Access for All? Custodial Authority in Legitimizing Places of Social Inclusion

The current scholarly view of places of social inclusion in management scholarship positions the societal-level tenet of “open accessibility” as taken-for-granted by local actors who are committed to maintaining citizens’ access to these places. Little is known about instances in which custodians differ in supporting the values of places of social inclusion and, consequently, question one another’s rights to uphold these values. In this paper, we conducted an inductive, qualitative, and sequential, comparative case study of two US community hospital emergency departments (EDs) to examine authority dynamics in places of social inclusion. We found that although federal and private health insurance companies in the US were tying patient satisfaction scores to financial reimbursement, the value of open access to ED care was not taken for granted in these places nor was asking patients to make judgments about their access to services. Our findings reveal how these dynamics triggered different authority dynamics and custodial work in the two EDs we studied, which ultimately shaped whether patients’ access to care improved. In doing so, we bring together and elaborate recent research on heterogeneous custodianship, places of social inclusion, and authority in organizations. We also offer practical solutions to health care challenges based on our research.