Healthcare Quarterly

Healthcare Quarterly 9(3) May 2006 : 50-54.doi:10.12927/hcq..18228

A Surrealistic Mega-Analysis of Redisorganization Theories

Andrew D. Oxman, David L. Sackett, Iain Chalmers and Trine E. Prescott


Background: We are sick and tired of being redisorganized.

Objective: To systematically review the empirical evidence for organizational theories and repeated reorganizations.

Methods: We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.

Results: We discovered many reasons for repeated reorganizations, the most common being 'no good reason'. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.

Conclusions: We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.


HARLOT1 was commissioned by PSEUD (an international organization for the Preservation of the Status-quo through Evasion, Unreason, and Diversion) to systematically review the literature on reorganization. We were offered not much money and 10 days to respond. After spending 8 days developing four strategic plans, undergoing three reorganizations, and going to a concert, we got started. Our preliminary search yielded 2526 organizational theories, 2 600 000 links (Google: organization theory; accessed 20 July 2005), 1309 books (Amazon: organizational theory; accessed 20 July 2005), 1811 hits in MEDLINE (PubMed: organizational theory; accessed 20 July 2005), and one empirical study. Not having time to sort through all this garbage, we considered several different methodologies for synthesizing this 'literature', including meta-analysis, best-evidence synthesis, qualitative synthesis, chaos synthesis, ethnographic synthesis, vote counting, random sampling, focus groups with 18 month olds, and realist synthesis.  

Given the amount of money we were offered and the boring nature of the topic, we elected to use surrealistic synthesis, a term that we coined to highlight the innovativeness of our venture and hide the fact that we do not know what we are talking about, nor it seems, does anyone else.  

Box 1 Glossary of redisorganizational strategies  

Centralization(syn: merging, coordination): When you have lots of money and want credit for dispensing it  

Decentralization (syn: devolution, regionalization): When you have run out of money and want to pass the buck (i.e. the blame, not the money) down and out  

Accordianization:When you need to keep everyone confused by instituting continuous cycles of centralization and decentralization. Best example: the NHS  

Equalization: When you have not (yet) sorted out which side is going to win  

Interpositionization:When you need to insert shock-absorbing lackeys between patients and managers to protect the latter from being held accountable (this strategy is often misrepresented as an attempt to help patients)  

Indecisionization trees:When you are massively uncertain and incompetent, picking numbers out of the air and placing them in diagrams. Also used as a party game at management retreats  

Matrixization structure:When your indecision tree has been exposed as meaningless twaddle, the introduction of a second indecision tree at right angles to it  

Obfuscasization:When you need to hide the fact that you have not a clue what is really going on, or what you should do about it. Makes heavy use of phrases such as 'at this moment in time' instead of 'now', and transforms things that are simple and obvious into complicated and impenetrable muddles  

R&Dization:When you have been exposed as a power-mad fraud and are offered a compensation package just to get you out of town. Employs the 'Rake it in and Disappear' ploy  

Black hole effect:When a reorganization absorbs large amounts of money and human resources without producing any measurable output  

Honesty:When your corporate conscience urges you to admit that when you say, 'It's not the money it's the principle', it is the money. A dangerous and abandoned strategy, included here for historic purposes only.


We used the following inclusion criteria for our review:  
  • Population: We considered restricting our review to healthcare personnel, but there was no point in doing so in light of the predominant conceptualizations of healthcare workers as assembly line workers (in modern theories), entrepreneurs (in post-modern theories), and as galactic hitchhikers (in theories that go beyond postmodernism into new realms of reality)  
  • Interventions: Anything that anyone has ever done to anyone (particularly to us) in the name of reorganization, reengineering, modernization, effectivization, revitalization, transformation, devolution, centralization, strategic planning, risk management or crisis maximization, regardless of whether it was well intentioned or not  
  • Outcomes: The consequences had to make us either laugh or cry or both (depending on how seriously we took them)  
  • Study design: Story telling. We used the standard for research in this field: at least one organizational consultant has to have been paid at least once for having said whatever the study concludes. We included studies that generated reorganizational recommendations that we could not understand (99.99%). We excluded studies that did not offer a reorganization plan (0.01%).

Search methods  

We browsed the web a bit, sat around and chatted for an enjoyable weekend, asked a few people who are actually interested in the topic what they think, circulated drafts of this article to a few buddies, and made up the rest. We recorded interviews and focus groups between organizational consultants and reorganized health workers, managers, ministers of health, and academics. Unfortunately, a recently reorganized company (DILBERT plc) produced the batteries for our recorder and we later discovered that our tapes were blank. None of us can remember much of what was said, so we have faked that part of our review.  

Data collection  

We used a large trash bin on wheels.  


We measured the heat:light ratio of consultants' recommendations when they were raised to Fahrenheit 451. We also used some fluorescent colours in our data summaries because bright colours increase credibility and statistical power.  


We discovered that the literature is almost impenetrable due to creative jargon and the meaningless terminology generated by a variety of cults adhering to different beliefs and led by competing gurus. An abridged glossary decoding some of these terms is attached to this report (Box 1). Each cult has its own theory (Table 1), none of which is particularly coherent. These theories all use complicated diagrams called organograms and support the OFF theory of research utilization. OFF can be summarized as follows: 'you don't need a theory'.2 Although thousands of articles and books have been written about these theories, the concepts they contain are remarkably simple and overlapping. These concepts are summarized here.  

Why reorganize?  

We identified several over-lapping reasons for reorganizations, including money, revenge, money, elections, money, newly appointed leaders, money, unemployment, money, power-hunger, money, simple greed, money, boredom, and no apparent reason at all. Because we wanted to muscle in on this consultation market, we attempted to estimate the extent of financial incentives for reorganizations. To our delight, the advice business is booming. Estimated income rose from around 20 billion dollars per year in 1990 to over 100 billion in 2000.3 Of course, nobody seems to know quite what the business is, let alone whether it delivers value for money. Consultants typically refuse to provide any evidence on the efficacy of their recommendations by pleading client confidentiality and hiding behind opaque terms such as 'value propositions' and 'service offerings'.  

We were unable to find any reliable estimates of how often newly elected governments, new academic deans, and other newly appointed leaders reorganize, so we unblushingly guessed at it. Based on a non-systematic survey of our own painful experience, we estimate that 'regime change' results in reorganization roughly 99% of the time.  

The benefits of reorganization in terms of consultant employment are undeniable. The largest consulting companies (such as Earnest & Old, McOutley and Cost-Dirthouse) each have over 50 000 employees and there are tens of thousands of smaller companies. Almost a third of MBA graduates go into consulting, lured by starting salaries for top graduates of $120 000 a year (plus tuition reimbursement and bonuses). Consulting companies are getting worried that they are drawing too heavily on business schools, and are now tapping new sources of recruits, such as PhD programmes, medical schools, and art courses.

Beyond the hundreds of thousands of people who are gainfully employed as consultants, the amount of time that employees in virtually every modern organization are forced to spend on strategic and organizational planning is astounding, even to us at HARLOT. A conservative estimate of 1 day per year per employee spent in strategic planning and at organizational retreats (not to mention leadership courses and team building adventures) would suggest that trillions of dollars are being spent on these activities each year. This figure does not include cost-centres in the hotel, restaurant and travel industries.  

The internal justifications for reorganizing identified in our mega-analysis include:  

  • You need to hide the fact that an organization has no reason to continue to exist  
  • It has been 3 years since your last reorganization  
  • A video conferencing system has just been purchased out of your employees' retirement fund  
  • Your CEO's brother is an organizational consultant  
  • The auditor general's report on your organization is about to be released.  

The external justifications for pushing for a reorganization of someone else's organization include:  

  • You are threatened by their organization  
  • You discover that their organization is functioning effectively  
  • You would like to direct attention away from your own organization's activities.

These justifications must never be made public. The fundamental rule is: 'Never let on why-really-you are reorganizing'.  

Leading in vicious circles of redisorganization  

New leaders typically take up their posts intoxicated with the prospect of transformation and radical revision. This triggers an avalanche of constant and hectic activity. Repeated redisorganizations4 result in exhausted managers who rush from one meeting to another with no time to step back and reflect. By the time the organization decides to saddle somebody with the blame for the resulting chaos, the leader has left to foul up some other organization. The end result is a perpetual cycle of redisorganization.  

While all new leaders feel compelled to redisorganize, it is nonetheless possible to distinguish among several breeds of leaders based on their canine redisorganization behaviour:  

  • MuttsThe most common type of leader: self-focused, with a need to piss all over everything to mark territory  
  • BulldogsWell meaning, but incompetent, and dangerous when aroused  
  • German Shepherds Bureaucratic, commonly suffer from anal retentiveness, which makes them irritable  
  • PoodlesIdeological, focused on a specific peculiar aim derived from a specific peculiar way of looking at the world, to the exclusion of empirical evidence, practical experience and common sense.  

These four breeds display, to varying degrees, the eight 'secrets of success': meet a lot, sniff a lot (yes, they can smell fear), talk a lot, listen infrequently, change a lot, delegate (particularly responsibility without authority), disappear and move on. These 'secrets' seem to be in the genetic make-up of the common breeds of leaders since there is high concordance in monozygotic twins.  

Two behaviours are common to all of these breeds. The first is a preoccupation with SWOT (Scandalously Wasted Opportunities and Time) analyses. The second is a natural talent for self-promotion. Leaders belonging to these breeds are masters of self-citation (exaggerating their credentials), and adept at 'spinning' negative feedback into testimonials (such as 'We were never the same again'). Their reputations resemble creative fiction more than genuine accomplishment. According to Tom Chalmers, by the time people have earned their reputations they do not deserve them (personal communication). Common breeds of leaders are good at moving on before their reputations can catch up with them.  

Two other breeds of leaders are now so rare that it is not possible to characterize them in any detail: golden retrievers (inspiring) and saint bernards (facilitative).  

Table 1 Organizational theories and their diagnostic signs
Theory Pathological features Diagnostic signs
Bushian An imperial and moralistic approach, couched in 'good old boy' chatter. Popular among inarticulate, inept leaders as an alternative to thought Proponents are unable to pronounce the word 'nuclear'
Disjointed incrementalism Advocacy of 'muddling through' rather than rational planning models Recent evidence of a failed reorganization based on rationality
Kafkaesquian Surreal distortion and a sense of impending danger Proponents are suffering from redisorganization, in an effort to explain their experience
Orwellian Futuristic totalitarian approach to organizing Big Brother
Machiavellian Expediency, deceit, and cunning Proponents are strong, authoritarian, benevolent leaders (often misinterpreted)
Maoist Permanent revolution and great leaps forward Proponents think you are talking about John when you quote Lenin
Modern Characterizes health professionals as assembly workers and patients as automobiles. Stresses supervision, division of labour, time and motion studies, and the work ethic Proponents are business school graduates of 1960-1989
Post-modern Psychedelic networks of poly-centres that fold and unfold Proponents are business school graduates ≥1990
Von Clausewitzian Equates organizational planning with war, and highlights the need to seize on unforeseen opportunities Proponents are retired generals or young geeks who grew up playing video games. Explanations written in dense Prussian
Sun Tzuian Like von Clausewitzian theory, but with a greater emphasis on deception Proponents are Western wannabe mystics
Ultra-self-centred celebretarian Ignores the expectations of all but its proponents, who live out their fantasies without worrying about the impacts they have on those they lead Proponents are former or wannabe jocks

Indicators of successful redisorganization


We found many useful indicators of a successful redisorganization, including:  

  • All the good people have left, or become catatonic  
  • Inept people have been given tenure, or its equivalent  
  • Important decisions have been postponed, or are being made on a whim-to-whim basis  
  • Resolutions are being mistaken for solutions  
  • The number of administrators has more than doubled  
  • In healthcare redisorganizations, vast resources have been diverted from patient care, research and education and spent on relocating and refurnishing executives' offices and supplying them with the flashiest business machines  
  • Administrators' office windows point toward, not away from, nearby mountains, lakes, and oceans  
  • Large consultancy fees have been paid to relatives by blood or marriage (hence HARLOT's recruitment programme).  

The generation of these indicators can niftily be summarized as the ABCD of any successful redisorganization:  

  • A minimum amount of thought has gone into a maximum amount of change  
  • Brownian motion has been mistaken for progress  
  • Coincidence has been mistaken for cause  
  • Decibels have been mistaken for leadership.

Implications for Practice

  We have discerned four key lessons from our mega-analysis of redisorganization:  
  1. For leaders and consultants who feed on cyclical redisorganizations: Be loyal to organizations always, and to people never  
  2. For victims of redisorganizing leaders and consultants: Remember that the best-laid plans of mice and managers can be disrupted by creative imagination. Exploit the chaos for more worthy goals  
  3. For those in well-functioning enterprises who want to avoid being redisorganized: Fake it. Make it look like you are redisorganizing already: Schedule (but don't hold) countless meetings; plagiarize, photocopy and distribute (on coloured paper) strategic plans lifted from out-of-town victims; rename traditional sporting and social events 'team-building'; and get on with doing your job  
  4. For perpetrators of perpetual redisorganizations: Why don't you just go … reorganize yourselves.

Implications for Research  

The requirement for ethics approval of anything labelled 'research' spells trouble for advocates of redisorganization. If they are going to continue to label as 'research' the anecdotes that pass for incontrovertible evidence in this area they are going to need ethics approval for the uncontrolled, unplanned experimentation that they inflict on organizations, including the health services and users of the health services (i.e. all of us). The alternative is to admit that the emperor has no clothes and that they are just messing around with us. To get around this, we at HARLOT are establishing special ethics committees, which, for a price, will review the ethics of plans for redisorganizations.  

The answers to five simple questions will determine whether we approve any redisorganization proposal. The first three questions must be answered NO, and the last two YES:  

  1. Is it possible for the new leader proposing the redisorganization to get his/her jollies in some other way?  
  2. Is it possible for the organizational consultants to earn an honest living?  
  3. Does the organogram used to illustrate the new organization have fewer than 22 boxes and 45 connecting arrows?  
  4. Is the organizational theory justifying the redisorganization lifted from a paperback best seller, written by a guru with good anecdotes and catchy phrases, and available in airport bookshops?  
  5. Will HARLOT get a piece of the action?

Redisorganization proposers who initially fail this review are invited to resubmit. If they are smart, they will then avail themselves of HARLOT's 'redisorganization-in-a-box' recovery service. Mind you, if they had been really smart, they would have come to us in the first place.  


ADO, IC, and DLS conceived the idea during a pleasant afternoon stroll on Port Meadow, in Oxford. DLS, IC and ADO went to the concert while TEP was working. All four authors enjoyed the fun of iterative redisorganizations of the manuscript. SA was invited to illustrate the article, but politely declined.  

Competing interests: Lots.

About the Author(s)

Andrew D. Oxman, Researcher, Norwegian Centre for Health Services Research, Oslo, Norway.  

David L. Sackett, Director, Trout Research and Education Center, Markdale, Ontario, Canada.  

Iain Chalmers, Editor, James Lind Library, Oxford, UK.

Trine E. Prescott, Physician, Medical Genetics, Rikshospitalet University Hospital, Oslo, Norway.  

Correspondence to: Andy Oxman, Norwegian Centre for Health Services Research Pb 7004, St Olavs Plass, 0130 Oslo, Norway. E-mail:  


This paper was originally published in the Journal of the Royal Society of Medicine, Vol.98, December 2005, and is reprinted with permission.


1. Sackett DL, Oxman AD. HARLOT, plc. An amalgamation of the world's two oldest professions. A new niche company specializing in how to achieve positive results without actually lying to overcome the truth. BMJ 2003;327:1442-5

2. Oxman AD, Flottorp S, Fretheim A. The OFF theory of research utilization. J Clin Epidemiol 2005;58:117-18

3. Anonymous. The advice business. The Economist 22 March 1997

4. Smith J, Walshe K, Hunter DJ. The ''redisorganisation'' of the NHS. BMJ 2001;323:1262-3


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