Physician leadership| Volume 202, ISSUE 2, P119-126, August 2011

Functional alignment, not structural integration, of medical schools and teaching hospitals is associated with high performance in academic health centers



      Debates continue regarding optimal structures for governance and administration between medical schools and their teaching hospitals.


      Structural integration (SI) for 85 academic health centers was characterized as high (single leader or fiduciary) or low (multiple leaders or fiduciaries). Functional alignment (FA) was estimated from questionnaire responses by teaching hospitals' chief executive officers, and an index was calculated quantifying organizational collaboration across several functional areas. SI and FA were examined for their association with global performance measures in teaching, research, clinical care, finance, and efficiency.


      AHCs with high SI had significantly higher FA, though overlap between high-SI and low-SI institutions was considerable. SI was not significantly associated with any performance measure. In contrast, FA was significantly associated with higher performance in teaching, research, and finance but not clinical care and efficiency.


      FA between medical schools and their primary teaching hospitals more strongly predicts academic health centers' performance than does SI. As demands for greater collaboration increase under health reform, emphasis should be placed on increasing FA rather than SI.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Culbertson R.A.
        • Goode L.D.
        • Dickler R.M.
        Organizational models of medical school relationships to the clinical enterprise.
        Acad Med. 1996; 71: 1257-1274
        • Weiner B.J.
        • Culbertson R.
        • Jones R.F.
        • et al.
        Organizational models for medical school—clinical enterprise relationships.
        Acad Med. 2001; 76: 113-124
        • Sanfilippo F.
        Academic health centers.
        Info K Sys Mgmt. 2009; 8: 383-414
        • Wietecha M.
        • Lipstein S.H.
        • Rabkin M.T.
        Governance of the academic medical center: striking the balance between service and scholarship.
        Acad Med. 2009; 84: 170-176
        • Pomeroy C.
        • Rice A.
        • McGowan W.
        • et al.
        Linking academic and clinical missions: UC Davis' integrated AHC.
        Acad Med. 2008; 83: 809-815
        • Sanfilippo F.
        • Bendapudi N.
        • Rucci A.
        • et al.
        Strong leadership and teamwork drive culture and performance change: Ohio State University Medical Center 2000-2006.
        Acad Med. 2008; 83: 845-854
        • Karpf M.
        • Perman J.
        • Lofgren R.
        • et al.
        Creating an integrated clinical enterprise at the University of Kentucky: the emergence of UK Healthcare.
        Acad Med. 2007; 82: 1163-1171
        • Phillips S.E.
        • Rubenstein A.H.
        The changing relationship between academic health centers and their universities: a look at the University of Pennsylvania.
        Acad Med. 2008; 83: 861-866
        • Ramsey P.G.
        • Miller E.D.
        A single mission for academic medicine.
        JAMA. 2009; 301: 1475-1476
        • Westerman J.H.
        A requiem for the university hospital?.
        Healthcare Mgmt Rev. 1980; 5 (Spring): 17-24
        • Nonnemaker L.
        • Griner P.F.
        The effects of a changing environment on relationships between medical schools and their parent universities.
        Acad Med. 2001; 76: 9-18
        • Griner P.F.
        • Blumenthal D.
        Reforming the structure and management of academic medical centers: case studies of ten institutions.
        Acad Med. 1998; 73: 817-825
        • Griner P.F.
        • Blumenthal D.
        New bottles for vintage wines: the changing management of the medical school faculty.
        Acad Med. 1998; 73: 719-724
        • Blumenthal D.
        • Weissman J.S.
        • Griner P.F.
        Academic health centers on the front lines: survival strategies in highly competitive markets.
        Acad Med. 1999; 74: 1037-1049
        • The Commonwealth Fund Task Force on Academic Health Centers
        Managing academic health centers: meeting the challenges of the new health care world.
        (Accessed June 7, 2011)
        • U.S. News & World Report
        Research rankings: best medical schools.
        (Accessed May 26, 2009)
        • Blue Ridge Institute for Medical Research
        Total NIH awards to each medical school.
        (Accessed September 15, 2009)
        • Keroack M.A.
        • Youngberg B.J.
        • Cerese J.L.
        • et al.
        Organizational factors associated with high performance in quality and safety in academic medical centers.
        Acad Med. 2007; 82: 1178-1186
        • Becker B.N.
        • Formisano R.A.
        • Getto C.J.
        Dinosaurs fated for extinction?.
        Acad Med. 2010; 85: 759-762
        • Kovner A.R.
        • Rundall T.G.
        Evidence-based management reconsidered.
        Front Health Serv Manag. 2006; 22: 3-22
        • Levine A.S.
        • Detre T.P.
        • McDonald M.C.
        • et al.
        The relationship between the University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center—a profile in synergy.
        Acad Med. 2008; 83: 816-826
        • Barrett D.J.
        The evolving organizational structure of academic health centers: the case for the University of Florida.
        Acad Med. 2008; 83: 804-808
        • Kirch D.G.
        • Grigsby R.K.
        • Zolko W.W.
        • et al.
        Reinventing the academic medical center.
        Acad Med. 2005; 80: 980-989