Sally Mayall Brasher
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Reform and consolidation
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The construction of Ospedale Maggiore was the culmination of reform efforts. In 1399, Duke Gian Galeazzo Visconti pursued the aim of reform by unifying and consolidating hospitals under civic authority, and based his plans on the process of unification already underway in Siena. The Black Death of 1348-1355 placed unprecedented pressure on all institutions but most specifically on hospitals, which were ill equipped to handle such a massive crisis. While the plague crisis and perception of increased poverty predicated an immediate communal response, reform efforts which included unification and centralization of hospitals were also implemented in reaction to mismanagement and jurisdictional disputes. Larger more centralized communal organizations replaced the smaller traditional confraternities and consortia that had been crucial players in the earlier era of foundation and administration of hospitals.

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