1. Nick Bloom and John Van Reenen, Management Practices, Spring 2009 1 Management Practices in Europe, the US and Emerging Markets Nick Bloom (Stanford Economics) John Van Reenen (Stanford GSB) Lecture 5: May 21 st 2009

2. Nick Bloom and John Van Reenen, Management Practices, Spring 2009 2 Management practices in healthcare Management research in India

3. Management is worse in developing countries Average Country Management Score, firms 100 to 5000 employees (score using Bloom and Van Reenen (2007) methodology)

4. The tails drive much of the lower developing average Firm-Level Management Scores

5. This raises three linked questions What is the impact – if any – of bad management on firm (and ultimately national) productivity? If management does matter, why are some firms badly managed? If management does matter and some firms are badly managed, what policies could improve management?

6. To address these questions we ran management experiments in India Prior research provides evidence that management is important for productivity But hard to confirm causality without field experiments Because of the cost of doing field experiments no prior work with medium or large firms. Only with micro entrepreneurs. Our approach has been to work with a small sample of large firms and collect detailed data across metrics and time

7. The experiment randomizes a management shock Select 16 plants in Indian fabric firms with ave 250 employees –Textiles is the largest Indian manufacturing industry –These firms are big enough to need formalized management Within this group we randomly select eight matched pairs: – 8 treatment plants, given extensive free consulting – 8 control plants, given very light consulting Firms selected according to –Size (100 to 1000 employees) –Location (near Mumbai and within 1 hour of each other) –Data (have sufficient pre-intervention data) –Agreement (CEOs & PMs agree to free consulting)

8. Textile firms in India have similar management scores to the rest of manufacturing in India All manufacturing except textiles N=424, mean=2.67, sd=0.664 (within SIC2) Textiles (SIC2==2), N=96, mean=2.69, sd=0.548 Management scores

9. Two stage project timing Started with a pilot wave on 6 firms in August 2008 Started main wave on 16 firms in April 2009 Today I am going to present data from the pilot wave

10. How can better management raise productivity? Operational efficiency and safety Inventory management Quality control Monitoring and planning People management Why were these practices not introduced before? This slide deck outlines some preliminary findings

11. Many parts of the factories are dirty and unsafe

12. The factories are also disorganized Instrument not removed after use, blocking hallway. Cotton lying on the floorInstrument blocking the hallway Oil leaking from the machine

13. Tools lying on the floor. Extremely dirty machine parts And machinery and tools are not maintained (which leads to frequent production downtime)

14. The treated firms have started to introduce basic initiatives (called “5S”) to organize the factory Worker involved in 5S initiative on the shop floor, marking out the area around the model machine Snag tagging to identify the abnormalities on & around the machines, such as redundant materials, broken equipment, or accident areas. The operator and the maintenance team is responsible for removing these abnormalities.

15. Large volumes of waste was removed from the factories and productivity is slowly rising

16. Daily labor productivity – one example firm Example data from firm A

17. How can better management raise productivity? Operational efficiency and safety Inventory management Quality control Monitoring and planning People management Why were these practices not introduced before? This slide deck outlines some of the key areas of management that we are improving in these firms

18. Yarn without labeling or in any sort of order Inventories were very disorganized, so that firms typically had more than a year of yarn inventory Different types/colors of weft Yarn lying mixed

19. Stock is organized, labeled, and entered into an Electronic Resource Planning (ERP) system which has details of the type, age and location. Inventory is now calculated on a daily basis as part of the set of metrics shown to the factory manager Organizing inventories enables firms to reduce capital stock and reduce waste (yarn rots)

20. New stock is ordered by demand forecast. Sales is also informed about excess stock so they can incorporate this in new designs. Shade cards now produced for all surplus yarn. These are sent to the design team - which are typically based in central Mumbai several hours drive from the factory - so they can utilize in future designs

21. Inventory levels are slowly falling Example data from firm A

22. No protection to prevent damage and rust There was a similar story for spares – these could often not be found or were damaged Spares without any labeling or order

23. Organizing spares reduces downtime (since parts can be located quickly), capital stock and waste Nuts & bolts sorted as per specifications A stand made in-house for storing reeds Parts like gears, bushes, etc. sorted as per specifications

24. How can better management raise productivity? Operational efficiency and safety Inventory management Monitoring and planning Quality control People management Why were these practices not introduced before? This slide deck outlines some of the key areas of management that we are improving in these firms

25. Production information is collected but is rarely stored electronically or analyzed

26. 26 Before treatment: the preventive maintenance record is not properly maintained. After treatment: the appropriate recording format is designed and used Part of the problem is much of the documentation is also ad hoc

27. Data formats were simplified & converted to electronic modes to facilitate analysis and tracking BeforeAfter The quality defects were captured in a format with poor readability which did not allow any data analysis Quality defects are now stored in electronic format and a daily quality score is calculated and tracked

28. This data is now used in the new daily production and the weekly sales & operations meetings Meetings aimed at continuous improvement based on high frequency performance analysis

29. Better organization helps in many areas – for example on time deliveries  Tracking production allows firms to change scheduling if orders are forecasted to be missed  Sales now has visibility of the production schedule so can commit to dates that are feasible when taking orders  Late production requires expensive air freight

30. How can better management raise productivity? Operational efficiency and safety Inventory management Monitoring and planning Quality control People management Why were these practices not introduced before? This slide deck outlines some of the key areas of management that we are improving in these firms

31. 31 About 1/4 of employees are involved in quality checking and repair

32. 32 Previously quality checking was only used for customer rebates No standardized way to capture defects, so daily quality score was not available. No standard fabric grading norms

33. 33 The quality format is changed to accommodate all the frequent defects. This is used to calculate a daily Quality Defects Index (QDI). This is analyzed daily. Now quality is measured in a systematic way, on a daily basis, and used for continuous improvement

34. Quality is gradually improving, and as this happens less labor is used for checking and repair Example data from firm A  Every fabric is given a grade (A, AB, B or C) at the gray checking stage  A fabric is graded as ‘A’ if it has one or lesser number of defects which can be cut from the fabric at the stage of packing  Grade A fabrics command the highest prices. Grade B or below are often unusable.

35. How can better management raise productivity? Operational efficiency and safety Inventory management Monitoring and planning Quality control People management Why were these practices not introduced before? This slide deck outlines some of the key areas of management that we are improving in these firms

36. Longer run improvements also require reforming HR practices to improve employee morale and incentives. Some limited changes have been done. Director presenting a reward to the Top Weaver at the factory in the month of November The names of the Top performers displayed on the notice board at the factory

37. How can better management raise productivity? Operational efficiency and safety Inventory management Monitoring and planning Quality control People management Why were these practices not introduced before? This slide deck outlines some of the key areas of management that we are improving in these firms

38. “information” and “human capital” were the main reasons these practices were not introduced before Across 128 individual management improvements Accenture undertook a root-cause analysis to evaluate why these management improvements had not previously been undertaken

39. This informational gap is not surprising Management practices are gradually evolving over time But these firms do not have links with well managed domestic firms (e.g. Tata or Reliance) or foreign multinationals They also have no employees with good engineering degrees, or any sophisticated customers And no firm has ever hired consultants – they seem to have no idea they are particularly badly managed So there is no easy route for better management practices to filter through into this population of firms

40. This suggests policies to increase managerial awareness could have major impacts Good management – like any technology – will generate direct productivity improvement and positive cross firm spillovers Policies to help improve management include: - Improved basic business and engineering education on finance, operations and HR basics - Greater foreign exposure via competition, ownership & exports - Government and industry association provided training - Encouraging a cheap domestic consulting industry

41. Generality of the Management Practice Tool The management scoring was originally designed for manufacturing and many examples are from this sector But almost of the questions are designed to be generic, so applicable across all industries Healthcare, retail, schools, tax collecting agencies...... 41

42. 42 Management practices in healthcare Management research in India

43. 43 THE HOSPITAL MANAGEMENT SCORECARD PATIENT PATHWAY (2 questions) – lay-out of hospital, inventories, how changes in this occurred MONITORING (6) - tracking, review & evaluation, follow-up etc. TARGETS (5) - transparent, stretching, inter-connected, time horizon, PEOPLE (5) - promotions, rewards, fix/fire, retention etc.

44. HOSPITAL MANAGEMENT SURVEY SAMPLE 161 respondents covering 100 English acute NHS hospital trusts (population sampling frame of 164) – Response rates uncorrelated with performance (and other observables ) Also a smaller sample of 21 private hospitals

45. “EXTERNAL VALIDATION” OF THE SCORING casemix, size, noise controls Performance measures all taken from external sources (NHS public databases) Note – not a causal estimation, only an association

46. Improving management scores associated with significant improvements in hospital performance Notes: This shows implied improvement in outcome (in standard deviations) following a one standard deviation increase in the hospital management score

47. Improving management scores associated with significant improvements in hospital performance

48. FIG 3: MANAGEMENT SCORES LOWER FOR NHS HOSPITALS THAN PRIVATE MANUFACTURING FIRMS Panel A: Public hospitals (161) Panel B: UK Private manufacturing Firms (651); [50-5000 workers, No multinationals]

49. Gap in Management Scores: Manufacturing vs. NHS Notes: 161 public hospitals interviews, 651 manufacturing plants., common questions only (16)

50. Gap in Management Scores: Private vs. Public hospitals Notes: 161 public hospitals interviews, 21 private hospitals interviews.

51. Dependent variable: Management Foundation hospital (more autonomy)0.633*** (0.180) % managers with clinical qualification0.926** (0.343) BETTER MANAGED HOSPITALS HAVE ALSO HAVE MORE AUTONOMY & CLINICALLY QUALIFIED MANAGERS Notes: 161 public hospital interviews Helps reduce the information & communication gap between senior consultants and management (cf US system & universities)

52. Competition also seems to help improve hospital performance and management practices About 20% of this effect effect is due to improvements in management The effect of competition in the private sector is about twice as big as this Notes: Competition is measured by the number of other hospital trusts in a 30km area Around the trust examined

53. Why could competition have an effect? Quasi-market due to healthcare reforms? Managerial career concerns Learning Something else? Universities?

54. Conclusions Useful tool for management in healthcare – contains information (performance results) Lower scores in public sector than private (especially for people management) Competition matters for performance & management, especially for private sector

55. MY FAVOURITE QUOTES: Customer involvement Interviewer : “Do staff sometimes end up doing the wrong sort of work for their skills? Manager: “You mean like physicians doing nurses jobs, and nurses doing porter jobs? Yeah, all the time. Last week, we had to get the healthier patients to push around the beds for the sicker patients!

56. BACKUP

57. Treatment on the treated: how we selected our sample of firms Started with a sample of 142 fabric firms around Mumbai with forecasted 50 to 5000 employees (based on assets) Kept the 64 firms within the Tarapor and Urmagaon districts, which are two central fabric firm hubs Of those 29 (47%) expressed an interest in free consulting on the initial telephone contact Of those 16 (55%) were willing to provide resources and data within 4 weeks to enable them to be part of the project – Average management score of 2.69 (same as all textiles)

58. Score(1): No, process improvements are made only when problems occur (3): Improvements are made in irregular meetings involving to improve performance in their area of work (e.g., ward or theatre) (5): Exposing problems in a structured way is integral to individuals’ responsibilities. Resolution involves all staff groups. Part of regular processes rather than by extraordinary effort Q3 MONITORING - Continuous improvement How do problems typically get exposed and fixed? Talk me through the Process for a recent problem that you faced. Can you give examples?

59. Score(1): Poor performers are rarely removed from their positions (3) Suspected poor performers stay in a position for a few years before action is taken (5): We move poor performers out of the hospital/department or to less critical roles as soon as a weakness is identified Q15 PEOPLE - Removing poor performers If you had a clinician or a nurse who could not do his job, what would you do? Could you give me a recent example? How long would underperformance be tolerated? Do some individuals always just manage to avoid being fixed/fired?

60. “INTERNAL VALIDATION”: CORRELATION BETWEEN FIRST AND SECOND INTERVIEWEE IN SAME HOSPITAL Correlation =0.53 Notes: standardized management score (16 questions) for hospitals where there Where 2+ interviews. 45 hospital trusts. Weight is inverse of number of sites(unweighted correlation is 0.4). Only trusts where all answers by managers (clinicians)