Regionalizing Healthcare in Alberta: Legislated Change, Uncertainty and Loose Coupling 1 C. R. Hinings, Ann Casebeer*, Trish Reay, Karen Golden-Biddle, Amy Pablow and Royston Greenwood Health Organization Studies, Department of Strategic Management and Organization, School of Business, University of Alberta Edmonton, Alberta T6G 2R6, Canada *Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta and wFaculty of Management, University of Calgary, Calgary, Alberta, Canada In this paper, we examine the re-organizing attempts of the Alberta government in healthcare from the viewpoint of uncertainty, loose coupling and the frequently unrecognized consequences of such change. We suggest that our understanding of change processes can be enhanced by conceptualizing the impact of task and environmental uncertainty through the nature of coupling between organizational elements. Based on our findings, we propose that the greater the degree of loose coupling in an organization, the more difficult change is likely to be, and the more likely the occurrence of unanticipated consequences. The ‘reform’ of healthcare during the 1980s and 1990s has been at the centre of debates about change and transformation in the public sector around the world, and as such has been instru- mental in re-shaping the healthcare organizatio- nal field and individual healthcare organizations. This reshaping has involved restructurings and reorganizations of health systems, and innova- tions and experiments designed to improve the delivery of health services. Coinciding with this restructuring has been an ongoing, more natu- rally occurring evolution of existing roles within healthcare as well as the introduction of new boundary spanning roles. All of these reforms are meant to produce more integrated services and better health outcomes as well as containing ‘out of control’ costs. These attempts are, to a greater or lesser degree, intentional, planned and legislated. That is, governments responsible for health-service provision pass legislation, develop new structures of governance, accountability and service deliv- ery and lay down timetables for the implementa- tion of these new systems of health delivery. Studies of organizational change demonstrate that planned change is never straightforward, but is full of paradoxes and tensions (Cameron and Quinn, 1988; Quinn and Kimberly, 1984). Some initiatives work out as planned; others do not. It is important to examine the re-organizing at- tempts of government in healthcare from the viewpoint of the frequently unrecognized con- sequences of change, to balance the rhetoric of visions, missions, goals, objectives and plans with organizational reality (Casebeer and Hannah, 1998). Analysis of the unanticipated, unrecog- nized and unstated, consequences of planned change offers the possibility of a distinctive theoretical and policy contribution. 1 The research on which this paper is based is supported by the Canadian Health Services Research Foundation and the Alberta Heritage Foundation for Medical Research. British Journal of Management, Vol. 14, S15–S30 (2003) r 2003 British Academy of Management