In an effort to improve efficiency and effectiveness, internal hospital restructuring is occurring on a massive scale in North America. There is extensive literature on restructuring models in health care that describe the reorganization of bureaucratic organizations (Fogel, 1989; Weber, 1991) and patient-focused or patient-centered hospitals (Brider, 1992; Jirsch, 1993; Lathrop, 1993; Sidky, Barrable, & Stewart, 1993; Tidikis & Strasen, 1994; Wakefield et al., 1994), program management models (Charns & Tewksbury, 1993; Harber, 1994; Jirsch, 1993; Morris, Stuart, Monaghan, & Alton, 1994), and matrix organizations (Clement, 1988). The literature also describes models of management and staff deployment that use shared governance (Eichelberger, Behl, Lees, Peterson, & Taylor, 1994; Fitch, 1994; McMahon, 1992; Peterson & Allen, 1986a, 1986b; Porter-O'Grady, 1993) and cross-training and "multiskilling" of staff (Sidky et al., 1993) and that will improve organizational effectiveness, efficiency, and the quality of patient care (Morris et al., 1994).
Morris and colleagues (1994) summarized several categories of reasons for restructuring hospitals. The most prominent reason cited in the literature involves an increased interest in focusing on the patient and family and organizing care so that they are the center of all activities (Wakefield et al., 1994). As described by Jirsch (1993), the goal is to have "patients ... regarded as organizational customers" (p. 28) so that the system is more accountable to clients or customers with resultant improved care. Economics, cost control, and fiscal restraint are also frequently cited as reasons for restructuring (Henderson & Williams, 1991). A third category of explanations relates to the organizational management literature, which emphasizes worker empowerment, control over the workplace, and the need to re-evaluate assembly-line thinking (Bolton & Gordon, 1994; Hammer & Champy, 1993). Finally, with the defragmentation of the patient, a move away from assembly-line health care, and a return to holistic care, evaluation opportunities are enhanced, and one can evaluate the effectiveness of patient care.
The most comprehensive description of the various organizational models is that offered by Charns and Tewksbury (1993). According to their continuum, hospitals are shifting from hierarchically organized functional organizations that are organized with discipline-specific departments with different functions (for example, social work) to flattened organizations that are integrative and in which disciplines are allocated to programs. Thus, at one end of their continuum are traditional, bureaucratic, pyramidal organizations with distinct departments that are independent and autonomous. In the middle of the continuum matrix organizations are lodged, where professional staff are equally responsible to their department and director or to their program or patient care unit and program director. At the far end of the continuum lies pure program management, where discipline-specific, functional departments such as social work or physiotherapy are eliminated and professional staff are hired, supervised, and evaluated by and completely accountable to their programs. The program management model, in theory, places professionals in programs in which they have greater autonomy and responsibility for their decisions and actions, thus effectively eliminating middle management and discipline-specific supervisory-level staff. With the flatter hierarchy and discipline-specific staff integrated in programs, there is an expectation of "results-oriented management" (Morris et al., 1994) and systems thinking (Senge, 1990).
Because of their interest in focusing on the patient and controlling costs, hospitals are engaged in reorganization activities that are frequently referred to as "shifts toward program management." Among professional staff, these changes have resulted in anxiety and concern about patient care and job security. …