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The health care system in the United States is undergoing substantial consolidation through mechanisms ranging from mergers and acquisitions to institutional affiliations to single service agreements, often with expectations of improving the safety and quality of care. However, there has been little evaluation of the risks that system expansion has on patients.1,2 In a partnership between a medical liability insurer (CRICO/Risk Management Foundation) and a health systems research center (Ariadne Labs), we analyzed the patient safety risks for Harvard-affiliated institutions by interviewing clinicians and convening system leaders both locally and nationally. System expansions create 3 types of significant safety risks, often unrecognized and unaddressed, that are related to changes in patient populations, infrastructure, or clinician practice settings (Table).
Risk. After system expansion, health care institutions may experience significant changes in patient populations, including increases in general volume and in patients with demographic characteristics or conditions that are new to a facility.
Analysis. When institutions anticipate changes in patient population (eg, opening a substance use disorder service), they commonly make unit-level adjustments such as training support staff. However, staff who interact with these patients elsewhere in the hospital may also need new knowledge, skills, practice patterns, and support, such as having the ability to recognize and promptly treat withdrawal symptoms. Further, these changes are often not anticipated; an increase in referrals may bring an influx of non–English-speaking patients, for instance, who require more interpreters, institutional relationships with different community services, and increased awareness of economic and social challenges these patients face in following care guidelines. Lack of wider institutional attention to specialized needs can result in serious deficiencies in provision of safe, timely care.
Risk. Achieving the financial benefit of system expansions often involves making substantial changes in supplies, equipment, formularies, protocols, and information systems.
Analysis. Changes in infrastructure create significant challenges for clinicians and are common in systems expansion. Without planning, such changes can cause significant patient risk. Even with training, a learning curve makes formerly routine tasks more time- and attention-intensive and error-prone; finding the correct form in an electronic health record for ordering a test, identifying the correct substitution medication and dose from a new formulary, or transferring a patient. The attention clinicians must now give to once “automatic” tasks also distracts from other aspects of patient care or slows throughput. Unless schedules and capacity are adjusted, such shifts in time and focus not only may result in dissatisfied patients but also in increased likelihood of major errors.
Risk. An industry survey of 82 health care institutions that have undergone expansions of their networks found that 87% require physicians to travel to new practice sites, the most common being specialists, including cardiologists, surgeons, oncologists, and obstetricians.3
Analysis. When clinicians travel, they often receive little systematic orientation to their new setting, leaving them to practice with infrastructure, processes, teams, and a clinical culture that can vary in significant and unexpected ways from those at their home institutions. In the absence of guidance, physicians indicated that they have adapted to these new circumstances through trial and error, which can put patients at risk. This includes determining which kinds of care can be provided in a given setting and during emergency situations, when clinicians can ill-afford to spend time trying to understand and manage the idiosyncrasies of an unfamiliar facility’s crash cart, electronic health record, or phone-number list. Physicians reported that although they know the right care to provide to patients, they commonly discovered situations in which they did not know how to deliver the care, and especially, how to do it quickly.
Teams with little expertise in patient safety are typically responsible for implementing health care mergers, acquisitions, and affiliations. Their primary impetus is often financial rather than clinical, and when the impetus is clinical, the concerns usually involve patient access and services rather than the way care is practiced in the affected institutions. Goals and responsibility for safety and quality are frequently unclear. As a result, risks to patients arise at the “sharp end” of care, where clinicians are asked to practice in new settings, with new populations, or with new infrastructure, without sufficient planning.
To address these risks, a patient safety toolkit has been developed to support clinical planning between institutions prior to launch.4 The toolkit is freely available and provides guidance on topics to discuss in order to surface and resolve institutional differences that could result in patient safety risks. These topics include differences in infrastructure and resources for management of a range of emergencies and specific subjects pertinent to surgery, obstetrics, and emergency medicine. The toolkit also provides a checklist for establishing a joint clinical integration council. These tools have now entered local use, but whether they improve quality and reduce errors that would have occurred because of expansion is unknown. Research remains necessary to better predict safety risk and to determine whether these or other approaches increase the margin of safety.
System expansions can have substantial effects on clinical care and patient safety, particularly when clinicians encounter changes in their practice setting, patient population, or infrastructure. Institutions must actively plan for, monitor, and manage the resulting risks as part of a comprehensive strategy, including sharing data on quality and safety, and sharing oversight of care for the joint patient population.
Corresponding Author: Susan Haas, MD, MSc, Ariadne Labs, 401 Park Dr, 3E, Boston, MA 02215 (firstname.lastname@example.org).
Published Online: April 6, 2018. doi:10.1001/jama.2018.2074
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Haas and Dr Gawande report receipt of a grant from CRICO Risk Management Foundation. No other disclosures were reported.
Additional Information: From Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, and CRICO Risk Management Foundation of the Harvard Medical Institutions.
Additional Contributions: We thank the following individuals from Ariadne Labs: Janaka Lagoo, MD, MPH, for articulating problems from system expansion and assisting in creating the manuscript and discussion guide; Bill Berry, MD, MPP, MPH, for guidance that expanded and deepened our understanding of this problem; Ami Karlage, BA, for editing and proofreading versions of the manuscript; and from CRICO Risk Management Foundation, we thank Kathy Dwyer, MSN, RN, for communication linking CRICO with Ariadne Labs; and Luke Sato, MD, for support and direction. None were compensated for their contributions to this article.
Haas S, Gawande A, Reynolds ME. The Risks to Patient Safety From Health System Expansions. JAMA. 2018;319(17):1765–1766. doi:10.1001/jama.2018.2074
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