here — is intrinsically tied to the organization’s operations, infrastructure, and daily practices. Achieving cultural alignment, the participant said, requires intentional effort to streamline processes, policies, and philosophies across all entities, which in turn helps staff acquire a consistent organizational identity.
5. Reinforcing “the why”
In my experience, the most critical factor for success in a merger is to ensure that everyone involved understands the why. Why are we doing this is usually the first question, but it eventually becomes more personal: why is a merger a benefit for me, my fellow staffers, and patients? Before the merger begins, leadership must clearly communicate the answers to those questions. After the merger is complete, leadership must continue reinforcing the why and include outcomes that support the reason for the merger. Staff’s understanding and buy-in are absolutely critical because people are more likely to support, adopt, and participate in changes when they see how the changes align with the larger purpose.
Ultimately, we all know that mergers never come without challenges — from building consensus to integrating policies and practices — but the rewards can far outweigh the challenges if the merger results in greater equity, better systems of care, and enhanced access for patients.
One of the participants highlighted the role of town hall meetings in answering the why. “The meetings are led by executive leadership,” the participant said. “And I think that bringing everyone together at one forum is important because that way, each entity is not having a different meeting about what we’re doing and why we’re doing it. Holding one meeting for all stakeholders is a global communication strategy so that everyone is hearing the same thing at the same time.”
Looking ahead
Mergers are never without challenges. There’s pain in change; akin to the grief cycle, there is loss of what was prior to the change so emotions are a factor to consider as leaders lead through change. Pragmatically, challenges are inevitable in aligning processes, building consensus, and navigating cultural differences. But the rewards of greater equity, shared best practices, and stronger systems of care, and greater access are worth the effort.
As healthcare organizations continue consolidating, leaders must focus on fostering trust, aligning cultures, and ensuring that no hospital, nurse, or patient gets left behind. Success lies in the details when it comes to the structure of leadership, the consistency of messaging, and the inclusivity of every voice in the system.
By embracing systemness with intention and empathy, healthcare organizations can turn the challenges of mergers into opportunities for transformation.
