As part of a case competition, I co-authored an in depth Excel SWOT analysis combined with a priority analysis based on the correction values between each of the defined issues. An excellent example of my analytical abilities.

1. Lead Support
# Operational Merger Guiding
Issues
CMO CFO CEO Proposition for
direction
Detailed analysis - SWOT from the perspective of One Heart Hospital
Dante Alexandra J-P Strenghts Weaknesses Opportunities Threats
1 Governance
1.1 Historical approach to
governance
0,5 1 B was a much stricter hospital, the
general attitude was formal, with
clear procedures, strict control on
the follow-up of any decisions taken
and heavy sanctions in case they
are not carried out. The catering
facilities were plain
"The general attitude at A was
informal, decision taking procedures
were unclear, many things were
'fixed', and there were no sanctions
for non-observance of decisions.
They lead a merry life. The catering
facilities for employees were ample."
To select ambassadeurs from both
hospitals, explore and learn from the
governance strenghts and
weaknesses of both hospitals.
Focus more on having more
regulations and accountabilty
mechanisms, however provide some
To take over 1 governance method
from 1 hospital, meaning, not
realising a balance.
1.2 Medical integration:
professional autonomy &
management participation
1 0,5 0,5 Autonomy very
important BUT good
strategies for
transparancy
1. B has laid down protocols for
many procedures
2. A has more autonomy for the
professional
1. Hospital A: too much autonomy
may affect the
standardisation/efficiency of
processes.
2. Hospital A: limited number of
protocols, and nobody observed the
protocols that were in place.
3. Hospital B: too many protocols
without a continuous improvement
context can prevent innovation from
happening
To define with a group from both
hospitals for the right mix between
protocols and autonomy and to
define the governance approach.
Groups of personnel are also rising
up in arms: Catholics have no
intention of working
with 'those protestants', and former
B's employees declare that in any co-
operation the
protocols of the protestants must be
followed.
1.3 Decentralisation vs. central.:
budgets, professional
accountability & responsibility
0,5 1 0,5 Combined:
Decentralised, but with
clear rules and
regulations + possibly
centralised budget for
innovation
Capital and reserves of the
economical B were much larger
Hospital A had less reserves.
Transparancy issues about costs
and fees in hospital (see DGT as
solution).
1. Increase decentralisation for
hospital A, learning from hospital B.
Decentralisation is needed as
specialists can not be held
responsible for centrally
administered budgets
2. Introduce a central innovation
budget, learning from hospital A (But
improve and ensure budget
discipline).
1. Accountability mechanisms
needed for A and hospital A needs
too agree 2. introducing new
centralised system for sharing
information will require training and
willingness of staff, may need
incentives
1.4 Functional vs. process-oriented
organisation
0,5 1 Process oriented (A
was functional, B
process)
Integral management is there in unit
B: managers are
responsible for everything that
happens in their area of
responsibility.
1. Integral management is not in unit
A: senior nurse would be the 'boss'
of the ward and only
responsible for and in charge of the
nurses who worked there (but not
the secretary, the kitchen help, the
analyst and laboratory assistant, let
alone the doctor); after the turnover
of the organisation, the head of a
Nursing Department will be
responsible for all the professionals
1. Move to a process-oriented
organisation --> decentralisation of
all operating processes to improve
the logistics of patients' processes.
This resulted in the establishment of
divisions, clusters or care groups, all
different names for the same
principle of ordering all the
professionals centred around a
particular group of patients into
organisational structures
1. Do we have enough quality
managers in hospital B
2. Do we have people with
managerial capabilities?
3. People can easily get the
impression that in the process of
change the managers of B (which
has had a process-oriented
organisational structure with integral
management for some time) are
favoured above hospital A
1.5 Private (hosp. A) & public (hosp.
B) to fully private
1 0,5 Two hearts hospital
will become a private
hospital
The employees should not have
issues dealing with this change.
Hospital B was public and has to
become private now. This entailed
contract changes for employees. It
also leads to a change in which the
supervisory board has to be
appointed.
1. Redefine governance and labour
practices.
Unit B is under stress with all those
changes. We need to take care they
don't block on any other major
change that is taking place.
1.6 Management and supervisory
boards
1 0,5 Management board
consisting of CEO,
CCO and CFO.
Moving to one
centralised supervisory
board, consisting of
around 8 people.
1. Hospital A has experience with an
elected supervisory board as it was
private in the past.
2. Hospital A has monthly
supervisory board meetings
3. Hospital B has a rotation
schedule for the board (4 years, 1 re-
elect), re-election only happens
when member functions well (360
grades technique).
4. Hospital B = the Supervisory
Board structurally consults the
Employees Council and the board of
the medical staff of B.
5. Hospital B = asks info about
hospital dev. from the first level of
management below the
Management
Board.
6. Hospital B deals with strategic
and operational issues, involves
staff members in these issues and
solutions
7. As a matter of course all these
meetings take place in the presence
of the Management Board
8. Once a year the president of the
Supervisory Board has a
1. Supervisory board A has no
rotation schedule, stuck in functions
for over 20 years, no evaluation of
functioning.
2. Supervisory board A = The
individual members are in frequent -
informal - contact with people from
the organisation. These members
regularly raise matters in meetings of
the Supervisory Board that they
heard 'on the grapevine'.
3. The Supervisory Board of B had
eleven members, three of whom
were appointed by the Mayor and
Aldermen of Town.
4. The Supervisory Board in hospital
B meets once every three months.
5. Hospital A has a conflict
avoidance policy
1. The Management Boards also
feels that the Supervisory Board (7
in total max) should be 'modernised'
in line with the most recent views on
Corporate Governance.
2. The management board = 2 (B -->
a general director and a director for
patient care) or 3 people (A --> a
Medical Director, an Economics
Director and a Nursing Director)?
Hospital B: If we let go of a part of
the board members, people in town
and of the goverment might protest
(due to loss of image / power)
1.7 Staff board: staff involvement in
decisions
1 0,5 Staff should be
involved in decisions,
combined approach
(top-down & bottom-
up)
1. Hospital B: Staff members are
involved in issues and solutions.
2. Hospital B: staff board that
represents the staff well, decisions
are not frequently changed.
3. Hospital B: The Staff Board has
frequent contact with the
Management Board.
4. Hospital B: Contacts with the
Management Board only take place
sporadically, because most matters
are dealt with at lower echelons in
the organisation (the hospital has an
annual plan).
1. Hospital A: staff members don't
have a united voice, each specialist
speaks for himself
2. Hospital A: decisions are
frequently reversed
3. Hospital A: funcitonal org.
Decisions have to be taken at the
top.
There is a best practice (B), so
people of A can be invited to join
this best practice to see that this
works
Changes in A will lead that not
everyone can speak for themselves
anymore, can lead to resistance
2 Digitalisation & finance 1 0,5
2.1 Digital systems (EPD, computer
system, etc.)
centralised
(investment) budget
for innovation, budget
discipline
Electronic health records (i.e. reduce
administration costs/ enhance
efficiency)
Hospital A has a sub-optimal
computer system
1. 80 GPs in Town and 80 more in
the region, are they integrated to
the Two Heart systems?
2. Improve the hospital computer
systems--> use EPD, automated
sharing platforms that enable
transparant and secure systems
(such as by blockchain
technology?). This will also enable
information sharing across
1. The Director of Finance of B (note
the name of her position!) is
prepared to co-operate with A, but A
will 'obviously' have to start using the
same computer system as B has, for
the system currently in use at A is
inadequate and badly in need of
replacement.
2.2 Patient representative
highlighted problem for
digitalisation with elderly
patients
0,5 0,5 1. Explore how technology can
improve the healthcare experience
for elderly patients

2. 2.3 Labour agreements 1 0,5 Rules and regulations In hospital B there are, apart from
partnerships with their own practices,
a considerable number of specialists
who are employed by the hospital.
In total also a 120 people. These
specialists have an individual
employment contract with the
hospital and receive a monthly
salary.
120 specialists that work as a private
practice and are part of a
partnership. Send invoices to
patients, have to pay for costs
(insurance, secretary, assistants),
but are employed by hospital.
Dissatisfaction about variety of
agreements of board).
1. The heads of department of
Human Resources, however, are
confident they can sort things out:
from their point of view it is an
interesting challenge to integrate the
staff and work towards introducing
one collective labour agreement
(that of A!) and harmonising the
fringe benefits (those of B, as this is
the cheapest option).
2. During the consultations with the
relevant trade unions it becomes
clear that the unions claim a role in
the process, as experience with
other mergers has taught them that
such changes have far-reaching
consequences for the personnel.
This means that at least a 'gilt-
edged' Social Plan will have to be
The negotiations will escalate due to
the presence of 5 trade unions
3 Organisational structure
3.1 Diagnosis Treatment
Combinations
0,5 1 Specialisations to
ensure financial
income (DTC), but too
many activities may
not be good for
budget or will increase
care costs
DGT provides link between efficiency
and performance. From supply
driven to demand driven care.
Standardised care costs
1) Very expensive patients may
increase average costs associated
to DGT and increase costs of care,
which may affect accessibility 2) The
implementation of DTCs is a
complicated matter (e.g because for
each average disorder it has to be
determined what is needed in terms
of laboratory research or X-rays,
dressing materials and medicine, the
number of hours of specialists and
nurses) --> need for gradual
implementation and will for the time
being only apply to elective care.
More transparency about the costs
that a hospital incurs and the fees it
charges with DGT compared to
previous.
3.2 Total beds 1 0,5 Also, the hospital
production will
continue to take
place at the locations
of the former hospitals
A and B for at least
the next five years.
Now total of 1050
beds with both
hospitals and the
small hospital. What is
the future? Taking the
population based
parametres it is 0.2%
of 600,000 people in
Town & region = 1200
beds in total. This
means 600 beds per
hospital. How will
DTC (diagnosis
treatment combi)
determine optimal
size?
Nearly equal division of beds
between the two hospital units.
Guarentees on that side a fair
treatment for both units.
With the DTCs (Diagnosis Treatment
Combinations), can the total bed
count be optimised (read reduced)?
Future specialisations of each
hospital unit should not alter the bed
count significantly. Only after 5 years
we can look at building 1 site. Or
can/should we?
3.3 Horizontal vs. vertical
integration: small hospital,
nursing home & 2x care homes
0,5 0,5 1 Bytown needs to be
reduced, but
opposition (? large
outpatients'
department and
daycentre)
The hospital is there and is known.
As are the nursing/care centres.
Now after the merger One Heart has
both breath (multiple specialisations
in unit B, 2 more then unit A) as well
as depth through the "care"
approach of unit A.
1. Now after the merger the priority is
to get a streamlined operational
process, increasing the quality of
care while reducing costs. By
merging we chose breath. Will it be
too complicated to maintain a whole
care chain. I believe it will. We lack
to the focus / capabilities to be good
in both.
2. The so-called basic functions of a
hospital are available in every
hospital. Even the smallest hospital
has internists, surgeons,
gynaecologists, paediatricians,
neurologists, ENT specialists (the so-
called 'gate' specialists), and a
radiology department, laboratories
and a pharmacy.
3) Problem of patient/population
opinion/satsifaction: "the population
considers it 'unacceptable' if the
For the smaller hospital, divert
patient load from the 2 head units to
the smaller hospital, which could
operate as a specialised outpatient
clinic. "more, for instance, than
outpatient treatment, which is more
desirable from a public funding
point of view)"
--> Smaller hospitals are increasingly
focused on one-day admissions
and outpatients' treatment, which
means that such sites no longer
need
to be available around the clock.
The work that requires 24-hour
availability is concentrated with the
larger partner in the merger.
1. Protests from inhabitants in
moving certain functions over the
head units. Despite it staying within
20 min drive.
2. Risk of competitors outperforming
us in the "care" sector.
3. Risk of competitors outperforming
us in the "cure" sector (4 other
hospitals of around 150 beds)
3.4 Hospital collaboration: teaching
hospital & academic center
1 0,5 1. Each hospital unit has one
academic hospital they work with.
Great to have the choice. Probably
a negotiation item. Unit A gets 1 and
B another one.
2. Several specialties offer general
physicians training as a specialist
and
provide clinical training to final year
students in Medicine (combined
hospitals in Town are training
approximately 100
physicians to become specialists
and approximately 100 students to
be
physicians).
1. There is one academic center too
much. We have to pick 1. X works
together with hospital A, do a lot of
research together. Z works together
with B.
1. Reduce waste, build a deeper
partnership with the academic
partner. --> The specialists from B
demand that the relationship with
'their' academic hospital is continued
because it 'is simply the better
academic hospital' and consider the
alternative 'not under discussion'.
2. Providing training in one or more
medical specialties is an indication of
the quality of a hospital and
therefore an important status symbol
for both specialists and Boards of
Directors of hospitals. --> Make part
of Stichting STZ,
Samenwerkende Topklinische
Ziekenhuizen
3. Attract more patients from the
region, a certain who now prefer to
go to their "own" 4 hospitals. 85% of
the total 600,000. There is a
potential to collaborate with the 4
other hospitals in line with the idea
of flow optimisation with the small
hospital of unit A.
4. Now, after the merger, in due
course they even intend to opt for
academic status.
Smaller hospitals
usually do not qualify for recognition
as a teaching hospital.
3.5 Super-specialisations (range of
functions)
1 0.5 0,5 Connection with
Diagnosis Treatment
Combination
Specialisation unit A = Large
cardiology and heart surgery
function and specialisation unit B =
paediatrics, neonatology department
and a large accident and
emergency department with a
recognised trauma function
Now spread of specialists between
the two unit hospitals. Different
specialisation of each unit.
1. The more specialists a group has,
the more superspecialisation
it can accommodate. The more
status. You need this as well to
become a teaching hospital.
2. Different specialisations of the
hospital units can be an advantage
to us. Allowing to balance workload.
3. Three specialties are practised in
both hospitals and have therefore
been merged for a longer time:
cardiology, urology and
dermatology. Some of the other
specialties have a locum
arrangement for weekends; others
do not, which is, among other
things, the result of existing
animosity between these
partnerships.
1. Specialising 1 unit over the other,
eliminating the function in the other
unit can lead to workflow
optimisation and patient experience
issues.
2. A number of partnerships of
specialists with a private practice
refuse to integrate. They have
commissioned lawyers to secure
their position. Some specialists (the
cardiologists, urologists and
dermatologists!) welcome a
concentration of medical functions
on one of the two hospital sites of A,
others consider it inevitable and yet
others call it 'madness' and
'unnecessary'
3. At the same time GPs fear that
the large hospital will
be much more impersonal and
contact with the specialists will suffer
accordingly.
4 Staff & medical team 1 0,5 0,5

3. 4.1 Cultural integration (expressed
through religion, & deeper held
beliefs)
0,5 1 Link with 1.3 and 2.2 Both parties always kept a close eye
on each other, and anything done
by one party was
copied by the other, and better. The
competition for customers kept both
organisations
alert
It also obstructed developments.
Patients, GPs and many employees
were satisfied with this situation and
were prepared to put up with the
downsides.
Two Hearts Hospital can develop
super-specialisations and put the
patient first, that is if we can
overcome the cultural barriers.
Top-clinical functions were realised
with difficulty or not at all in Town.
4.2 Staff & abortion policy 0,5 0,5 1 To find ways in which we can work
together, despite the differences,
putting the client first, and
respecting the employee.
Threat that orthodox ministers will tell
staff to resign due to abortion
policies
4.3 Staffing for the new organisation 1 0,5 Interesting mix between employed
and private specialists (A more
private, B more employed). Also
make sure too have sufficient
specialists in certain area in order to
ensure that the hospital will not be
granted too little funding.
Different working conditions between
employed and private specialists. (2)
How will we integrate/incorporate old
staff : "A number of partnerships of
specialists with a private practice
refuse to integrate. They have
commissioned lawyers to secure
their position."
1. More ability to superspecialise,
grow in departments
2. Prevent costly duplication in the
care: for instance the two firstaid
departments that operate 24 hours
a day, although neither have much
work to do
outside office hours.
3. Improve quality by reducing costly
duplication and the connected
understaffing.
4.4 HR management 1 Good working
conditions, enough
staff employability
B has a good HR management: use
of good sickness absence policy
A has a good ambiance
A has conflict avoidance, ambience
is important than working
environment and rules. Rules differ
for different specialists.
To define together what balance we
must strike between pragmatism,
individual considerations and the
needs of the hospital.
1. Staff of A may not be happy with
more structured management,
possible incentives needed 2.
Health inspectorate concerns:
detailed plan needed
5 Quality of care
5.1 Quality of care 1 0,5 0,5 1. Hospital A works together with
GPs in Town, have regular meetings
1. Hospital B is not in good contact
with GPs
2. More activities may be good for
quality of care, but may yield a great
increase in costs.
2. Better collaboration with GPs for
both hospitals (especially hospital
B).
1. Specialists of B are possibly not
open for collaboration with GPs
5.2 Public Health Inspectorate & a
formal quality management
system at hosital A (unit A)
Professionalism
combined with
protocols
1. Hospital B has been developing a
quality assurance system
2. Hospital A had many projects that
aim at quality improvement
2. Hospital A has no integral
systematic approach of quality of
care
1. Activities belong to budget
parameter and DGT
2. Develop an improved quality
management system based in inputs
from both former hospitals.
6 Other
6.1 Building quality / clothing /
equipment
0.5 0.5 0.5 Use building B for
now, but make plans
for newer and grander
building in few years
and plan for it. Use of
equipment from both
hospitals.
The hospital buildings of the former
B look well. Hospital B had a general
and technical services
company that had subcontracted
the entire cleaning operation and
internally worked with
management contracts that regulate
the volume, contents and price of
the services
rendered.
1. Hospital buildings of A were built
around the same time, regular
maintenance has been
omitted and the buildings look
shabby. Hospital A employed its own
cleaners and had a traditional
General and
Technical Services Department.
2. The clothing worn by specialists
and staff from both hospitals also
differs.
3. Different equipment in both
hospitals.
The clothing worn by specialists and
staff from both hospitals differs.
Opportunity to pick a new one as a
symbol of united Two Hearts
Hospital! Regarding building: use
the better maintained building of B,
but introduce some of the
equipment of A as a compromise.
Specialists from B don’t 'feel like'
working in 'that dump A', and to
make matters worse: with entirely
different equipment.
11,5 10,5 11,5

4. Operational Merger Issues
Purpose of the document
How to read it 1) Decide whether you want to read the table horizontally or vertically
2) The % are based on a subjective assessment ranging from 0% = not influenced, to 50% = partly influenced by and to 100% = fully influenced.
3) One example, the relation between 1.3 and 1.4 = 75%. It means that both points influence each other quite significantly.
4) Conclusions, based on the column totals, both 1.1 and 1.2 influence / are influenced by a lot of other points. Hence these probably require attention.
5) To make sure each point is clear, an example of a possibly direction is included in the horizontal issue list.
# 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7
Examples of the possible
directions
Governance Historical approach to
governance
Medical integration:
professional autonomy &
management
participation
Decentralisation vs.
central.: budgets,
professional
accountability &
responsibility
Functional vs. process-
oriented organisation
Private (hosp. A) &
public (hosp. B) to fully
private
Management and
supervisory boards
Staff board: staff
involvement in decisions
1 Governance
1.1 Historical approach
to governance
To select ambassadeurs
from both hospitals, explore
and learn from the
governance strenghts and
weaknesses of both
hospitals.
75% 25% 25% 50% 50%
1.2 Medical
integration:
professional
autonomy &
management
participation
To define with a group from
both hospitals for the right
mix between protocols and
autonomy and to define the
governance approach. 75% 50% 25% 75%
1.3 Decentralisation vs.
central.: budgets,
professional
accountability &
responsibility
25% 50% 75%
1.4 Functional vs.
process-oriented
organisation
Move to a process-oriented
organisation -->
decentralisation of all
operating processes to
improve the logistics of
patients' processes.
25% 75%
1.5 Private (hosp. A) &
public (hosp. B) to
fully private
Redefine governance and
labour practices.
25% 75%
1.6 Management and
supervisory boards
Supervisory Board (7 in total
max) should be 'modernised'
in line with the most recent
views on Corporate
Governance.
50% 75% 50%
1.7 Staff board: staff
involvement in
decisions
There is a best practice (B),
so staffers of A can be
invited to join this best
practice to see that this
works.
50% 75% 50%
225% 225% 150% 100% 100% 175% 175%
1) To objectively assess which issues require most attention during the change process.
2) This is achieved by establishing the degree of influence between each issue.
3) The sum total of each column then indicates which issues are most influential.
4) This analysis does NOT necessarily highlight an order in which issues should be addressed, some less influential issues might be blocking points
and require attention.
Operational Merger Issues
Which issues are connected most

5. Foundation Enabler for success
Blocking point Other issues

6. # Operational Merger Issues 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 2 2.1 2.2 2.3 3 3.1 3.2 3.3 3.4 3.5
Examples of the possible directions
Governance Historical
approach to
governance
Medical
integration:
professional
autonomy &
management
participation
Decentralisation
vs. central.:
budgets,
professional
accountability &
responsibility
Functional vs.
process-oriented
organisation
Private (hosp. A)
& public (hosp.
B) to fully private
Management and
supervisory
boards
Staff board: staff
involvement in
decisions
Digitalisation &
finance
Digital systems
(EPD, computer
system, etc.)
Patient
representative
highlighted
problem for
digitalisation
with elderly
patients
Labour
agreements
Organisational
structure
Diagnosis
Treatment
Combinations
Total beds Horizontal vs.
vertical
integration: small
hospital, nursing
home & 2x care
homes
Hospital
collaboration:
teaching hospital
& academic center
Super-
specialisations
(range of
functions)
1 Governance
1.1 Historical approach to governance To select ambassadeurs from both hospitals, explore and
learn from the governance strenghts and weaknesses of
both hospitals. Focus more on having more regulations and
accountabilty mechanisms, however provide some special
occassions/events for (supervisory board) staff to unwind.
75% 50% 25% 50% 50%
1.2 Medical integration: professional
autonomy & management participation
To define with a group from both hospitals for the right mix
between protocols and autonomy and to define the
governance approach.
75% 50% 25% 75% 50% 10% 50%
1.3 Decentralisation vs. central.: budgets,
professional accountability &
responsibility
Increase decentralisation for hospital A, learning from
hospital B. Decentralisation is needed as specialists can not
be held responsible for centrally administered budgets
50% 50% 75% 0% 25% 50% 10% 50%
1.4 Functional vs. process-oriented
organisation
Move to a process-oriented organisation --> decentralisation
of all operating processes to improve the logistics of patients'
processes.
25% 75% 10% 10% 75% 25% 25%
1.5 Private (hosp. A) & public (hosp. B) to
fully private
Redefine governance and labour practices.
25% 75% 75% 25%
1.6 Management and supervisory boards Supervisory Board (7 in total max) should be 'modernised' in
line with the most recent views on Corporate Governance. 50% 75% 50% 10% 25% 10%
1.7 Staff board: staff involvement in
decisions
There is a best practice (B), so staffers of A can be invited
to join this best practice to see that this works. 50% 75% 50% 10% 10% 10%
2 Digitalisation & finance
2.1 Digital systems (EPD, computer system,
etc.)
80 GPs in Town and 80 more in the region, are they
integrated to the Two Heart systems? 50% 50% 10% 75% 50%
2.2 Patient representative highlighted
problem for digitalisation with elderly
patients
Explore how technology can improve the healthcare
experience for elderly patients.
2.3 Labour agreements What are the negotation points of the 5 trade unions, and
how does it impact the staff and work integration (collective
labour agreement harmonious fringe benefits).
10% 10% 10% 75% 25%
3 Organisational structure
3.1 Diagnosis Treatment Combinations More transparency about the costs that a hospital incurs and
the fees it charges with DGT compared to previous.
50% 75% 75% 85% 25% 25% 75%
3.2 Total beds With the DTCs (Diagnosis Treatment Combinations), can
the total bed count be optimised (read reduced)? 85% 75% 25% 75%
3.3 Horizontal vs. vertical integration: small
hospital, nursing home & 2x care homes
Improve care, reduce costs by repurposing or closing the
smaller hospital.
25% 25% 10% 10% 50% 25% 75% 25%
3.4 Hospital collaboration: teaching
hospital & academic center
Become a teaching hospital, part of Stichting STZ, providing
training is an indication of quality. 25% 25% 10% 25% 25% 75%
3.5 Super-specialisations (range of
functions)
The more specialists a group has, more superspecialisation
= more status + ability to become a teaching hospital. 50% 25% 10% 10% 25% 75% 75% 25% 75%