Discretion and the effective implementation of public policy in urban health care institutions

摘要

Case study research identified characteristics of the individual, the environment and the client as salient influences over the use of discretion by front line non-professionals. The main hypothesis was that discretion is a necessary function of how these personnel understand and act on policy directives. Whether current theories regarding the use of discretion, which focus on the professional level within organizations, should be extended to include non-professionals as well was the focus of the study.;Using mixed methods embedded in the research design, a total of 83 respondents were interviewed at three urban medical institutions. Interview responses related to hypothetical situations as well as those in the context of the actual work environment were audio taped, coded and analyzed using ethnographic and statistical software (Atlas.tiRTM and SPSSRTM ) to determine the extent to which non-professionals were willing to exercise discretion in determining care for patients.;Findings revealed that personal influences such as education, seniority and job title significantly contributed discretionary decisions of front non-professional personnel. In the absence of strong policy formulation and enforcement, they are also influenced by personal experiences, individual values and empathic feelings toward clients in making service access decisions. In addition, the explicit mission of medical institutions to provide care to those in need serves to inform and influence the behaviors of this unique group of bureaucrats.