Professional discretion and length of work experience: what findings from focus groups with care managers in elder care suggest

ABSTRACT

Research has explored how care managers in elder care – who often function as ‘street-level bureaucrats’ – regard professional discretion. The way in which length of work experience affects care managers’ use of professional discretion remains, however, unexplored. This article present findings from 12 focus groups with 60 care managers. By bringing attention to how care managers experience the needs assessment process, this article sheds light on how these ‘street-level bureaucrats’ struggle when they try to balance their clients’ needs against institutional frameworks and local guidelines. Length of work experience seems to play a role in how care managers claim to use professional discretion. Experienced care managers describe how they deviate from the guidelines at times in order to create an increased scope of action in their decision-making process. Those with less time in the profession describe greater difficulties in this respect. Findings suggest that research should explore if length of work experience plays a role in the actual way in which care managers assess needs and make decisions. As such, they contribute to our understanding of how needs assessment processes are navigated by professionals while also pointing towards the nature of professional discretion in gerontological social work.     

技术特征、关系结构与社会化购买行为

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国家治理体系与政府购买公共服务

政府购买公共服务关系到政府职能的转变和政府治理水平的提升,关系到政府与市场之间功能与地位的调整与理顺,因而是国家治理体系的重要一环。政府购买公共服务背后体现的是国家治理体系现代化的取向,那么在理论逻辑上是要以新公共管理理论、政府治理、第三方治理和多中心治理理论为理论基石。目前,我国政府购买公共服务还存在着范围不清、关系不顺、法律不健全的制度现实,因而必须构建科学规范的现代化的政府购买服务制度和配套制度体系,以进一步推进国家治理体系的制度现代化。     

地方政府重大决策机制存在问题及优化路径

地方政府作为地方公共事务管理者，决策正确与否直接关系到公共管理活动的成败，并且在一定程度上影响地方经济发展的水平及其核心竞争力。由于我国地方政府现阶段决策主体多元性及其职能模糊性，一些重大决策失误现象屡屡发生，造成了有限资源的巨大浪费，严重影响了地方政府在人民群众中的威信和形象。对此，我国地方政府迫切需要优化重大决策机制，包括明晰体制内外决策主体的职能、第三方评估、公众参与、决策终身责任追究及倒查机制等，以推进地方政府决策的民主化、科学化和法治化。     

政府向社会力量购买服务改革的制度障碍及对策

政府向社会力量购买服务不仅是推动政府职能转变的重要着力点,而且是扶持社会力量发展的重要措施。各地在推动这项改革过程中取得了很大成效,但也存在着制度设计不严密、制度衔接不顺畅等问题和障碍。将这项改革深入推进下去,需要坚持有层次地放开政府资源,加强对整个购买过程的动态管理以及建立政府购买公共服务改革同其他改革之间的联动机制等多项措施的推动。     

Using Lean Six Sigma to improve mobile order fulfilment process in a telecom service sector

This study proposes and follows a specific and systematic framework for implementing Lean Six Sigma (LSS) methodology in a telecom company in order to improve customer satisfaction by minimizing the company’s response time to customer requirements. The goal of this study was achieved by utilizing several LSS tools under five phases of the DMAIC methodology. Unlike previous studies in the telecom sector that used only qualitative method, in this study, both qualitative and quantitative methods were utilized to draw meaningful conclusions. As a result of the implementation of the LSS methodology, the average order fulfilment lead time for sales orders (SO) and value-added service (VAS) orders was reduced from 10.3 to 5.9 days and from 1.5 to 0.5 days, respectively. The reduction in lead time resulted in an increase in the sigma level for SO and VAS orders from 0.44 to 1.26 and from 0.73 to 2.66, respectively. These improvements were expected to lead to a financial benefit in savings of over $600,000 per year in operational costs, enhancements to customer experience and an increase in revenue generating opportunities. Moreover, this article enriches the existing literature on the application of LSS concept in the service industry, and helps the company to speed up the response to customer requirements.     

一把尺子如何“量到底”:基层治理中的制度硬化——以一个城市更新试点项目为例

城市更新中日益增长的社会压力使基层政府产生制度硬化的需求，但持续的高压体制又使其延续制度弹性的逻辑，两者间张力凸显，构成当前的治理困境。本文通过对一个试点项目中制度硬化实践的观察提出核心问题：权力运作空间如何在日益增强的规范性约束下得以再生产。本案例中，制度硬化被拆分为“结果硬化”和“过程硬化”两部分，前者标识着鲜明的刚性边界，后者则暗中预留出弹性空间。通过外部条件硬化、让步规则硬化、加压底线硬化这三重机制，基层政府在与社会的互动中由表及里地拓展了硬化原则背后的边界，使权力运作空间以一种更为正式化、制度化、组织化的形式不断生产出来，展现出更深层、隐秘的治理技术及国家与社会的相互形塑过程。     

Max‐infinitely divisible models and inference for spatial extremes

For many environmental processes, recent studies have shown that the dependence strength is decreasing when quantile levels increase. This implies that the popular max‐stable models are inadequate to capture the rate of joint tail decay, and to estimate joint extremal probabilities beyond observed levels. We here develop a more flexible modeling framework based on the class of max‐infinitely divisible processes, which extend max‐stable processes while retaining dependence properties that are natural for maxima. We propose two parametric constructions for max‐infinitely divisible models, which relax the max‐stability property but remain close to some popular max‐stable models obtained as special cases. The first model considers maxima over a finite, random number of independent observations, while the second model generalizes the spectral representation of max‐stable processes. Inference is performed using a pairwise likelihood. We illustrate the benefits of our new modeling framework on Dutch wind gust maxima calculated over different time units. Results strongly suggest that our proposed models outperform other natural models, such as the Student‐t copula process and its max‐stable limit, even for large block sizes.     

Every Minute Counts: Using Process Improvement and Performance Feedback to Improve Patient Flow in an Emergency Department

Prolonged emergency department (ED) visits are associated with a number of adverse outcomes for patients as well as lower patient satisfaction scores and increased costs. Several factors that influence the length of ED visits are out of the control of hospital employees, but some opportunities exist to improve performance. For this study, the ED department of a 150-bed hospital in the southeastern United States wanted to improve door-to-discharge time. To do so, a subprocess of door-to-discharge time was targeted, door-to-order. After analyzing the process, the team created standard orders for the 10 most common presenting conditions in the ER with preapproval, allowing nurses to submit the orders without the provider first visiting the patient. Following the process change, daily feedback was added to increase utilization of the preapproved orders. Reductions in door-to-order times and door-to-discharge were observed and patient satisfaction remained stable. Implications for future research in this area are discussed.