This paper draws on a review of the literature about the types of health promotion activities conducted by health promoting hospitals and an observation of how some Australian hospitals have structured the organizational arrangements to be more health promoting. This paper also draws on the experiences of one of the authors (A.J.) in managing and evaluating an organizational change process at a major specialist hospital in Adelaide, South Australia, that sought to re-orientate the hospital towards placing more emphasis on health promotion. From these three sources, a typology of four approaches of organizational arrangement to health promotion is presented. These approaches are: 'doing a health promotion project'; 'delegating it to the role of a specific division, department or staff'; 'being a health promotion setting'; and 'being a health promotion setting and improving the health of the community'. For the re-orientation of the specialist hospital to occur and be sustainable, the research indicated that over the case study period of 1994-1998 there had to be strong organizational commitment to change, supported at multiple levels of the organization, and reflected in policy and practice change. The paper concludes that more evaluative research of this type will be important if the rhetoric of healthy settings is to become a reality.