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A multidimensional model of legitimacy offers both theoretical and empirical benefits to organizational and, more broadly, social scientific inquiry. Much of the diversity in legitimation processes can be captured by closer attentiveness to the varying sources of legitimacy, the levels at which they operate, the institutional elements that they target, and the environments that contextualize their effects Armed with these distinctions, researchers can advance beyond simple, unitary conceptions of legitimacy to address the trade-offs faced by social actors in seeking public approval for their actions from diverse constituencies.We have demonstrated how an empirical framework might be constructed around some of these distinctions. By considering the separate accreditation processes associatedwith the managerial and technical layers of hospital organizations, this study has identified variation in both the benefits and antecedents associated with organizational legitimacy. Our analysis suggests that the salience of managerial and technical forms of normative legitimacy can fluctuate across different institutional regimes Hospitals whose managerial structures achieve a high degree of legitimacy may enhance their survival chances most significantly in regimes that are characterized by the presence of extensive formalized relations. In contrast, hospitals that enjov a high degree of tech- nical legitimacy may enhance their survival chances most significantly in regimes characterized by centralized regulatory and funding controls. While our findings are consistent with these predictions, more extensive study designs, incorporating larger samples and crossnational or crosssectoral analysis, are required to fully evaluate the relation between regime characteristics and the salience of diverse bases of normative legitimacy.The results also suggest that antecedents of legitimacy vary, depending on the nature of the Institutional environment as well as the organizational function that is being legitimated. The mission of an organization, as reflected in its ownership characteristics, is particularly important for attracting managerial legitimacy. Its effects depend primarily, as Parsons once suggested, on the match between the mission and the logic of the overarching institutional regime within which an organization operates. In the healthcare sector, in particular, we found that the shift in dominant logic from one of providing collective goods (e.g., the Great Society programs of the 1960s) to one of profit maximization has had a major influence on the managerial legitimacy of hospitals with different ownership characteristics. The resulting legitimacy crisis of the nonprofit hospital in the era of managed competition raises important policy questions about confidence in eleemosynary healthcare organizations.The analysis has shown that the degree of niche specialism markedly affects the legitimation of managerial structures. We found that general hospitals matched their managerial structures to normative expectations more readily than did specialized hospital forms. With the continuing drive toward universal administrative protocols, as typified by TOM and ISO-9000 standards, there will be increased pressures for specialists to join integrated provider organizations to maintain their managerial legitimacy. Whether such legitimacy measures real administrative advantages remains a separate issue (d. Westphal, Gulati, and Shortell, 1997). By coupling analyses of legitimacy with studies of efficiency or strategic adaptation (e.g., Huef's 1997 study of hospital service portfolio changes), it may be possible to separate true differences in managerial efficacy among generalists and specialists from the socially constructed aspects of accreditation.
Methodological limitations in the present analysis can also be addressed in future research. We have already noted that larger event samples are desirable in considering period specific legitimacy effects. More direct measures of variables such as centralization are also useful and may eliminate the need for broad based period characterizations. Our discussion of the impact of age on legitimacy has ignored the possible relevance of relative inertia as it affects organizational legitimation-e.g., the fact that an older hospital that is
highly legitimate in one period may be less so in another be- cause of difficulties in adapting to new standards of technicalor managerial excellence. The overlapping of legitimation sources is another issue that can benefit from further con- sideration. What pressures exist for sources to differentiate or combine the targets of their evaluation efforts? What accounts for the historical pattern of sponsorships between legitimacy sources? These questions must await a separate treatment.
A final comment is in order concerning the generalizability of our findings. Hospitals are somewhat atypical among organizations in confronting so many kinds of formalized accreditation sources. While all organizations require some level of legitimacy as a condition of their viability, and all must confront and relate to varied sources of legitimacy, few face as exacting an evaluation as hospitals currently do. Nevertheless, the last decade has witnessed the rapid spread of formal technical and managerial standards (e.g., ISO certification), even in those sectors that have not traditionally been subject to strong institutional demands. Although the loss of accreditation or certification in other sectors may not introduce the crisis that it can for hospitals, it is worth noting that formal normative approval clearly conveys important strategic advantages to many other organizational types. As Oliver (1991) and Such man (1995) have proposed and Elsbach and Sutton (1992) have demonstrated, organizations are not simply passive recipients in legitimation processes but work actively to influence and manipulate the normative assessments they receive from their multiple audiences.
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