Perspectives on Various Issues of Interest

Gavi to make Parsyl’s quality assurance platform available in Uganda and Senegal to address last mile distribution challenge

Vaccine supply chain in Uganda 🇺🇬 and Senegal 🇸🇳 to be boosted by a partnership between @gavi and @ParsylHQhttps://t.co/zpsJbargCH#GotLife pic.twitter.com/X8vPHoKyDg

— Gavi (@gavi) January 25, 2019

Differential Impact of Network Size on Cost Performance for High and Low Quality Hospitals

In a recently published study my co-authors and I consider the deductive configuration perspective and distinguish high and low quality hospitals by using clinical and experiential quality as two dimensions of quality capability. We examine the impact of healthcare network size on operating costs of hospitals. Additionally, we investigate the interaction effect of hospital demand and healthcare network size on operating costs.  The results of this study show that quality laggards experience lower costs per day through their affiliation with larger healthcare networks, but experiential quality focusers and clinical quality focusers experience higher costs. In contrast to our hypothesis, affiliation with a large healthcare network does not adversely affect the operating costs of holistic quality leaders. We show that clinical quality focusers and holistic quality leaders can complement the effect of network size and hospital demand to reduce their operating costs. However, quality laggards and experiential quality focusers do not observe a reduction in their costs due to the complementary effects of network size and hospital demand. 

Our results offer important theoretical and managerial implications that we discuss next. Healthcare networks are becoming ubiquitous. Even distinct health systems that can either take the form of a diversified single hospital system or multi-hospital system comprising of two or more hospitals owned, leased, sponsored, or contract managed by a central organization are entering into network arrangements. By being part of a network quality laggards may gain additional patients, which helps in increasing their resource utilization levels. In addition, the ability to learn best practices from other hospitals in the network further helps in reducing their operating costs. The marginal cost for these hospitals to be part of a network is low. However, experiential quality focusers and clinical quality focusers face the challenge of coordinating with other hospitals in the network while at the same time maintaining their quality levels. While health systems have a central governance structure, health networks do not have this ability to exert centralized control for efficiency. Hence, operations of healthcare networks require hospitals to complement their network-based benefits with their demand. Holistic quality leaders are especially well positioned to gain this complementary benefit. The clinical process of care and the practices that are aimed at enhancing patient experience are synergistic. These quality leaders attract larger numbers of patients by their intrinsic quality characteristics and network effects; however, they stand in good stead to achieve demand-based utilization levels and reduce the coordination burden of affiliation with large healthcare networks.

Growth in hospital networks, healthcare demand, and experiential learning calls attention to a better understanding of the relationship between a hospital’s holistic quality profile and its ability to gain benefits from healthcare network. This research sheds some important insights in this domain. There has been increasing evidence suggesting that hospitals must carefully manage both clinical and experiential quality. By focusing on both clinical and experiential quality, unlike experiential quality focusers and clinical quality focusers, holistic quality leaders are not adversely affected by the size of their network. Our results suggest that experiential quality focusers and clinical quality focusers should either embrace holistic quality management or restrict the size of their networks to maintain their quality level and to reduce coordination costs. 

Project Structure and Buyer-supplier Collaboration Quality in New Product Development: A US-China Comparative Study

In a study my co-author and I study how the national context (the social system) interacts with the project structure (the technical system) in influencing buyer-supplier collaboration quality, an indicator of project-level effectiveness of inter-firm interactions. We further examined how structural deviation, the difference between the actual and ideal project structure, differentially influence collaboration quality in China and U.S. We tested the hypotheses using survey responses from 214 U.S. based and 212 China based buying companies. Due to their distinctive national cultures and economic ideologies, the two countries differ in their ideal project structures, the ones that lead to the highest level of collaboration quality. Our research model is as follows:

 

Results suggest that a formal project structure is only effective in enhancing buyer-supplier collaboration quality in the U.S. and not in China. Centralization hurts collaboration quality only in U.S. based projects. These results highlight the important and differential role played by the administrative structure for motivating collaborative behaviors in different national contexts. The task structure, characterized as task interdependence, does not play such a differentiating role as the results show it to be equally effective in improving buyer-supplier collaboration quality in both U.S. and Chinese NPD projects. Supporting the STS view, we also show that the ideal project structure, a result of the interaction between the social and technical systems, varies between U.S. and China. Specifically, the ideal project structure in U.S. is more formal and less centralized as compared to that in China. We also found some support for our prediction that the negative effect of structural deviation on collaboration quality is dampened by China’s national context. Below we discuss theoretical and managerial implications of these findings.

This study presents key insights for project managers about the relative importance of different aspects of the project structure in influencing the quality of buyer-supplier interactions. Compared to the task structure, the administrative structure has a more nationally-contingent impact in shaping buyer-supplier project interactions. Specifically, a formal and decentralized structure, though usually advocated by the project management literature, does not always lead to more effective project-level interactions, especially in countries with similar cultural and economic contexts as China. The significant association between task structure and collaboration quality in both countries suggests the importance of assigning interdependent tasks to each group for encouraging collaborative behaviors. This finding questions the traditional wisdom about outsourcing modular, rather than integral, tasks to external suppliers with the purpose of reducing transaction cost. Specifically, we show that task modularity, though reducing short-term transaction costs, might hurts the quality of inter-firm interactions, which limiting the dyad’s value creation potential. Overall, our findings suggest that project managers could encourage effective project-level collaborations by creating mutually dependent tasks involving both buyer and supplier sub-groups.

Results from this study point to the importance of considering the national context when structuring an interorganizational team. Testing the conceptual model in two culturally distinct countries, China and the U.S., reveals varying effects of project structures on collaboration quality. The comparison between U.S. and China presents two culturally distinct nations who are playing important role in the emerging global product development initiatives. While U.S. has always been a leader in NPD, China is increasingly displaying its product development capabilities. The findings from this study have direct implications for project managers who are in charge of NPD teams in these two countries. Specifically, a formal and decentralized inter-group structure is found to be more effective in enhancing collaboration quality in the U.S. than in China, while task interdependence is equally effective in promoting inter-group collaboration in China and in the U.S. Thus, when initiating interorganizational product development efforts in the global context, project managers are advised to consider the impact of the national culture and economic ideology of different locations in order to cultivate a high-quality collaboration process. By revealing country-level contingency effects evidenced in Chinese and the U.S. based NPD projects, this study shows the inappropriateness of a “one-size-fits-all” approach when structuring NPD teams globally.

The stronger negative effect of structural deviation in the U.S., as compared to China, also has managerial implications. In low-context cultures, such as the U.S., project manages need to pay more attention to identify and stick to the ideal project structure because deviating from it adversely impacts collaboration quality. As shown in this study, the ideal project structure should be congruent with social values held by project members. Such structure-value congruence motivates collaborative behaviors among project members. In contrast, managerial efforts of ensuring maximum conformance to the ideal project structure are less rewarding in high-context cultures, such as China, where negative effect of divergence from the ideal-state is partly mitigated by cultural ethos that dominate public life beyond NPD projects. In such high-context cultures, rather than solely relying on the governance of the ideal project structure, project managers need to understand the implicit rules and unspoken protocols embedded within the cultural ethos in order to cultivate a high-quality collaboration process.

Source: Yan, T. and Nair, A. 2015. Project Structure and Buyer-supplier Collaboration Quality in New Product Development: A US-China Comparative Study. Unpublished manuscript.

Buyer-supplier network structure and product architecture

In a study my co-authors and I investigate the contingent role of product architecture on the relationship between buyer-supplier network structure and product quality. The hypotheses are tested on a combination of primary and secondary data from the North American automobile industry. The results suggest that correspondence between buyer-supplier networks and product architecture networks may not be conducive for product quality. While buyer network density (or tight coupling) is better suited for improving the product quality of modular systems, buyer network centrality (or loose coupling) is better suited for improving the product quality of integral systems. The implication is that greater information sharing between buyers and suppliers is more likely to improve product performance of modular products as compared to integral products.

To test our hypotheses, we assembled data using a combination of archival and primary sources. We focus on firm-system as the unit of analysis. This choice was guided by the observation that there is considerable variation in the composition of supplier networks for different systems of a given firm. We collected data on buyer-supplier links for twelve vehicle systems in 2010. The systems we examine are as follows: transmission, major engine system, engine cooling, suspension, drive systems, exhaust, electrical, power equipment, body hardware, braking system, climate system and fuel system. We focus on these 12 vehicle systems instead of more disaggregate subsystems or vehicle components to keep the functional interactions or dependencies tractable (Novak and Eppinger 2001, Gokpinar et al. 2010). Additionally, a practical consideration was that data on product quality are available at the vehicle system level but not at the subsystem level. We identify suppliers of thirteen automobile manufacturers with significant operations in North America (BMW, Chrysler, Ford, General Motors, Honda, Hyundai, Kia, Mazda, Mercedes-Benz, Mitsubishi, Nissan, Subaru and Toyota). The thirteen auto manufacturers accounted for approximately 85 percent of vehicles sold in North America. The data collection efforts yielded a total of 964 unique suppliers for 13 automobile firms and 12,667 unique B-S relationships. The following figure presents an illustrative supply network for the electrical system network comprising of 3,656 ties between 507 entities (13 automakers and 494 suppliers).

 

The data on quality of auto manufacturer’s vehicle systems for 2011 was assembled from Consumer Reports. There are two important issues to be considered in matching B-S relationships with quality outcomes. First, data on B-S relationships was available at the ‘automaker-vehicle system’ level whereas data on product quality is at the ‘model-vehicle system’ level. For example, consider the case of Subaru of America, the automaker. While we constructed the supplier network for Subaru, the quality data is available at the model level (e.g., Outback, Legacy) of Subaru. We aggregated model-level quality by weighting on model sales to construct the automaker’s quality for a vehicle system. Second, we only included suppliers of models that were manufactured in North America. For example, Subaru of America manufactured three of its five models (i.e., Outback, Legacy and Tribeca) in its North American assembly plants. We identified suppliers of these three models of Subaru and excluded suppliers of two manufactured outside North America. Likewise, we aggregated product quality for Subaru by using sales weights for the three models manufactured in North America.

We relied on primary data sources to operationalize the Strength of Design Interface (SDI) variable. We conducted 31 in-depth interviews with product and design engineers in automobile and supplier firms to gauge the dependencies between various systems in a vehicle. The in-depth interviews lasted approximately 90 minutes in duration. The experts participating in the survey were employed at General Motors (USA and India), Ford, Chrysler, Honda, Toyota, BMW, Porsche, Hyundai (USA and South Korea), Aisin (USA), Bosch (USA and South Korea), Cummins, Denso, Mando, SAIC Motors, Maruti (India) and Ashok Leyland (India) and had, on average, approximately 13 years of experience in automotive design. To assess SDI, we asked product and design engineers to evaluate the degree of information, spatial, structural, material and energy dependencies between vehicle systems (see ‘Measures Section’ for details on the questionnaire items). We also asked these experts whether the level of dependency criticality and absolute criticality of systems vary across major automakers. All but one expert indicated that dependencies do not vary across automakers. In other words, the strength of the design interface is system-specific and is not contingent on the automobile manufacturer.

We also collected data on several supplier and buyer characteristics. Data on the size of the supplier’s plants (in square feet), distance in miles between the supplier and auto manufacturer, the union status of suppliers, and quality awards of supplier were obtained from ELM Analytics. We also collected data on buyer characteristics such as sales from the Ward’s Automotive Yearbook and R&D expenditures from COMPUSTAT and annual company reports.

A test of our hypotheses requires a close alignment between the theory, measures and the empirical model. We model the impact of buyer-supplier network characteristics in time period ‘t-1’ on product quality in time period ‘t’. The temporal separation facilitates a more confident interpretation of the quality consequences of B-S network structure. Our final dataset for empirical analyses is comprised of 156 firm-system observations (13 makes x 12 systems). The B-S network characteristics and control variables are for 2010 and product quality data is for 2011.

Our findings show that buyers in dense networks experience better product quality outcomes compared to buyers that are centrally located. We find that integral systems have higher quality compared to modular systems. More importantly, our results reveal that buyer network density enhances the quality of modular systems to a greater extent compared to integral systems. On the other hand, a central position for buyers is beneficial for improving product quality for integral systems than for modular systems. 

The findings of this study offer numerous valuable insights for managerial practice. In recent years, there has been increased emphasis on improving supply chain performance. The emphasis has been on using concepts such as modularization, flexible and lean manufacturing to boost performance. Despite such advances, the poor performance of supply chains, as evidenced in growing number of product recalls in the marketplace, continues to frustrate and disenchant managers. Our findings caution managers to refrain from viewing network density as beneficial and network centrality as detrimental to quality. Our findings, instead, point to the need to evaluate the normative B-S network structure in conjunction with the architecture of the product. We performed a univariate transfer function analysis to understand the economic value added by matching buyer-supplier network structure and product architecture. We computed the direct impact of changes in automakers’ network density and network centrality on product quality for high and low levels of SDI. The high and low levels for buyer network density, buyer network centrality and SDI are set at the 90th and 10th percentiles. To compute the dollar impact of change in product quality, we turn to previous research that has assessed the shareholder value impact of product quality. Tellis and Johnson (2007) note that increasing product quality from 10^th percentile to 90^th percentile value leads to a 9.35% increase in shareholder wealth. The average market capitalization of publicly traded automobile firms in our sample is $73.37 billion. In our sample, this translates to an increase of $6.86 billion. The difference in product quality between 90^th and 10^th percentile in our sample is 1.87 points. Thus, a one point increase in product quality corresponds to an increase in market capitalization of $3.67 billion.

Our post-hoc analyses reveal that if buyer network density is increased from the 10^th percentile to the 90^th percentile, there is significant increase in product quality for low SDI systems relative to high SDI systems (difference in quality = 0.11 points). That is, when buyer network density is increased, there is a greater increase in product quality for modular systems than for integral systems. The total economic value created when buyer network density is aligned with modular systems is $403.56 million. Although dense networks are costly to maintain because of intensive information sharing, our post-hoc analyses reveal that buyers could harness considerable economic value from dense ties by aligning it with the appropriate product architecture. Similarly, if buyer network centrality is increased from the 10^th percentile to the 90^th percentile, there is significantly greater increase in product quality for high SDI (system design interface) systems relative to low SDI systems (diff = 0.05 point change). Correspondingly, there is greater increase in shareholder wealth at high levels of SDI than at low levels of SDI. The total economic value created when buyer network centrality is aligned with integral systems is $183.43 million.

Source: Kalaignanam, K., Kushwaha, T. and Nair, A., 2015, January. Buyer-supplier network structure and product architecture. In Academy of Management Proceedings (Vol. 2015, No. 1, p. 13626). Academy of Management.

Six Sigma Quality Innovation & Organizational Theory Typology

Implementations of Six Sigma quality innovation (SSQI) have resulted in performance benefits for several leading firms. While SSQI has its roots in the foundations of Total Quality Management (TQM) and ISO 9000 certification, it presents a set of unique organizational practices and ideas that provide an opportunity for interesting and important investigations of relevance to operations and supply chain management. With a few notable exceptions, the academic literature in operations management has not given sufficient attention to various aspects of SSQI. In a paper, my co-author and I identify some potential areas for future research and develop research questions pertaining to these areas. We call for theory-driven investigations by presenting the organization theory typology as a framework for linking SSQI research issues with appropriate theoretical perspectives. Using the unit of analysis and the various perspectives for managerial action as a basis, the typology presents six categories of organization theories. The typology provides a convenient basis for categorizing the research issues in SSQI based on their underlying theoretical rationale. We use the linkages between the research issues in SSQI and the theoretical perspectives to develop research propositions that could potentially aid and instigate theory-driven research studies in quality innovation.

The following figure positions research issues pertaining to SSQI in the organization theory typology:

Source: Narasimhan, R., Nair, A. 2015. “Towards a Theory-Driven Research Agenda in Six Sigma Quality Innovation: Linking Research Opportunities with Organization Theory Typology,” International Journal of Quality Innovation, 1:5.

ISO 9000 practices and the Development of Intellectual Capital

In a recent paper my co-authors and I investigate the relationship between internalization of ISO 9000 practices and the development of intellectual capital within organizations. We posit that intellectual capital, which comprises of human capital, organizational capital, and social capital, leads to improved processes in an organization. Process improvement, in turn, results in superior operational performance.The research model is as follows:

Using a sample of 321 ISO 9001 certified organizations, the hypothesized relationships are tested by means of the structural equation modeling technique. The results of this study show that performance benefits from the internalization of ISO 9000 standards occurs mainly through the development of human and organizational capital, and the consequent improvement in business processes. 

The results of this study show that We show how continuous improvement initiatives in the ISO 9000 internalization process result in enhanced use of information to improve products and processes as well as in development of human capital. Internalization of ISO 9000 initiates training and development programs for the workforce, and documentation and storage requirements for the knowledge dissemination throughout the organization. As a result, the organization becomes a medium of proficient knowledge sharing and socialization of the competent employees. These factors enable the firm to move toward superior performance. This indicates that managers should focus on internalization of ISO standards instead of merely aiming for ISO 9000 certification. This helps in boosting confidence of employees and enhancing their effectiveness in performing tasks. It also results in more consistency in terms of the way various activities are performed within an organization.

Knowledge management practices resulting from internalization of ISO 9000 standards create norms and procedures as to how the knowledge is stored and disseminated in the organization. The employees refer to the codebooks, which are basically the stored knowledge, and rely on each other to achieve
process improvement. Effective development of organizational and human resource capabilities with the help of internalized ISO 9000 standards enable an organization to outcompete other firms. This study shows that the implementation of ISO 9000 is not simply about complying with the requirements and attaining the certification; rather, it is concerned with the intellectual structure of the firm.

Understanding this issue represents a real step forward in developing capabilities since the focus is now on the effectiveness of the quality system for the entire organization as against solely the “conformance” of processes to the prescriptions of ISO 9000 standards. A quality management system, such as ISO 9000 standards, must be focused on internalizing knowledge about processes and the steps needed for process improvement as against merely on compliance to set procedures. Therefore, while ISO 9000 certification does not provide competitive value on its own due to its imitability, the internalization process provides a good platform for intellectual capital building, if managed properly.

In conjunction with the aforementioned point, the findings of the study point to the need for balancing knowledge with competent workforce within the quality management system as both human resources and knowledge storage devices, routines and emergent network structures are potential assets for organizations. Given the differences in their nature, each of these types of assets will require unique kinds of investments. The findings of this study emphasize the importance of building
complementarities mainly between organizational capital and human capital, which will together produce more effective and unique capabilities for organizations.

Source: Ataseven, C., Prajogo, D., Nair, A. (2014). “ISO 9000 Internalization and Organizational Commitment - Implications for Process Improvement and Operational Performance.” IEEE Transactions on Engineering Management, 61(1), 5-17.

Quality and Flexibility in Cardiology Units

In a recently published article my co-authors and I examine the association of clinical quality and clinical flexibility capabilities on cardiology unit length of stay and cost performance. These relate to the operational performance of cardiology units and capture the timeliness and cost efficiency of cardiac care. We also investigate the complementary role played by the experiential quality in enhancing the impact of clinical quality and clinical flexibility on operational performance measure. Experiential quality relates to patient-centered delivery of care by a hospital. We collect and combine data for 876 U.S. hospitals from four distinct sources and undertake multi-level analyses that consider a hierarchical structure in which the hospital is nested within county and state. To disentangle the effects at the levels of states, counties, and hospitals, we use the mixed-effects modeling approach.The research model is as shown below:

The results obtained from econometric analyses indicate that clinical quality and clinical flexibility reduce cardiology unit average length of stay. Clinical flexibility also helps in reducing the average cost of cardiology units. Experiential quality moderates the impact of clinical quality on length of stay and plays a complementary role in the relationship between clinical flexibility and cost.

The findings of this study present implications for structuring processes and allocating resources in hospitals. It is important to ensure that hospitals supplement their clinical quality and flexibility capabilities with personalized attention to patient needs. Facets such as empathy and consideration for patients’ situation, and room environment play important role in providing patient-centered care. The results highlight the complementary role of these facets, referred to as experiential quality capability, in enhancing the impact of clinical quality and flexibility capabilities on cardiology unit operational performance. Hospitals are operating in a very different environment compared to the 1990s. During these earlier times a significant portion of hospital costs were fixed. There was sufficient capacity and the per-diem revenue earned by increasing patients’ length of stay was higher than the variable costs to provide healthcare. In today’s environment, many hospitals are facing capacity constraints since the decline in managed care utilization management and aging demographics have increased demand. Furthermore, the fixed per diem contracts are also much less prevalent in many markets. Our results show that a holistic management of clinical quality, clinical flexibility, and experiential quality capabilities can make cardiology units better equipped to cope with these changed circumstances by reducing length of stay and costs.

The results of our study present implications for setting up multidisciplinary clinical business units comprised of various services and different functional representatives such as the physician, the nurse, the pharmacist, the radiologist, and the manager. This enables gaining complementary benefits of clinical quality, clinical flexibility, and experiential quality capabilities. Multiple services within a clinical unit help in effectively managing co-morbidities, such that a patient can be moved to different sub-divisions within the clinical unit depending upon their prevailing conditions. Team members with varying perspectives on healthcare could jointly review clinical condition of patients, patient and staff satisfaction data, and operational performance measures within the unit. This team approach results in improved communication among various members, which in turn provides ongoing interdisciplinary education, better coordination of care for patients, and concurrent data feedback. The team-based efforts and open lines of communication with patients could also aid in incorporating evidence-based best practices, which enables audit with feedback such that a summary of the clinical performance of healthcare over a time interval is maintained and is then communicated back to practitioners.

Recognizing the importance of healthcare quality and to facilitate a broader understanding among healthcare providers, consumers and policy makers, the Institute of Medicine offered the following definition: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The definition proposed by the Institute of Medicine clarifies the meaning of healthcare quality, yet several of the aspects referred in the definition could vary considerably depending on whether one considers the point of view of the healthcare providers or that of the patients. For instance, “desired health outcomes” refers to the accuracy of diagnoses and the effectiveness of treatments in producing health, but providers and patients could have varying perspectives regarding this aspect of healthcare. While providers would consider the clinical aspect of healthcare quality (i.e., type of medical equipment used, the use of healthcare techniques, etc.), patients would form opinions based on overall perception of the healthcare experience. Similarly, the aspect of “current professional knowledge” could vary substantially since healthcare service providers differ in their level and type of training. This difference could intensify depending on the range of related services, type of medical equipment, and techniques that providers use for healthcare. The national debate about healthcare often emphasizes inefficient processes, rising costs, and variations in quality. The necessity of satisfying the needs of various stakeholders (healthcare providers and patients) makes it obligatory to look more carefully into the key factors that influence healthcare operational performance. A holistic consideration of quality and flexibility capabilities is important in order to deliver on the promise of improving healthcare. In this study we establish the distinct role played by cardiology unit clinical quality and clinical flexibility in improving adjusted average length of stay and adjusted average cost performance. The results of this study shed important light into distinguishing these capabilities and highlighting how these capabilities improve operational performance.

Disparities in cardiovascular health across geographic locations are well documented. These disparities manifest in the form of healthcare challenges and access barriers, and pose one of the most serious public health problems. Socio-economic factors, such as unemployment, poverty, low educational level, and income inequality, also vary across geographic locations and contribute towards cardiovascular health disparities. Although there have been remarkable declines in cardiovascular mortality observed nationally over the last three decades, the disparities across population subgroups and geography are widening. In fact, Healthy People 2020 national public health agenda8 includes the elimination of these disparities as one of its goals. Our multi-level investigation in which the effects of state and county manifest at different levels accounts for disparities associated with complex environmental conditions within which hospitals operate.

Source: Nair, A., Nicolae, M., Narasimhan, R. (2013). “Examining the impact of clinical quality and clinical flexibility on cardiology unit performance - Does experiential quality act as a specialized complementary asset?” Journal of Operations Management, 31(7-8), 505-522.

Plant Exports and the Link between Manufacturing Technologies and Performance

In a forthcoming paper my co-authors and I examine if plant exports influence the link between manufacturing technologies and performance. Over the course of last two decades there has been a steady degradation of technological and competitive capabilities of manufacturing firms in several developed nations. Proponents of trade-liberalization have asserted that a policy aimed at increasing exports could help in resurrecting the manufacturing sector and strengthening manufacturing competitiveness. Trade liberalization provides new set of opportunities and instigates innovation and adoption of new technologies. Since competition brings out high degree of innovation and improved performance, it is reasoned that a firm that is exposed to foreign markets will seek to use new and advanced technologies for competitive performance. International trade also facilitates transfer of knowledge and ideas pertaining to technology and innovation, and international best practices, which contribute to learning and productivity growth in manufacturing firms. Further, exporting also enables scale economies because of expanded markets which permit increased technology use and innovation. It has also been noted that exporters are more likely to develop staff competencies in technology use.

In concert with this expected link between innovation capabilities and exports, we witness several policy decisions that are trying to bring the two issues together. For instance, the recent National Export Initiative (NEI) aims to double American exports over the next five years. While the core aim of this initiative is to bring the unemployment level down, it will also positively impact manufacturing innovations provided the policy consciously consider the need to propel export of manufactured goods. The 2010 economic report released by the Council of Economic Advisers of the Presidentof United States emphasizes asserts that the government is interested in taking concrete steps to encourage exports. Several governmental agencies, such as the Trade Promotion Coordinating Committee, Export-Import Bank, and Commerce Department are engaged in helping firms export.

Interestingly, while these policy initiatives consider a link between exports and innovation, it is unclear how these patterns of innovations would manifest in manufacturing plants. To gain clarity on how manufacturing plants will gain innovation-based competitive advantage from exports, it is important to undertake an in-depth examination of process innovation patterns within manufacturing plants. It is important to link the macro-economic context of trade-liberalization and exports with micro plant-level technology and process realities. This will help in extending our knowledge base beyond the current understanding that has mostly focused on firm and national innovation competitiveness.  This study’s thesis is that exporting manufacturing plants face strong competitive pressures and consequently adopt advanced manufacturing technologies to maintain competitive advantage. We empirically examine this thesis by using historical data from a period in which U.S. plants witnessed increased trade and growth.

Specifically, we focus on the period of 1993 – 1997 which presents an excellent setting for this study. Between 1993 and 1997, the United States enjoyed a sustained economic expansion with real GDP growth averaging over 2.8% during the years 1992-96 and accelerating to 3.9% in 1997 and 1998 partly due to the impetus provided by trade and investment liberalization resulting from the Uruguay Round Agreements and the North American Free Trade Agreement (NAFTA). In essence, the time-frame represents a period of high export growth in the United States. The impressive growth during this time period was enabled by the growth in investments in technology, plant, equipment, and other productivity enhancing factors due to the ready availability of external financing and the marked reduction in government borrowing, which left more resources available for private use (World Trade Organization, 1999). The insights gained from this period characterized by increasing exports provide a valuable baseline of the linkage between exports, skilled use of technologies, and performance. It has been observed that the U.S. economy goes through cycles of expansions and contractions. The lessons learnt from this study may be used to understand the problems of US manufacturing sector now or in the future.

Using this macro-economic environment as its background, this study adds to the literature by examining how exporting plants differ from non-exporting plants in terms of their use of hard and soft manufacturing technologies; no previous study has ever investigated this issue. The study posits that plants with varying export intensities differ in terms of the use bundles of practices within the set of hard and soft manufacturing technologies. As overall exports within the economy increase, the emphases on technology bundles change and evolve over time. Further, the study examines how the emphases placed on the bundles of soft and hard manufacturing technologies impact performance over time.

The paper integrates the macro-economic environment and the issue of plant exports with the rich stream of literature in operations management domain that focuses on manufacturing technologies. Studies have distilled the difference between technology investments and technology use and have asserted that it is the latter that leads to performance improvements. We consider the skilled use of technology and examine its impact on firm performance. Furthermore, manufacturing technologies can be classified into hard and soft technologies. Hard manufacturing technologies generally include capital intensive investments in manufacturing operations, such as flexible manufacturing systems (FMS), computer integrated manufacturing (CIM), computer-aided manufacturing (CAM), computer-aided design (CAD), robots, automated inspection(AI), local area networks (LAN) and computer numerical control (CNC) machines. On the other hand, soft manufacturing technologies focus more on the planning and administrative practices such as just-in-time (JIT) manufacturing practices, materials requirement planning (MRP I), manufacturing resource planning (MRP II), manufacturing cells (MC), statistical quality control (SQC) and total quality management (TQM). In our research investigation we explicitly categorize manufacturing technologies into hard and soft technologies to gain deeper insights into the distinct ways in which the use of these technologies relates to exporting and to understand how these technologies impact performance outcomes.

The paper employs several multivariate statistical analyses techniques to examine four hypotheses that link plant exports (high, medium, and non-exporting), manufacturing technologies, and performance (objective measures of plant rejects and lead time from orders to shipment). The results of this study indicate that exporters engage in more skilled use of manufacturing technologies than non-exporters. Further, exporters not only have higher skilled use of manufacturing technologies from non-exporters, but they also expand the scope of technologies that they skillfully employ in their operations. We find that over the course of liberalized trade regime, medium exporters get closer to high exporters in their skilled use of manufacturing technologies providing evidence of learning effect from exporting. Finally, higher skilled use of manufacturing technologies by high exporters translates into lower rejects and shorter lead times. However, non-exporters were not able to gain similar benefits from using manufacturing technologies.

The results of this study indicate that exporters not only invest more in manufacturing technologies, they also engage in more skilled use of these technologies than non-exporters. The skill-biased technical change in 1980s has resulted in changes in production practices; the introduction of computers and related technologies increased the demand for more educated workers. Further, plants with outdated technologies were replaced by plants with latest technologies. Export sales were found to be strongly correlated with increases in between plant movement of skilled labor, suggesting that the skilled use of technologies by exporters may be a function of the skilled labor advantage that exporters have over non-exporters. Overall, the finding that exporters are more active in skilled use of manufacturing technologies corroborates previous research.    

The results of this study indicate that over the course of liberalized trade regime, medium exporters get closer to high exporters in their skilled use of manufacturing technologies. This emphasizes the role of exporting, irrespective of its relative size, in instigating the skilled use of technologies. In essence, we find that, over time, exporting plants learn the need for improving their innovation capabilities by skilled use of technologies. Trade liberalization results in increased economic efficiency manifested in terms of gross domestic product (GDP), foreign direct investment (FDI), employment, and trade balance. The results of this study highlight that trade liberalization also play a positive role in manufacturing innovations. This is further corroborated by evidence of an expanded scope of technology use by high exporting plants as time progresses within the free trade regime.

The results of this study find evidence for “learning by exporting,” specifically as it relates to manufacturing innovations manifested by skilled use of hard and soft manufacturing technologies. This learning by exporting is a result of information exchange within foreign markets as well as due to the increased competitive needs to complete in the global stage. International buyers of goods provide informational assistance to improve process technology of exporting firms and trigger the skilled use of installed technologies in the plant. Further, these buyers also expose the exporters to competition and make them privy of their products, manufacturing processes, and technology use. Exporters not only have higher skilled use of manufacturing technologies from non-exporters, but they also expand the scope of technologies that they skillfully employ in their operations.

We find that from 1993 to 1997 exporters enhanced the range of technologies in which they differentiate themselves from non-exporters from 5 (Automated Inspection, CAD, CNC, LAN, and Robotics) to 8 manufacturing technologies (Automated Inspection, CAD, CAM, CIM, CNC, FMS, LAN, and Robotics). With regards to the skilled use of hard manufacturing technologies, exporters engaged in combinative capabilities.

We also observe the adaptive nature of learning as seen in the case of the skilled use of soft manufacturing technologies in which exporters distinguish themselves. Over the course of 1993 to 1997 exporters adapted the need for JIT practices in their operations. As a part of their technology bundle in 1997, exporters replaced TQM (one of the differentiating soft manufacturing technology in 1993) with JIT based on changing competitive needs.

Business leaders have long reasoned that exporting is good for firms since the competition is fierce in international markets than domestic ones, demanding higher levels of performance. Opportunities for technological or knowledge spillovers and learning increase when firms are competing in foreign markets. Progressive firms realize that exports are important for sustained future growth and hence improve performance before embarking into foreign markets. Thus, while firms might be similar in their performance before making the decision to export, once a firm decides to export it substantially increases its performance relative to others in the industry. Exporting is also associated with reallocations of resources from less efficient to more efficient firms. This provides inherent advantage to exporting firms as compared to non-exporters.

The results of this study indicate that higher skilled use of manufacturing technologies by high exporters translates into lower rejects and shorter lead times. We also find that these high exporters were able to exploit the complementarities associated with skilled use of technology and exporting. In 1997 only high exporters were able to gain the positive impact of skilled use of soft manufacturing technologies on their quality and delivery performance and were not affected by the adverse effects of the skilled use of hard manufacturing technologies. Non-exporters were not able to gain the benefits of soft manufacturing technologies, but were being adversely impacted by their hard manufacturing technologies.

Interestingly, an analysis of high, medium and non-exporters indicate that high exporters were not affected by the constraints of plant size. As a post-hoc analysis the size of exporters and non-exporters was compared and the results suggest that exporting plants were significantly greater in size than non-exporters. The results indicate that exporting plants are able to overcome the liabilities of hierarchical structure and bureaucracy associated with large size and take the advantages of learning, economies of scale and economies of scope exhibited by large plants. The results also indicate that in 1997 plant size did not negatively influence quality and delivery performance. These results once again point towards the positive role of exporting on plant’s processes and consequent performance. We controlled for the process type by using three dummy variables corresponding to “small batch” (PD1), “large batch” (PD2), and “mass production” (PD3), respectively. In our comparisons, the reference process type is “one-of-a-kind.” The results obtained using 1997 data for non-exporters suggest that the lead times were not statistically different irrespective of the process type. This is counter to the expectation that high volume production is generally associated with stable quality and shorter lead times. It appears that non-exporters are not experiencing the benefits of large volume production—an indication of inefficiency and uncompetitive production in non-exporting firms.

Source: Nair, A., Ataseven, C., and Swamidass, P. (2013). An examination of the use of manufacturing technologies and performance implications in US plants with different export intensities. International Journal of Production Research, 51(11), 3283-3299.

Six Sigma Quality Improvement & Organizational Theory

In an unpublished paper (that was subsequently published as a substantially revised and changed version), I had thought about linking issues underlying Six Sigma quality improvement (SSQI) with foundations of organizational theory. Below, I am presenting some important aspects that I had proposed:

In a typology proposed by Pfeffer (1982), organizational theories are classified based on their perspectives on action and their level of analysis. Three perspectives on action are suggested. These are:

-        Purposive, intentional, goal-directed, rational

-        Externally constrained and controlled

-        Emergent, Almost-Random, Dependent on Process and Social Construction

The level of analysis can be categorized into two types:

-        Individuals, Coalitions or Subunits

-        Total organization

Based on the three perspectives on action and the two levels of analysis, organization theories can be categorized into six types as shown below:

Pfeffer’s typology of theoretical perspectives in organization theory; Source: Pfeffer (1982)

Category I

In these theories the focus is on individual-level concepts such as preferences, goals, values, or needs and the social action is often implicitly assumed to be resulting from the aggregation of individual-level behavior or behavior-determining processes. Rational utility-maximization is the core idea. These theories presume a preexisting purpose or intent and rely on cognitive information-processing capability of an individual. Context does not play an important role in these theories. Specific theoretical perspectives in this category are presented below:

Expectancy theory argues that people undertake actions according to the probability that these actions will lead to some instrumentally valued outcome.

Goal Setting suggests a rational, consciously chosen, motivated individual behavior emphasizing cognitive processes to achieve their goals.

Needs theory & job design argues that people act purposefully to fulfill their needs or to overcome need deficiencies.

Political theories assert that individual action is motivated to achieve some desired outcome such as more resources, promotion, or additional power.

Category II

The basic premise of these theories is that individuals are adaptive to their environments and therefore to understand behavior it is both necessary and largely sufficient to consider only the characteristics and constraints of the environment in which the individuals act. Specific theoretical perspectives are presented below:

Operant conditioning perspective argues that behavior is a function of its consequences. Positive reinforcement increases the frequency of a behavior in the future, whereas, negative reinforcement decreases the frequency of future occurrences of the behavior.

Social learning theory considers the role of cognition in the learning process and admits learning through a variety of means such as vicarious learning, in which behavior and consequences to another individual serve as a learning experience, and learning from explicit emulation.

Socialization emphasizes the understanding of the organization’s culture, way of doing things, and decision-making style that is internalized in the individual.

Role theory argues that organizations are systems of mutual social constraint in which the activities of any given role occupant are determined by the demands and expectations of others in his or her role set.

Social context effects & groups perspective emphasize the effects of the attitudes and behaviors of others in the individual’s environment on his or her own attitudes and behavior.

Retrospective rationality theories, unlike theories that assert that behavior is prospectively rational and consciously chosen to obtain some goal, suggest that behavior is largely under some external control and behavior is rationalized after the fact.

Social information processing theories suggest that social context affects the perceptions of the work environment, attitudes, and need statements; perceptions and attitudes are linked; and an individual’s own past behaviors, which are partly socially mediated, affect self-perceptions of attitude.

Category III

These theories recognize individuals as the creator of meaning and the focus has been on the subjective nature of reality and on the constraining effects of social definitions of reality on behavior. The theoretical perspectives in this category are presented below:

Ethnomethodological approach is characterized by its relative emphasis on a situation-specific frame of reference and its emphasis on cognitive sense making.

Cognitive theories of organizations consider organizations as bodies of thought or causal schemata which are characterized by two dimensions – the differentiation & complexity and the specific relationships embodied in the causal structure.

Language in organization perspective argues that language is important in understanding organizations and how they are managed because language is one of the key tools of social influence, and organizations are contexts in which social influence is exercised.

Affect-based processes assert that it is the affect or emotion that maintains the repetitiveness of behavior and maintain the interlocked cycles of interaction.

Category IV

These theories presume rational and conscious action and address large-scale organizations as a whole rather than as environments in which individuals work, and are influenced by power, status and fulfillment of various needs and goals. The main points underlying the theoretical perspectives in this category are presented below:

Structural contingency theory argues that the design of the organization depends on various contextual factors. The motivational assumptions are efficiency and strategic choice and the dependent variables typically relate to the form and structural dimensions.

Market failures approach also referred to as the “transaction cost approach” emphasizes the role of transaction costs which could arise due to a number of conditions such as, small numbers or noncompetitive markets; opportunism; environmental uncertainty; and bounded rationality. The motivational assumption is efficiency and the dependent variables include, boundaries and integration, form and organization of employment relations.

Marxist analysis of organizations focuses on the premise of conscious, rational, strategic action taken on the part of the capitalist class and organizations, controlled by that class. The motivational assumptions are power, accumulation, intergenerational transmission and the dependent variables include, organization of employment relations, accumulation and allocation, patterns of association and the choice of technology.

Category V

Theories in this category address the issue of how, or if, organization-level rational choice or decision making gets produced. The two variants of this perspective, population ecology and resource dependence, differ in terms of behaviorism and social information processing seen at the individual level of analysis. Population ecology focuses attention on birth and death processes impacted by environmental conditions and the resource dependence theory focuses on internal adaptations and the politics that occur inside organizations. Specific points pertaining to the theoretical perspectives in this category are presented below:

Population ecology theory argues that change in population of organizations occurs, in part, because of the operation of selection processes working on those organizations.

Resource dependence theory argues that organizations are externally constrained and therefore organizations seek to manage or strategically adapt to their environment. According to the theory it is important to pay greater attention to internal organizational political decision-making processes.

Category VI

Organizations are conceived as paradigms and processes, and the explanation and prediction of behavior proceed by incorporating structural and contextual effects, while retaining some of the developmental perspective and the theme of social construction of reality. Specific theoretical perspectives in this category are presented below:

Organizations as paradigms perspective conceptualizes organization in terms of the concept of paradigms, which refers to the shared understanding and beliefs about cause-effect relations and standards of practice and behavior.

Decision process theories and administrative rationality perspective argue that organizations develop performance programs, standard operating procedures, and rules of thumb, to make decisions; hence, it is necessary and largely sufficient to understand these performance programs or procedures.

Institutionalization theory argues that the process of institutionalization is the main reason for practices or procedures to be continued and transmitted without question and for meanings to be shared without thought or evaluation. The theory on one end imparts permanence to an organization that extends beyond the requirements of the task at hand and on the other end addresses the processes by which social processes, obligations, or actualities come to take on a rule like status in social thought and action.

He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.

-- Leonardo da Vinci

In the paper I present ten potential areas that need to be studied further to have a better understanding of SSQI. In the following table I present the research issues pertaining to SSQI within the framework of organization theory typology.

The following table succinctly presents the potential linkages between the ten areas of SSQI discussed in the paper and the various theoretical perspectives.

Reference:

Pfeffer, J. 1982. Organizations and Organization Theory. Marshfield, MA: Pitman Publishing Inc.

Source: Nair, A. 2005. Towards a Theory-Driven Research Agenda in Six Sigma Quality Improvement: Linking Research Opportunities with Organization Theory Typology.

Using Quality Management Methods to Reduce the Length of Stay in a Hospital

The case of Inova Mount Vernon hospital, a small, 237-bed hospital in Mount Vernon, VA, presented in the March 2011 edition of Quality Progress provides some useful insights for hospital quality management. The hospital used several quality methods to reduce its average length of stay for discharge home patients within the emergency department (ED) from 266 minutes to 135 minutes. The hospital used abbreviated kaizen events, value-stream mapping, spaghetti diagrams, metric definitions with regular reporting, brainstorming and control charts to facilitate the performance improvement.

Some concrete steps that were taken after gathering relevant data and identifying the problem are as follows:

1) The project members realized that metrics related to key time elements within the ED process were not being tracked. The hospital implemented an ED tracking system (using Picis software) in November 2008 to track key information about patients. This include information regarding chief complaints, acuity level, diagnoses and patient dispositions. The software was also used to track process steps such as registration time, triage time, time for patient to arrive in the ED room, time for medical provider to first visit the ED room, time for medical provider to make disposition on patient, time from disposition to patient leaving ED (to be released to go home, admitted to another hospital room or transferred to another hospital).

2) This time tracking was done at the level of individual doctor, registered nurse or shift management coordinator. The required trust was built with the concerned hospital staff so that they realize that the objective is not to punish but to understand the process. The helped in gaining confidence and obtaining cooperation from all members of the hospital.

3) The data were downloaded daily, and the results were posted and distributed to key managers and management coordinators. With the data, the hospital began to understand the parts of the process that need fixing and root cause analysis was done to devise corrective actions.

4) With baseline metrics in place and an understanding of the vision and mission, the ED, floor units, and other departments met to identify the critical needs in the ED. To achieve consensus, all parties maintained focus on the needs of ED patient. 

The following six steps highlight the specific action taken by the hospital to reduce the length of stay:

i) Streamline the triage and bedding process: 

The first change activity focused on the front-end processes of getting a patient triaged and into a bed, as shown in the highlighted boxes in the emergency department (ED) process flow in the figure below. Spaghetti diagrams drawn using a floor layout were used in this step to better understand patient, registration and ED staff movement. This helped the team visualize excess movement between areas, and facilitated moving some process steps closer to each other to remove wasted staff and patient movement.

Because the ED nurses and technicians were involved in creating the new process, buy-in was readily obtained. The team decided to modify the triage process and only have a quick triage prior to moving a patient to a room—after the patient was registered and given a hospital identification wristband. This quick triage involves obtaining the patient’s vital readings, chief complaints and initial acuity level. The initial acuity level is the emergency severity index that stratifies patients into five groups—from one (most urgent) to five (least urgent) on the basis of seriousness and clinical staff resource needs. The patient then is walked back to a room assigned by the charge nurse, and the full triage is completed later by the assigned nurse. The doctor is given access to the patient as soon as the patient arrives in the room. The time-to-doctor metric ultimately dropped by 10 minutes as a result of this change. It also helps reduce instances in which patients are sent to the waiting room and left there for extended periods.

After the triage changes were made, the team discovered that the ED doctors often were seeing patients before the assigned nurse completed the full triage. This was a cultural change for some nurses, but ultimately they came to appreciate some of the benefits. One obvious benefit was that the nurse could obtain the doctor’s orders more quickly. The bedside nurse could combine the nurse assessment and triage (as shown in the shaded boxes in the figure presented above) with execution of the orders—for example, blood draws—and accelerate the care of the patient. Some rules had to be established based on the ED activity, and these were shared and agreed to by ED management after the kaizen event. The partial up-front triage will be in effect whenever the ED has more than two of the 18 ED rooms available for more acute patients, regardless of staffing. When the ED is full (two or fewer rooms available), the triage nurse returns to performing complete triages and getting patients to rooms when they become available. Advance triage protocols (ATP) also were established to allow the triage nurse to get some initial orders started so results are obtained before the doctor sees the patient or shortly after the patient arrives in the room. 

The overall performance gain from the changes initiated in step one was more than 20 minutes.

(ii) Streamline discharge-to-home process:

The portion of the ED process from doctor disposition to patient discharge also was addressed early in the improvement endeavor. All nurses and charge nurses were trained to review the ED status board regularly. The ED doctors also were charged with verbally calling out whenever they discharged a patient to go home. This would start the ball rolling more quickly to get the patient their discharge instructions. Individual nurse performance on the disposition-to-discharge times is tracked regularly, and the comparative times are posted openly for review. Coaching is instituted when necessary. The goal was to complete the patient discharge instructions and get them on their way within 20 minutes of disposition. Total time savings from this change has been about 10 minutes. An additional six-minute improvement will be necessary to hit the 20-minute goal for this step of the process.

(iii) Measure Length of Stay for doctors:

The ED data-capture system allowed the hospital to easily gather information on all the key metrics in the ED, including the time from when the doctor first sees a patient to time of patient disposition. Each doctor’s disposition time was monitored and graphed monthly. The disposition time by doctor also was shared in a daily report so we could investigate when someone had either a slow or fast day. The team looked at patient acuity, but the one area where the team noticed longer length of stay (LOS) times were with patients with stomach or chest pains and patients being treated for alcohol and substance abuse. Over time, patient loads by doctors by acuity seemed to even out, so the monthly charts are good indicators of comparative performance. The monthly charts are used by the ED medical director to counsel ED doctors who are slow on their dispositions. The key is charting performance by doctors and understanding which doctors need training and coaching. For example, slower-performing doctors would spend additional time double charting patient notes. When counseled, the doctors—being competitive, as expected—tend to change their patterns and improve their performance. Faster doctors provide small, informal seminars for the group and share techniques they use to increase speed. The total time saved from step three was about 35 minutes as presented in the following figure:

(iv) Implement an ED fast track for less-acute patients

Early in the improvement process, ED leadership recognized that lower acuity and less complex patients were spending more time in the ED than their conditions warranted. If a fast-track process (manned by a nurse practitioner) was established for this type of patient, patients could be treated in the ED more quickly and the ED could focus more resources on more severely ill patients. This process would take a little longer due to the need to hire nurse practitioners and adjust nurse and tech staffing. The hospital also needed to renovate the ED’s registration and triage areas to accommodate the fast-track staff and patients.

The hospital carved out space for this area and added a nurse practitioner desk and one ED bed for exams. Space also created in the cast room for ED staff to treat less-acute patients and apply casts and splints. This room is not included in the 18 dedicated to acute patients, but is one of the 20 in the ED. It is across the hall from the fast track and can be used as a second fast-track bed because it generally has low use. In addition, a family waiting room was commandeered and four recliners were added to accommodate fast-track patients. The entire fast-track space was developed with little capital, but is considered temporary. The hospital has plans to complete a more extensive renovation and expansion of this function using space from the larger patient waiting room.

The fast-track approach achieved its goals of enabling less-acute patients to be seen more quickly and dispositioned. Use of the patient waiting area dropped significantly, and LOS times for the fast-track patients have stabilized at about 90 minutes. Another advantage is that the number of patients leaving without being seen was reduced by 75% (as shown in the figure below), which actually added to the total revenue gathered by the ED. The impact to overall LOS from step four was a reduction of more than 15 minutes.

v) Implement bedside triage

The team organized a kaizen event with value stream mapping to see what further improvements could be made in the ED process. The goal was to get the patients to the doctors as quickly as possible. With that in mind, the team decided to look at revising the triage process to bring patients directly to the ED rooms and complete the quick and full triage at the bedside. The team thought this would get patients to a room quickly and that the doctors could see them more quickly. This value stream change resulted in a decrease of 10 minutes to inpatient LOS. The following figure shows the overall LOS metric plotted daily on a control chart to keep focus and allow awareness of when to take actions.

The several hurdles to overcome in this step mostly related to equipment. The hospital had to ensure all patient rooms had the necessary working equipment to perform triages and make the necessary inputs into a room computer. Triage nurses also had to be retrained to make their first call to the charge nurse, who would then direct them to the proper room where they would begin their quick triage.

Teamwork also played a big part in this success. If the triage nurse is bringing a patient to a room and another patient is ready to go to another room, the charge nurse or other free nurse handles the second patient. When the ED becomes busy and all rooms are occupied, the process must revert back to full triage at the front triage station. This is OK because there will be no rooms to place the patients. After step five reduction of the discharge LOS dropped another nine minutes as a result of the bedside triage process.

Source: Watson, R. Q., Leeson, K. 2011. On the Clock: Hospital uses quality methods to eliminate delays and move patients along. Quality Progress March 2011, 44-50 (and on-line supplement)