Date of Award


Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Rajendra Singh


Considering the increasing challenge to providing access to affordable healthcare in the United States and its effect on the economy, it is critical for patients, healthcare organizations, financial institutions, and federal and state agencies to understand the impact of different organizational structures within affiliated hospitals. The objective of this study was to investigate the impact of different organizational structures within rural multi-hospital systems (MHS) on the hospitals’ financial performance and the quality of patient care. The data for this study were drawn by linking two national datasets: the 2011 American Hospital Association (AHA) Annual Survey and the 2012 American Hospital Directory (AHD). The two databases were linked via the Medicare ID Number. The AHA survey provided information on rural hospitals’ organizational structure and financial information. The AHD data, extracted from the 2012 CMS Medicare Compare National Dataset based on researchers’ specifications, provided the quality of care and financial measures for the study. The three financial measures used were 1) operating margin, 2) return on equity (ROE), and 3) days cash on hand. Furthermore, the qualityof- care indicators studied were the 30-day readmission rate and the 30-day mortality rate associated with acute myocardial infarction, heart failure, and pneumonia. Multivariate pairwise regression analysis was used to examine the relationship between the outcome

variables, financial and quality indicators, and hospitals’ organizational structure (centralized, decentralized, and moderately centralized). This study explored both the financial and quality indicators of rural MHS. There were 757 hospitals in the financial indicators pool. The financial indicators showed that there are significant variations related to days cash on hand and the types of MHS organizational structures. It was concluded that both centralized and decentralized structures had a significant relationship to days cash on hand, with decentralized MHS having the lowest days cash on hand (32.63 days). This indicates negative financial performance as more days cash on hand would suggest greater organizational stability. With respect to quality of care data, there was a total hospital pool of 233 units. The main quality indicators explored were 30-day readmission and mortality rates. These main indicators were subcategorized based on the Inpatient Quality Indicators (IQI) recommended by the Agency for Healthcare Research and Quality (AHRQ). The selected IQIs included acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. These IQIs were selected to gauge the quality of care of patients within hospital settings. This study found that centralized MHS had the lowest 30-Day readmission rate for CHF (23.65%). In comparison, the CHF rates were 24.75% for moderately centralized and 24.65% for decentralized MHS. Therefore, it can be concluded that when comparing decentralized, moderately-centralized, and decentralized hospitals centralized MHS provides the highest level of care for patients based on 30-day readmission rates for heart failure.