Date of Conferral



Doctor of Business Administration (D.B.A.)


Business Administration


Gregory Washington


Healthcare centers face increasing revenue risk under the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA). The purpose of this multiple case study was to explore strategies that successful leaders of healthcare centers use to mitigate the risk of reimbursement penalties under MACRA. The conceptual framework of this study was Generation 3 cultural-historical activity theory (CHAT-III), and the analysis process used was Yin's recursive and iterative phases. Participants of this study were 6 leaders of healthcare centers in the United States identified as having high quality and low cost via the Centers for Medicare and Medicaid public use files. Semistructured interviews were used to explore the identification of strategic opportunity, strategy formation, implementation, and control. Themes for organizational culture that emerged from data analysis included a foundation core with flexibility and iterative process-improvement practice. Themes in the strategy formation process included total employee involvement and a quality-first, cost-benefit strategy structure. Themes in the implementation process included multiple departmental and organizational collaboration, task-based implementation, and data transparency. Localized cadence meetings were a theme in the control process. Improvements to the organization as a result of this study include a series of standards for organizational culture, a toolbox including CHAT-III as a tool for the identification of strategic opportunity and a methodology for strategy formation and implementation, and control to help ensure financial sustainability. Implications for positive social change include the increased probability of continued ready access to healthcare, improved population health, and lower mortality rates for the communities served.