Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Related Sciences

First Advisor

Jan P. Clement

Second Advisor

Jim Cotter

Third Advisor

Michael McCue

Fourth Advisor

Laura McClelland

Fifth Advisor

Patrick Shay


Clinical and academic missions place Academic Health Centers (AHCs) at the center of the American health care system, and the future viability of these institutions requires successful performance in competitive environments. AHCs are organizations involving hospitals, physician group practices, and medical schools, and treat patients with complex conditions, conduct bio-medical and health science research, and educate future physicians and health professionals. AHCs account for 20% or $540 billion of national health care expenditures, conduct over 80% of all heart, liver, and lung transplants, utilize over $27 billion in annual sponsored research funding, and graduate approximately 17,300 medical doctors annually. Financial management at AHCs is intricate, where the clinical enterprises ideally generate surplus funds to sustain the hospital and physician group practice while subsidizing the operations of the medical school and investing in research. This funds flow is dependent on AHCs successfully competing in health care markets and contending for external research grants. As competitive environments change, AHCs respond by restructuring the organizational arrangements among the hospital, physician group practice, and medical school to gain operational efficiencies or market advantages. What does not exist is consensus on what type of organizational structure is effective given certain environmental conditions. The literature contains mostly case studies of individual AHCs or empirical research on the clinical mission only. A gap in the literature is a comprehensive, multivariate, empirical study of the relationship among environments, organizational structures, and performance at AHCs involving both the clinical and academic missions.

The objective of this study is to conduct research on AHCs that fills the gap using a theoretical framework that addresses these relationships. This study uses the primary proposition of structural contingency theory, which states that certain organization structures align with specific environmental conditions, and this fit leads to successful performance. This research investigates the relationship between environmental-structural fit and performance among a sample of 79 AHCs.

This study analyzes data that reflects patient care and research environmental conditions, organizational structure types, and performance in pursuit of the clinical and academic missions from 2007 to 2016. The methods involve calculating environmental–structural fits and misfits, and testing whether those AHCs in fit arrangements perform better than AHCs in misfit arrangements. The analyses involve multivariate regression equations using rates of change in hospital market share and total margin as dependent variable measures for the clinical mission, and rates of change in medical school NIH R01 funding, the percentage of medical school faculty with NIH R01 funding, and the number of interns and residents as dependent variable measures for the academic mission.

The results of this research support the proposition that AHCs in a fit arrangement perform better in growing hospital market share, medical school NIH R01 funding, and the percentage of medical school faculty with NIH R01 funding. The outcomes offer insights as to how AHCs can organize the hospital, physician group practice, and medical school to fit environmental conditions, and how this fit relates to measures of success in the clinical and academic missions.


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