Larger, smaller, and flatter: the evolution of the modern health care organization.

In a changing world, organizations must change as surely as individuals must change. Recent years have seen an increase in organizational "flattening," the tendency to shrink the organizational structure through the removal of layers in the hierarchy. At present, flattening is especially prevalent in health care, particularly hospitals, as the industry adjusts to various external pressures through mergers, acquisitions, and sometimes closures. Although organizational growth, or "fattening," is usually slow, occurring sometimes imperceptibly over long periods, flattening is usually abrupt and therefore painful. Organizations are trimming down and becoming smaller unto themselves while becoming components of larger entities, health systems. Concurrent with these changes is the proliferation of freestanding provider organizations providing specialized services formerly offered only in the hospital setting. Especially affected are first-line supervisors and middle managers. Those who are fortunate enough to survive reengineering, merger, or organizational flattening will find their roles altered considerably. More work, more employees, more responsibility, more territory to cover overall-these are the lot of the department manager following most of today's organizational adjustments. The manager's primary defense against obsolescence in the new health care environment is to become as multifaceted as possible, recognizing that one's future security lies not in constancy and specialization but rather in flexibility and adaptability.