This paper presents a qualitative inductive analysis of attempts to re-order the bases of legitimacy in fields of professional organizations. Concepts from institutional theory, political science and social movement theory are integrated to provide a model of the antecedents, processes and implications of this phenomenon. Findings from a study of US academic health centre mergers illustrate each element of the model. They show that as part of the political agenda to repress the prevailing institutional logic and structures of professionalism (Scott et al. 2000), executives are expected to adopt certain managerial innovations to maintain organizational legitimacy. Against this new basis of legitimacy, powerful agents have promoted merger so successfully that it has achieved mythical attributes of widespread and uncritical adoption (Meyer and Rowan 1977). The paper explains why the intended outcomes of this innovation emerge rarely when it is `sedimented' (Cooper et al. 1996) uncritically upon enduring aspects of the logic and structures of professionalism.
Abbot, Andrew1988The system of professions: An essay on the division of expert labour. Chicago: University of Chicago Press.
2.
Abrahamson, Eric1991`Managerial fads and fashions: The diffusion and rejection of innovations' . Academy of Management Review16/3: 586-612.
3.
Ackroyd, Stephen1995`The new public management and the professionals: Assessing the impact of Thatcherism on the British public services'. Working Paper No. 24, Work, Organisation and Economy Working Paper Series, Stockholm University.
4.
Alexander, Jeffrey , and Thomas D'Aunno1990`Transformation of institutional environments: Perspectives on the corporatization of U.S. health care' in Innovations in health care delivery. S. Mick (ed.), 53-85. San Francisco: Jossey Bass.
5.
Andreopoulos, Spyros1997`The folly of teaching-hospital mergers' . The New England Journal of Medicine336/1: 61-64.
6.
Arndt, Margarete , and Barbara Bigelow2000`Presenting structural innovation in an institutional environment: Hospitals' use of impression management'. Administrative Science Quarterly45/3: 494-5222.
7.
Barley, Stephen1986`Technology as an occasion for structuring: Evidence from observations of CT scanners and the social order of radiology departments' . Administrative Science Quarterly31/1: 8-108.
8.
Barley, Stephen , and Pamela Tolbert1997`Institutionalization and structuration: Studying the links between action and institution'. Organization Studies18/1: 93-117.
9.
Bigelow, Barbara , and Margarete Arndt2000`The more things change, the more they stay the same'. Health Care Management Review25/1: 65-72.
10.
Biggart, Nicole1977`The creative-destructive process of organizational change — the case of the post office' . Administrative Science Quarterly22/3: 410-426.
11.
Blumenthal, David , and Gregg Meyer1996Academic health centers in a changing environment'. Health Affairs15/2: 200-215.
12.
Bogue, Richard , Stephen Shortell, Gloria Bazzoli, and Cheeling Chan1995`Hospital reorganization after merger'. Medical Care33fl: 676-686.
13.
Brint, Steven , and Jerome Karabel1991`Institutional origins and transformation: The case of American community colleges' in The new institutionalism in organizational analysis. W. W. Powell and P. J. DiMaggio (eds.), 311-336. Chicago: University of Chicago Press.
14.
Brock, David , Michael Powell, and C. R. Hinings1999Restructuring the professional organization: Accounting, health care and law. London: Routledge.
15.
Brooks, Geoffrey , and Grace Jones1997`Hospital mergers and market over-lap'. Health Services Research31/6: 701-722.
16.
Brunsson, Nils1982`The irrationality of action and action irrantionality: Decision ideologies and organisational actions' . Journal of Management Studies19/1: 29-44.
17.
Burns, Lawton , John Cacciamani, James Clement, and Welman Aquino2000`The fall of the house of AHERF: The Allegheny Bankruptcy'. Health Affairs19/1: 7-42.
18.
California State Auditor1999UCSF Stanford Health Care: The new entity has not yet produced anticipated benefits and faces significant challenges. August. Sacramento: Bureau of State Audits.
19.
Center for the Health Professions1999`Academic Health Center case studies'. Mimeo, Center for the Health Professions, University of California San Francisco.
20.
Clarke, John , and Janet Newman1997The managerialist state. London: Sage.
21.
Commonwealth Fund Task Force on Academic Health Centres2000Managing academic health centers: Meeting the challenges of the new health care world. October. New York City: Commonwealth Fund.
22.
Cooper, David , Bob Hinings, Royston Greenwood, and John Brown1996`Sedimentation and transformation in organization change: The case of Canadian law firms'. Organization Studies17/4: 623-647.
23.
Dacin, Tina1997`Isomorphism in context: The power and prescription of institutional norms' . Academy of Management Journal40: 46-81.
24.
Deephouse, David1996`Does isomorphism legitimate?' . Academy of Management Journal39/4: 1024-1039.
25.
Denis, Jean-Louis , Lise Lamothe, and Ann Langley1999`The struggle to implement teaching hospital mergers'. Canadian Public Administration42/3: 285-311.
26.
Devers, Kelly1999`How will we know "good" qualitative research when we see it? Beginning the dialogue in health services research' . Health Services Research34/5(Part II): 1153-1188.
27.
DiMaggio, Paul , and Walter Powell1983`The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields'. American Sociological Review48: 147-160.
28.
DiMaggio, Paul , and Walter Powell1991`Introduction' in The new institutionalism in organizational analysis. W. W. Powell and P. J. DiMaggio (eds.), 1-41. Chicago: University of Chicago Press.
29.
DiMaggio, Paul1988`Interest and agency in institutional theory' in Culture and environments: Institutional patterns and organizations. L. G. Zucker (ed.), 3-22. Cambridge, MA: Ballinger.
30.
DiMaggio, Paul1991`Constructing an organizational field as a professional agenda: US art museums, 1920-1940' in The new institutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 267-292. Chicago: University of Chicago Press.
31.
Dobbin, Frank , John Sutton, John Meyer, and W. Richard Scott1993`Equal opportunity law and the construction of internal labor markets'. American Journal of Sociology99: 396-427.
32.
Dranove, David , and Mark Shanley1995`Cost reductions or reputational enhancement as motives for mergers: The logic of multihospital systems'. Strategic Management Journal16/1: 55-74.
33.
Eastwood, Gregory1999`Leadership amid change: The challenge to academic heath centers' in Mission management: A new synthesis, Vol. 2. E. Rubin (ed.), 67-86. Washington DC: Association of Academic Health Centers.
34.
Ellwood, Paul1972`Models for organizing health services and implications of legislative proposals' . Milbank Memorial Fund Quarterly/Health and Society50: 73-101.
35.
Enthoven, Alain1980Health plan: The only practical solution to the soaring cost of medical care. Reading, MA: Addison-Wesley.
36.
Estes, Carroll , and Robert Alford1990`Systematic crisis and the nonprofit sector: Toward a political economy of the nonprofit health and social services sector'. Theory and Society19: 173-198.
37.
Etten Van, Peter1999`Camelot or common sense? The logic behind the UCSF/Stanford merger' . Health Affairs18/2: 143-148.
38.
Fennel, Mary , and Jeffrey Alexander1987`Organizational boundary spanning and institutionalized environments'. Academy of Management Journal30: 456-476.
39.
Ferlie, Ewan , Lyn Ashbumer, Louise Fitzgerald, and Andrew Pettigrew1996The new public management in action. Oxford: Oxford University Press.
40.
Fligstein, Neil1996`Markets as politics: A political-cultural approach to market institutions' . American Sociological Review61: 656-673.
41.
Freidson, Eliot1970Professional dominance: The social structure of medical care. Chicago: Aldine.
42.
Friedland, Roger , and Robert Alford1991`Bringing society back in: Symbols, practices, and institutional contradictions' in The new insitutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 205-232. Chicago: Chicago University Press.
43.
Fuchs, Victor1997`Commentary: Managed care and merger mania' . Journal of the American Medical Association277/11: 920-921.
44.
Galdabini, Greg1999`Stanford/UCSF merger dissolves, stubborn faculty loyalty and lack of cooperation blamed' . Executive Solutions for Healthcare Management2/11: 5-7.
45.
Goldsmith, Jeff1999`UCSF/Stanford: Building a "prestige cartel"' . Health Affairs18/2: 149-151.
46.
Greenwood, Royston , and C. R. Hinings1996`Understanding radical organizational change: Bringing together the old and new institutionalism'. Academy of Management Review21: 1022-1054.
47.
Griner, Paul , and David Blumenthal1998`Reforming the structure and management of academic medical centers: Case studies of ten institutions'. Academic Medicine73(July): 818-825.
48.
Hafferty, Frederic , and Donald Light1995`Professional dynamics and the changing nature of medical work'. Journal of Health and Social Behavior36(extra issue): 132-153.
49.
Hannan, Michael , and Glenn Carroll1995`An introduction to organizational ecology' in Organizations in industry: Strategy, structure and selection. G. R. Carroll and M. T. Hannan (eds.), 17-31. New York: Oxford University Press.
50.
Hardy, Cynthia , Ann Langley, Henry Mintzberg, and Janet Rose1984`Strategy formation in the university setting' in College and university organization: Insights from the behavioral sciences. J. L. Bess (ed.), 169-210. New York: New York University Press.
51.
Hasselbladh, Hans , and Jannis Kalinkos2000`The project of rationalization: A critique and reappraisal of neo-institutionalism in organization studies'. Organization Studies12/4: 697-720.
52.
Hellman, Warren , John McArthur, Sammel Their, Charles Farkas, and Kristine Miller1996UCSF Medical Center/Stanford health services: Proposed merger of clinical enterprises: Third party review. Report to UC Regents, 8 November (Open Session Version). Oakland, CA: University of California Regents.
53.
Hoggett, Paul1996`New modes of control in the public service' . Public Administration74: 9-32.
54.
Hood, Christopher . 1991`A public management for all seasons?'. Public Administration69/1: 3-19.
55.
Hunter Group1999Performance improvement opportunities. July 23.
56.
Hurley, Robert1999`Qualitative methods: What are they and why use them?' . Health Services Research34/5(Part II): 1119-1136.
57.
Iglehart, John1995`Academic health centers enter the marketplace: The case of Philadelphia' . The New England Journal of Medicine333/15: 1019-1024.
58.
Kitchener, Martin1999`All fur coat and no knickers: Organizational change in UK hospitals' in Restructuring the professional organization: Accounting, health care and law. D. Brock, C. R. Hinings and M. Powell (eds.), 183-200. London: Routledge.
59.
Kitchener, Martin 2000 `How a myth made a turkey from two eagles': Lessons from the UCSF/Stanford merger'. Paper presented to research seminar, UC Riverside, 30 March.
60.
Kitchener, Martin , Ian Kirkpatrick, and Richard Whipp1999`Decoupling managerial audit: Evidence from the local authority children's homes sector'. International Journal of Public Sector Management12/4: 338-350.
61.
Kitchener, Martin , and Charlene Harrington 2001 `Deinstitutionalizing long-term care in the US: A study of field dynamics'. Paper presented to Academy of Management meeting, 4-11 August, Washington DC.
62.
Langley, Ann1999`Strategies for theorizing from process data' . Academy of Management Review. 2414: 691-710.
63.
Lincoln, Yvonna , and Egon Guba1985Naturalistic inquiry. Beverly Hills, CA: Sage.
64.
Luke, Roice , Yasar Ozcan, and Peter Olden1995`Local markets and systems: Hospital consolidations in metropolitan areas'. Health Services Research30/4: 555-576.
65.
Martin, Joseph , Haile Debas, and Bruce Schroffel1997`UCSF letter addresses merger concerns'. Stanford Report, 9 April, 29(24): 12.
66.
McAdam, Doug , John McCarthy, and Mayer Zald1996`Introduction: Opportunities, mobilizing structures, and framing processes — Toward a synthetic, comparative perspective on social movements' in Comparative perspectives in social movements. D. McAdam, J. McCarthy, and M. N. Zald (eds.), 1-24. Cambridge: Cambridge University Press.
67.
McKinley, William , Jun Zhao, and Kathleen Rust2000`A sociocognitive interpretation of organizational downsizing'. Academy of Management Review25/1: 227-244.
68.
Meyer, John , and Brian Rowan1977`Institutionalized organizations: Formal structures as myth and ceremony'. American Journal of Sociology83/2: 340-363.
69.
Meyer, John , and W. Richard Scott1983`Centralization and the legitimacy problems of the local government' in Organizational environments: Ritual and rationality. J. W. Meyer and W. R. Scott (eds.), 199-215. Beverly Hills, CA: Sage.
70.
Miles, Mathew , and A. Michael Huberman1994Qualitative data analysis: An expanded sourcebook. Newbury Park, CA: Sage.
71.
Mintzberg, Henry1979The structuring of organizations. Engelwood Cliffs, NJ: Prentice-Hall.
72.
Oliver, Christine1991`Strategic responses to institutional processes' . Academy of Management Review16: 145-179.
73.
Oliver, Christine1992`The antecedents of de-institutionalization' . Organization Studies13/4: 565-588.
74.
Orru, Marco , Nicole Woolsey Biggart, and Gary Hamilton1991`Organizational isomorphism in East Asia' in The new insitutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 361-389. Chicago: Chicago University Press.
75.
Osbourne, David , and Ted Gaebler1992Reinventing government: How the entrepreneurial spirit is transforming the public sector. Reading, MA: Addison-Wesley.
76.
Patton, Michael1999`Enhancing the quality and credibility and credibility of qualitative analysis' . Health Services Research34/5(Part II): 1189-1208.
77.
Pettigrew, Andrew , and Richard Whipp1991Managing change for competitive success. Oxford: Blackwell.
78.
Powell, Walter1991`Expanding the scope of institutional analysis' in The new insitutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 183-203. Chicago: Chicago University Press.
79.
Ragin, Charles1999`The distinctiveness of case-oriented research' . Health Services Research43/5(Part II): 1137-1152.
80.
Reuter, James , and Darrell Gaskin1997`Academic health centers in competitive markets'. Health Affairs16/4: 242-252.
81.
Rubin, Elaine1999`Minding the tripartite mission' in Managing the mission: A new synthesis, Vol. 1. R. Bulger, M. Osterweis and E. Rubin (eds.), 23-37. Washington DC: Association of Academic Health Centers.
82.
Ruef, Martin , and W. Richard Scott1998`A multidimensional model of organizational legitimacy: Hospital survival in changing institutional environments'. Administrative Science Quarterly43/4: 877-904.
83.
Russell, Sabin2000`Hospitals bill for merger $176 million' . San Francisco Chronicle, 14December, p. A25.
84.
Scott, W. Richard1991`Unpacking institutional arguments' in The new institutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 164-182. Chicago: University of Chicago Press.
85.
Scott, W. Richard 1999 `A call for two-way traffic: Improving the connection between social movement and organization! institution theory'. Paper presented to a conference to honor Mayer D. Zald, University of Michigan, 17-18 September 1999.
86.
Scott, Richard , Martin Ruef, Peter Mendel, and Carol Caronna2000Institutional change and healthcare organizations: From professional dominance to managed care. Chicago: Chicago University Press.
87.
Shortell, Stephen , Ellen Morrison, and Shelley Robbins1985`Strategy making in health care organizations: A framework and agenda for research'. Medical Care Review42: 219-266.
88.
Showstack, Jonathan 1997 `The social framing of strategic planning in academic health centers'. Unpublished Ph.D. Thesis. San Francisco: University of California, San Francisco.
89.
Singh, Jitendra , David Tucker, and Robert House1986`Organizational legitimacy and the liability of newness'. Administrative Science Quarterly31: 171-193.
90.
Sirower, Mark1997The synergy trap: How companies lose the acquisition game. New York: Free Press.
91.
Snail, Timothy , and James Robinson1998`Organizational diversification in the American hospital industry'. Annual Review of Public Health19: 417-453.
92.
Starr, Paul1982The social transformation of American medicine. New York: Basic Books.
93.
Staw, Barry , and Lisa Epstein2000`What bandwagons bring: Effects of popular management techniques on corporate performance, reputation, and CEO pay'. Administrative Science Quarterly45/3: 523-556.
94.
Strauss, Anselm1988Qualitative analysis for the social sciences. Cambridge: Cambridge University Press.
95.
Strauss, Anselm , Leonard Schatzman, Danuta Ehrlich, Rue Bucher, and Melvin Sabshin. 1963`The hospital and its negotiated order' in The hospital in modern society. E. Freidson (ed.) 147-169. London: Collier-Macmillan.
96.
Suchman, Mark1995`Managing legitimacy: Strategic and institutional approaches' . Academy of Management Review20: 571-610.
97.
Thompson, James1967Organizations in action. New York: McGraw-Hill.
98.
Tolbert, Pamela , and Lynne Zucker1983`Institutional sources of change in the formal structure of organizations: The diffusion of civil service reforms, 1880-1935'. Administrative Science Quarterly28: 22-39.
99.
Tysome, Tony2000`Universities square up for e-challenge' . The Times Higher Education Supplement, 24 March, p. 1.
100.
University of California1997a`Item for discussion'. Paper for the members of the committee on health services (402), 10 September. Oakland: Office of the President.
101.
University of California1997b`Item for action'. Paper for the members of the committee on health services (403), 10 September. Oakland: Office of the President.
Westphal, James , Ranjay Gulati, and Stephen Shortell1997`Customization or conformity? An institutional and network perspective on the content and consequences of TQM adoption'. Administrative Science Quarterly42: 366-394.
104.
Westphal, James , and Edward Zajac1998`The symbolic management of stockholders: Corporate governance reforms and shareholder reactions'. Administrative Science Quarterly43: 127-153.
105.
Williamson, Oliver1985The economic institutions of capitalism. New York: Free Press.
106.
Woodward, Beth , Myron Fottler, and Anne Kilpatrick1999`Transformation of an academic medical center: Lessons learned from restructuring and downsizing'. Health Care Management Review24: 81-94.
107.
Yin, Robert1994Case study research: Design and methods. Beverly Hills, CA: Sage.
108.
Yin, Robert1999`Enhancing the quality of case studies in health services research' . Health Services Research34/5 (Part II): 1209-1225.
109.
Zucker, Lynne1991`The role of institutionalization in cultural persistence' in The new institutionalism in organizational analysis. W. Powell and P. DiMaggio (eds.), 83-107. Chicago: University of Chicago Press.
