Organizational Discretion in Responding to Institutional Practices: Hospitals and Cesarean Births

It was found that hospitals' characteristics were influential in determining the use of cesareans only when the level of institutional uncertainty was high, that is, when patient risk was at an intermediate rather than a high or low level.

Abstract

The authors thank Rob Burns, Huseyin Leblebici, Ann Flood, and Randy Brown for comments on earlier versions of this paper. This paper has also benefited from the helpful comments of the associate editor, Christine Oliver, as well as the feedback provided by the three anonymous ASO reviewers. The data were generously provided by Ronald L. Williams, Community and Organization Research Institute, University of California. While others have tried to accommodate agency and interests within institutional theory by directly incorporating a strategic choice perspective, we propose here that institutions are primary and exist as the context within which interests operate. We argue that uncertainty provides discretion, implying that organizational influence on practice will be greatest when institutional standards are most uncertain. We examine these arguments in the context of cesarean section surgeries in hospitals with different ownership and teaching structures. As expected, we found that hospitals' characteristics were influential in determining the use of cesareans only when the level of institutional uncertainty was high, that is, when patient risk was at an intermediate rather than a high or low level.*