As the United States moves forward with healthcare reform, many hospitals and health systems continue to pursue and form partnerships ranging from strategic alliances to sales or mergers. While there is no rule for the type of hospitals or health systems that form the most successful partnerships, similar culture and goals are important. However, just because hospitals may have differences does not mean a partnership will not work. For example, there has been uptick in potential mergers of Catholic and non-Catholic institutions.
Recent examples
Non-profit, secular Faxton St. Luke's Healthcare in Utica, N.Y., and St. Elizabeth Medical Center, a Catholic hospital, announced a unique affiliation — an active parent model — that would allow the hospitals to affiliate while maintaining their respective operating philosophies.
St. Vincent Health System in Little Rock, Ark., a Catholic organization, and the University of Arkansas Medical Sciences, an academic health center, announced they are pursuing in affiliation, while allowing both organizations to preserve their identities.
Earlier this year, a three-way merger between Louisville, Ky.-based University Hospital, a public institution; non-profit Jewish Hospital & St. Mary's HealthCare, also in Louisville; and St. Joseph Health System in Lexington, Ky., part of Englewood, Colo.-based Catholic Health Initiatives, was rejected after state review. Of particular concern was the likelihood that St. Joseph Health's Catholic policies would be extended to University Hospital, which receives taxpayer funds. In addition, University Hospital, which is currently operated by the University of Louisville, serves as a safety-net hospital, and its merger with a Catholic hospital system would have been the first of its kind in the United States. The issues of combining a public health facility with a private and religiously affiliated corporation led to the rejection by Gov. Steve Beshear and Attorney General Jack Conway. 
Finally, Chicago-based hospitals, Sinai Health System and Holy Cross Hospital recently signed a letter of intent to merge. Holy Cross would continue to be a Catholic hospital while becoming a part of the non-Catholic Sinai Health System.
Although Catholic hospitals have ethical and religious and directives, such as what women's health services are offered, and non-Catholic hospitals do not, it does not mean a partnership between those types of organizations cannot work.
"The good news is that Catholic hospitals and non-academic medical centers are a good match for each other. They have many similarities," says Andrew Agwunobi, MD, MBA, leader of the hospital performance improvement practice at Berkeley Research Group. Dr. Agwunobi has also served as COO of St. Joseph Health System, a Catholic organization in Orange, Calif.; CEO of Grady Health System in Atlanta; CEO of Tenet South Fulton Medical Center in East Point, Ga.; and CEO of Providence Health Care, a Catholic organization, in Spokane, Wash.
Cultural similarities
In order for mergers and acquisitions to be successful between Catholic hospitals and non-Catholic hospitals, both sides need to understand that while there are differences in culture, rituals and operations, there are also a lot of similarities. Some of the similarities include:
• A culture of respect for dignity of the patient. One key underpinning of a Catholic hospital's culture is respect for the dignity of the patient, which translates into providing the highest quality of care even for those who cannot afford it, says Dr. Agwunobi. Similarly, academic medical centers, by definition, teach and provide the "gold standard of care," meaning they always strive to provide the best possible, evidence-based care to every patient. Combine this with academic centers tendency to reach out to needy and vulnerable populations who often cannot afford 
their healthcare services and you achieve the same result.
• Focus on a higher mission. Catholic hospitals are altruistic, emphasizing their mission of care over profits. This similar to an academic medical center's focus on teaching and research to advance patient care. "There is a lot of synergy in the purpose behind these missions," says Dr. Agwunobi.
• Inclusive atmosphere. "Catholic hospitals are very inclusive. They do not preach or proselytize. They welcome all individuals, and academic medical centers are the same," says Dr. Agwunobi.
Differences
Beyond the obvious difference of religious symbols displayed around a faith-based hospital, there are other differences in processes, rituals and culture that non-Catholic and academic hospitals should be aware of. 
• Heritage. One area of difference lies in the mission and heritage of Catholic hospitals, which is focused on the healing ministry of Jesus Christ. "Most Catholic hospitals today where founded by Religious Congregations of women and men responding to evolving community needs. They did so by following the model of the person Jesus and that is the mission of Catholic healthcare," says Patrick Gaughan, vice president, Center for Formation in the mission group of Catholic Health Initiatives.
• Routines. The routines that Catholic hospitals practice may be new for non-Catholic hospitals. For instance, many Catholic hospitals start meetings with a reflection — a story, faith-based or non-faith-based, with a moral, lesson or sometimes a prayer. "There is constant encouragement to share stories of the lived spirituality of our workforce (i.e., how people find greater meaning in what they do every day). Widespread sharing of individuals' spirituality in the workplace and how they find purpose in their work creates an environment where others feel encouraged — without pressure — to do the same," says Mr. Gaughan.
• Decision-making. Catholic hospitals use a structured process to make sure their mission and values are considered in every serious or significant decision. This process is called ethical discernment, which may be something new for non-Catholic hospital leaders. "The process aims to make sure that all affected stakeholders are included in the decision-making process or at least notified, that no values are in conflict and so on," says Dr. Agwunobi.
• Leadership factors. The way Catholic hospitals approach, collaborations (for example joint ventures) with other organizations may be different for academic medical centers and non-Catholic hospitals. "For example, Catholic hospitals have to notify the Diocesan bishop of some major decisions. There are certain things that the Diocesan bishop may or may not want to weigh in on. This could be foreign to an academic medical center," says Dr. Agwunobi.
Catholic hospitals also honor and "form leaders" differently. When CEOs join Catholic institutions or when leaders are promoted, they are often recognized through a missioning ceremony. "As part of their formation, we engage our leaders in missioning services calling them to be spiritual and servant leaders in these forums. For example, we set aside intentional time during our semi-annual CEO meetings to recognize and mission new CEOs," says Mr. Gaughan.
• Leadership Development. The approach to leadership development in Catholic hospitals envelops traditional leadership development and incorporates understanding of how their spiritual journey is permeating their leadership. "Enhancing one's awareness and expanding one's capacity to effectively lead in ministry requires practicing a discipline to hear, discern and respond to the invitation of the Holy Spirit as it calls people to cooperate with its healing activity. That invitation is present in the richness of challenge, accomplishment, diversity, conflict and demand found in our daily work," says Mr. Gaughan.
Catholic hospitals and secular hospitals can and do learn a great deal from each other when they come together. "Catholic hospitals get to see firsthand the positive power of physician leadership, because in an academic medical center, the physicians and the medical faculty lead the clinical mission. The Catholic hospitals welcome that," says Dr. Agwunobi. "Academic medical centers learn the importance of the holistic approach to care, which involves body, mind and spirit. And, that is something that academic medical centers welcome as well," he says.
Despite the differences that exist between Catholic and non-Catholic hospitals, such as the extent of reproductive and women's health services that are offered, many decide to work together to advance patient care and coordinate services. In order to be successful, the policy for ethical and religious directives is usually taken into account and addressed long before any affiliation deal is announced to the general public. According to Dr. Agwunobi, there are different ways to satisfy the Catholic hospital's ethical and religious directives, and the community's need for access to certain services, but these will differ in each case; what will work best for each hospital is up to them.
"I have seen situations where a for-profit [hospital] has come into a Catholic system. It has been an absolutely wonderful merger of the two," says Dr. Agwunobi. "I have seen situations where Catholic hospitals have affiliated with academic medical centers, which is usually a good partnership. It can also depend on whether the Catholic hospital is to remain Catholic, whether the Catholic hospital is being purchased or is the acquirer," he continues.
Drivers for a successful transaction
There are methods and approaches that can help hospitals navigate differences, turn them into similarities and overall run a smooth transaction process to develop a successful partnership. Here, Dr. Agwunobi and Karen Teitelbaum, executive vice president and COO of Sinai Health System, discuss three drivers for a successful transaction, some of which have worked so far in Sinai Health's transaction process with Holy Cross Hospital.
1. Shared culture and mission. First, the hospitals need to achieve a shared culture, which means coming together and articulating what a shared mission, values and vision would mean to both. The shared mission, values, vision and ultimately culture should become the glue between the hospitals. "The Catholic hospital has to feel that the shared vision and values are in alignment with its own independent mission," says Dr. Agwunobi.
Ms. Teitelbaum also believes the key to merger success is sharing a mission. "For Sinai Health and Holy Cross, the mission has been to serve the community members, regardless of their ability to pay. That is absolutely key for both Sinai and Holy Cross," she says.
In order to gauge whether or not Sinai Health would have a shared culture with Holy Cross, Ms. Teitelbaum spoke with employees at both hospitals. "My interest for speaking was to begin to understand how our culture would be synergistic. What can we really expect? What should we have our eyes open for? What I heard was confirming. Our mission is similar. [Both hospitals focus] on what's best for the patient and the community," says Ms. Teitelbaum.
2. Respect for differences. In order to take the best practices from each hospital and put them to use in collaboration, each hospital needs to have respect for the other's differences, whether or not those are religious differences or not. "There is a certain type of value in how each organization runs and you need to have respect for that. Getting to know the organization and having respect for its values and mission is key. That will encourage a good working relationship so that the byproduct of the teamwork will be a successful merger," says Ms. Teitelbaum.
3. Constant and honest communication. According to Dr. Agwunobi, any kind of affiliation needs to have constant and honest communication. The sooner the leadership becomes integrated, the faster the transition can occur. "You'll get a successfully integrated organization that has a shared mission, values, culture and vision — a pride in both organizations. The organization that comes out at the end of the day should still have pride in its own heritage but in the heritage of the other as well," says Dr. Agwunobi. This only comes when leaders communicate.
According to Ms. Teitelbaum, open communication will help the hospitals' governing bodies to understand the religious affiliations going forward. "In our case, everyone understands that Holy Cross will continue as a Catholic organization. It is important for the success of the proposed affiliation to recognize this as part of the thread — as what helps define Holy Cross," says Ms. Teitelbaum.
This year saw many hospital deals announced between faith-based organizations and non-faith based organizations. Those organizations may differ in the amount of religion that guides patient care, but they also have a great deal of similarities, such as caring for all patient populations and offering quality, efficient services. For this reason, mergers between religiously affiliated and non-religious hospitals can work. The hospitals need to address religious and ethical directives early on and then be open, honest and respectful through all negotiations.
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