This paper aims at positioning organizational design as an important phenomenon in the field of project management with a high potential of contributing to organizational theory. While organizational design has been neglected by scholars of management and organizational theory, it has been of great interest to those from the project management field. This incongruence—comprising the focus of this study—calls for new insights on theorization in context. The paper provides a preliminary theoretical framework combining contingency theory, the historical approach and social theory to understand organizational design, both as a thing and as a process . It provides empirical evidence from three case studies in healthcare. Findings confirm the specificity of each design while at the same time adopting a similar temporal pattern. We take this opportunity to highlight the seminal work of Rodney Turner on project-based organization and design. Executive summary In this day and age, it is commonplace to assert that organizations are complex and that they change continuously over time. The complexity is said to exist, for example, in large organizations dealing with multiple competing projects while at the same time performing their regular operations. The concept of organizational design refers to both the resulting organization (the thing ) and the process of performing the design. The field of project management has made many theoretical contributions to organizational design; yet it has also created confusion by introducing a plurality of terms for describing and understanding such organizations. Organizational design is increasingly a topic in the literature from management and organizational theory and, especially, from project management. A review of the literature from both fields demonstrates that contingency theory is still considered as a major theoretical foundation for situating the organization within its context. The review also points to an increasing interest in social perspectives taking into account politics, organizational dynamics, paradoxes and pluralism. In addition, it shows an opportunity for scholars in project management to contribute to management and organizational theory. This research proposes a pluralist theoretical framework for tackling contingency theory with the historical approach and social theory. The empirical setting is comprised of complex large organizations—in this case, three university hospitals engaged in major organizational transformations—that are challenged to pursue their regular operations while undertaking multiple completing projects. Interestingly, the three hospitals are from the same geographical region. The organizational design was thus a crucial question and, in light of the complexity, no one-size-fits-all type of solution was strived for. Results confirmed the prevalence of individual organizational design rather than mimetism, or homogenization, between the three hospitals. Being in the same region, the heads of the respective project management offices met on a number of occasions to exchange about their challenges and solutions. Nevertheless, in the end each hospital made an individual decision regarding its organizational design. The study also identified organizational design as an ongoing process, introducing the concept of trajectory to illustrate how projects and organizational design change over time. In doing so, we observed a pattern where reflection and sense-making took place before engaging in any specific decision regarding the organizational design. The theoretical contribution of this research is to demonstrate the potential of pluralist theoretical frameworks for understanding complex phenomena such as organizational design in the context of managing multiple projects. More specifically, the process view of organizational design was found to reveal new insights that would have remained hidden otherwise. From a practical view, our research challenges certain utopian assumptions regarding the stability and replicability of a one-size-fits-all model in organizational design. Instead, we recommend developing an in-depth understanding of an organization's specific context by means of sense-making activities. The latter should be performed in an ongoing approach to ensure that the organizational design evolves in keeping with its environment.