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To cite this article: Zhongfeng Su , Dongtao Yang & Jianjun Yang (2012) The match between efficiency/flexibility strategy and organisational culture, International Journal of Production Research, 50:19, 5317-5329, DOI: 10.1080/00207543.2011.618149
Download by: [London South Bank University] Date: 02 November 2017, At: 17:50 International Journal of Production Research Vol. 50, No. 19, 1 October 2012, 53175329
A mismatch between efficiency/flexibility strategy and organisational culture results in production inefficiency within the firm, whereas a proper match leads to superior performance. This study tries to find out the proper match between them by investigating their joint effect on firm performance. Based on the data of 212 ChineseDownloaded by [London South Bank University] at 17:50 02 November 2017
firms, this research finds that the proper organisational culture for efficiency strategy is characterised by individualism, high power distance, and low uncertainty avoidance, whereas the proper culture for flexibility strategy has the characteristics of collectivism, low power distance, and high uncertainty avoidance. Keywords: efficiency/flexibility strategy; organisational culture; firm performance
1. Introduction The internal consistency issue in the manufacturing strategy research indicates that a mismatch between manufacturing strategy and organisational culture results in production inefficiency and competition within the firm, whereas a proper match leads to a competitive advantage and superior performance (e.g. White 1986, Bates et al. 1995, Prajogo and McDermott 2005). Thus, the strategic fit between manufacturing strategy and organisational culture is an important research issue (Dangayach and Deshmukh 2001). But, what is the proper match between them? Although previous research found that manufacturing strategy and organisational culture are highly related, surprisingly few studies have investigated the proper match between them, which is a serious research gap (Maull et al. 2001, Metters et al. 2010). The purpose of this study is, therefore, to provide some insights into the strategic fit between manufacturing strategy and organisational culture. We achieve our objective in several steps. First, because manufacturing strategy can be classified by the type of product to be produced (Voss 1995, Morita and Flynn 1997), and firms can compete in the market by offering either standard products or made-to-order products (e.g. Filley and Aldag 1980, Lowson 2001), we highlight efficiency/flexibility strategy (standard products/made-to-order products) as a key manufactur- ing strategy. Second, we hypothesise how efficiency/flexibility strategy and three dimensions of organisational culture (specifically, individualism/collectivism, power distance, and uncertainty avoidance) interactively affect firm performance. Third, we empirically test our hypotheses using the data of Chinese firms. Finally, we discuss our contributions, limitations, and future directions. China is taken as the research setting of this study for three compelling reasons. First, although China is deemed as the worlds factory, only a few studies on manufacturing strategy have been conducted in China (Zhao et al. 2006, Li et al. 2010). The importance of Made in China makes it critical to know more about what is going on there (Li et al. 2011). Second, more and more multinational corporations have transferred, are transferring, or are going to transfer their manufacturing departments to emerging economies such as China (Hahn and Bunyaratavej 2010). Improved knowledge about China has enormous practical implications for them to operate in China (Child and Tse 2001). Finally, the Chinese experience can shed light on other emerging economies (Su et al. 2009). Several theoretical values fuel this study. First, this study provides some insights into the critical research question: what is the proper match between manufacturing strategy and organisational culture? Second, by investigating the match between efficiency/flexibility strategy and organisational culture, this study joins a series of recent work on the internal consistency issue in the manufacturing strategy research (Voss 1995). Finally, this study responds to a critical call in the organisational culture literature that asks for identifying the associations between
organisational culture and manufacturing strategy (Metters et al. 2010). In addition, insights in this study also have important practical applications because they help managers accomplish the match between manufacturing strategy and organisational culture and further enhance firm performance. Overall, the importance of the research topic and context suggests that this study is in a position to extend our theoretical understanding and to guide managerial implications.
greater consistency among the elements which define operations (Bozarth and McDermott 1998, p. 428). Conversely, a failure to achieve internal consistency can result in a mismatch between the various choices in manufacturing which will severely impair a companys ability to be competitive (Voss 1995, p. 9). Herein, there is general agreement in the manufacturing strategy literature that the decisions regarding the structure and infrastructure of an organisation should be in line with its manufacturing objective/competitive priorities (Dangayach and Deshmukh 2001, p. 910). Because of the importance of the internal consistency, scholars have highlighted several organisational elements, such as controls, procedures, communications, attitudes, experience and skills, and human resource policies (e.g. Skinner 1974, Hill 1989, Vokurka and Leary-Kelly 2000).2 In addition to these elements, it is also crucial to realise the internal consistency between manufacturing strategy and organisational culture in that organisational culture defines the way in which a firm conducts its business (Barney 1986, p. 657). Extant research indicates that a proper match between manufacturing strategy and organisational culture leads to competitive advantage and superior performance, whereas a mismatch results in production inefficiency and competition within the firm (e.g. White 1986, Bates et al. 1995, Prajogo and McDermott 2005). Thus, the strategic fit between manufacturing strategy, organisational culture, and business performance represents an important research issue (Dangayach and Deshmukh 2001, p. 911). But, what is the proper match between manufacturing strategy and organisational culture? The proposition that manufacturing strategy and organisational culture are highly related has been well acknowledged in prior research, and several scholars have investigated the impact of organisational culture on manufacturing strategy. For example, McDermott and Stock (1999) find that organisational culture affects advanced manufacturing technologies implementation outcomes; Nahm et al. (2004) highlight the impact of organisational culture on time-based manufacturing practices; Prajogo and McDermott (2005) find that different subsets of total quality-management practices are determined by different types of culture; Prajogo and McDermott (2011) examine the relationships between the cultural dimensions of the competing values framework with product quality, process quality, product innovation, and process innovation; and Baird et al. (2011) conduct an analysis of the association between organisational culture with the use of total quality management. Although extant studies have enriched our knowledge of the association between manufacturing strat- egy and organisational culture, few studies have investigated what would be the proper match between them (Maull et al. 2001, Metters et al. 2010). The only study we are aware of that touches upon this issue is Bates et al. (1995), which finds that a manufacturer with a well-aligned and implemented manufacturing strategy exhibits a group-oriented organisational culture with coordinated decision-making, decentralised authority and a loyal work force. It is noteworthy that the research on manufacturing strategy can be divided into the process approach and the content approach (e.g. Leong et al. 1990). The process approach refers to the process of formulating and implementing manufacturing strategy, while the content approach concerns the content of manufacturing strategy (e.g. Adam and Swamidass 1989, Leong et al. 1990). Bates et al. (1995) focused on the manufacturing strategy process and left the content approach as a topic for future research (Bates et al. 1995, p. 1568). Thus, to provide a more fine-grained picture on the internal consistency between manufacturing strategy and organisational culture, this study will highlight the content approach. International Journal of Production Research 5319
the manufacturing literature suggests that a firm can compete in the market by offering either standard products or made-to-order products (e.g. Lowson 2001). Firms offering standard products compete on their organisational efficiencies, whereas firms offering made-to-order products compete on their flexibilities to meet individual customer needs (Filley and Aldag 1980, Ebben and Johnson 2005). Thus, manufacturing strategy can be classified as efficiency strategy or flexibility strategy, depending on the products the firm offers (e.g. Ebben and Johnson 2005, Tan and Wang 2010). Firms taking efficiency strategies generally provide only a few products that are the core offerings of the firm, which combined with predictable demand allows for simpler production scheduling, inventory levels, and delivery (Ebben and Johnson 2005, p. 1252). In contrast, firms operating flexibility strategies are more responsive to individual customer needs by providing made-to-order products (Tan and Wang 2010). The key to efficiency and flexibility strategies does not only come from the ability to meet variation in quantity of product provided, but also from the variation in types of products that are offered (Ebben and Johnson 2005, p. 1250). Extant research indicates that the organisational and operational requirements to achieve efficiency conflict with those to achieve flexibility (e.g. Filley and Aldag 1980, Fiegenbaum and Karnani 1991). For example, Stigler (1939) suggests that the technology needed for efficiency is entirely different from that required for flexibility. Thompson and Bates (1957) indicate that firms with flexible goals prefer skilled labour to specialised equipment; conversely, firms emphasising efficiency often invest in specialised equipment. A detailed presentation of the differences in organisational and operational requirements between efficiency strategy and flexibility strategy is summarised in Table 1. It is noteworthy that some firms try to mix efficiency strategy and flexibility strategy. Yet, the differences in the organisational and operational requirements lead to firms experiencing difficulties in achieving efficiency and flexibility synchronously (Doty et al. 1993). Thus, firms that try to mix efficiency strategy and flexibility strategy often suffer from an inability to provide standard or made-to-order products effectively (Tushman and OReilly 1999), and they are at a significant disadvantage to other firms and underperformed (Ebben and Johnson 2005). Tushman and OReilly (1999) suggests that a firm can only provide both standard and made-to-order products effectively if they are pursued in physically separate entities, with different organisation characteristics, such as structures, systems, and culture. As a result, it is impossible for a firm with only one entity to provide both standard
and made-to-order products synchronously. Hence, efficiency strategy and flexibility strategy are two ends of a continuum (Ebben and Johnson 2005), and they are taken together as efficiency/flexibility strategy to describe manufacturing strategy in this study. Regarding the impact of efficiency/flexibility strategy on firm performance, Filley and Aldag (1980, p. 305) indicate that the survival of organisations seems to depend, on the one hand, upon creating efficiency of operations, or on the other hand, producing an outcome which is relatively made-to-order. Thus, either efficiency strategy or flexibility strategy can lead to superior performance. For example, Ebben and Johnson (2005) find that both efficiency strategy and flexibility strategy contribute to firm performance, and there is no difference in their performance effects. Although extant research has improved our understanding of the performance implication of efficiency/ flexibility strategy, understanding its internal consistency with organisational culture can further enrich our knowledge on its performance implications (Dangayach and Deshmukh 2001). However, few studies have probed such an issue, which is a serious research gap (Maull et al. 2001, Metters et al. 2010). To address such a gap, we will investigate how efficiency/flexibility strategy and organisational culture interactively impact firm performance to find out the proper match between them. In the next section, we will briefly introduce organisational culture andDownloaded by [London South Bank University] at 17:50 02 November 2017
sharing (Wagner 1995, Michailova and Hutchings 2006). Thus, it assists manufacturing line employees to perform their tasks and further enhance the performance implication of flexibility strategy. In addition, to facilitate cooperation and knowledge sharing, firms operating flexibility strategies would emphasise group or collective, rather than individual, contributions (Filley and Aldag 1980). Collectivism creates a socialisation mechanism that encourages organisational members to commit to group goals (Jaworski 1988, Li et al. 2010). Thus, flexibility strategy and collectivism are a proper combination and have synergistic effects on firm performance. In contrast, individualism emphasises independence (Power et al. 2010), which impedes cooperation and knowledge sharing (Michailova and Hutchings 2006). Moreover, people in an individualist culture believe in formal systems that explicitly define, control, and evaluate individual contributions (Bates et al. 1995), which are in opposition to the need of flexibility strategy. Thus, individualism does not fit with flexibility strategy. Regarding efficiency strategy, manufacturing line employees perform standard tasks (Filley and Aldag 1980). There is less need for cooperation and knowledge sharing among employees. In addition, efficiency strategy competes on organisational efficiencies (Filley and Aldag 1980, Ebben and Johnson 2005). The detailed formal systems that explicitly define, control, and evaluate individual contributions can significantly enhance organisational efficiencies (Ouchi 1979). Thus, efficiency strategy prefers individualism to collectivism. Therefore:Downloaded by [London South Bank University] at 17:50 02 November 2017
Hypothesis 1: The interaction between efficiency/flexibility strategy and individualism/collectivism has a positive impact on firm performance. Power distance refers to the distribution of authority within a firm (Bates et al. 1995). It reflects the practice of inequalities in the distribution of. . . power and authority (Hofstede 1980, p. 72). High power distance focuses on the limits of authority and explicit definition of tasks, whereas low power distance emphasises equality and consultative decision-making (Hofstede 1980, Bates et al. 1995). In this study, we suggest that the interaction between efficiency/flexibility strategy and power distance has a negative impact on firm performance for three reasons. First, efficiency strategy involves simple and straightforward decision-making (Lee et al. 2002, Ebben and Johnson 2005). Superiors in the firm are able to make these decisions themselves. Thus, autocratic decision-making is suitable for efficiency strategy. In contrast, flexibility strategy often requires more complicated decisions (Lee et al. 2002, Dreyer and Gronhaug 2004). Superiors can hardly do it by themselves. Thus, consultative decision-making is a better choice. High power distance leads to an autocratic decision-making, whereas low power distance results in a consultative one (Hofstede 1980; Bates et al. 1995). Thus, high power distance and efficiency strategy is an appropriate combination, while low power distance and flexibility strategy is the other one. Second, the tasks and contributions of manufacturing line employees in firms taking efficiency strategies can be explicitly defined, controlled, and evaluated, whereas those of manufacturing-line employees in firms operating flexibility strategies are not able to be easily defined, controlled, or evaluated (Filley and Aldag 1980, Persentili and Alptekin 2000). High power distance leads to firms with explicit definition of tasks and tight control (Shane 1995); thus, it fits with efficiency strategy rather than flexibility strategy. Finally, as shown in Table 1, efficiency strategy works prefers a mechanistic organisation structure, whereas flexibility strategy prefers an organic one (Thompson and Bates 1957, Filley and Aldag 1980). Because the power distance of a mechanistic organisation is high, whereas that of an organic organisation is at a low level (Jennings and Seaman 1994, Sine et al. 2006), it is reasonable to conclude that low power distance is appropriate for flexibility strategy. In summary, we argue that flexibility strategy and low power distance are an appropriate combination. In other words, the interaction of efficiency/flexibility strategy and power distance has a negative impact on firm performance. Therefore, Hypothesis 2: The interaction between efficiency/flexibility strategy and power distance has a negative impact on firm performance. A firms uncertainty avoidance reflects the extent to which the firm feels threatened by and tries to avoid uncertain, ambiguous, or undefined situations (Hofstede 2001). Firms high in uncertainty avoidance believe that risks are dangerous and ambiguity is threatening (Sitkin and Pablo 1992). They value adaptability because adaptability aids in coping with the uncertainties and reduces the risks and ambiguity (e.g. Bright and Cooper 1993, Erramilli 1996). Because efficiency strategy and flexibility strategy are affiliated with different levels of uncertainty, uncertainty avoidance plays a critical role in the performance implication of efficiency/flexibility strategy. As shown in Table 1, 5322 Z. Su et al.
a firm taking flexibility strategies holds general purpose equipments and light or medium fixed assets, which can easily be used for different purposes (Lowson 2001). In addition, its manufacturing line employees are able to perform altering tasks that further enhance its adaptability (Ebben and Johnson 2005). Thus, the firm operating flexibility strategy has a high level of adaptability. Uncertainty avoidance values adaptability (e.g. Bright and Cooper 1993, Erramilli 1996), and so there is a match between uncertainty avoidance and flexibility strategy. In contrast, in a firm operating efficiency strategy, the equipments are specialised and the assets are heavy fixed (Lowson 2001). They can hardly switch uses, which depress the adaptability of the firm. In addition, the manufacturing line employees also counteract the adaptability, in that they are only able to perform standard tasks (Filley and Aldag 1980). As a result, the firm operating efficiency strategy often faces high uncertainties. For this firm, it must be able to tolerate such high uncertainties. Otherwise, it would suffer a significant conflict between high uncertainties caused by efficiency strategy and the organisational culture with low uncertainty tolerance. Therefore, Hypothesis 3: The interaction between efficiency/flexibility strategy and uncertainty avoidance has a positive impact on firm performance.Downloaded by [London South Bank University] at 17:50 02 November 2017
3. Methods Different units of analysis have been used in various empirical studies on manufacturing strategy, such as manufacturing business unit, plant, and firm (Swink and Way 1995). Yet, the appropriate unit of analysis depends upon the particular research questions to be addressed (Leong et al. 1990, p. 119). This study takes the firm level for two reasons. First, efficiency/flexibility strategy is a firm-level manufacturing strategy, and previous research on it is adopted at the firm-level (e.g. Ebben and Johnson 2005, Tan and Wang 2010). Second, organisational culture is a firm-level phenomenon (e.g. Bates et al. 1995, Wuyts and Geyskens 2005, Wang et al. 2011). To keep in accord with organisational culture, the manufacturing strategy should be measured at the firm level as well. Overall, the research question of this study suggests that the appropriate unit of analysis is the firm.
In addition, to avoid the possibility that a firm have several separate entities to pursue both standard and made-to-order products, we have checked all the usable firms. None of them met this criterion. Thus, the final sample included 212 firms. One issue commonly concerning survey methodology is non-response bias. To check it, we compared the responding and non-responding firms along major attributes such as firm age and ownership status using the t-test. All t-statistics were insignificant. Moreover, there were no significant differences between the 212 usable firms and the 29 deleted firms. In addition, the likelihood of non-response bias was further tested by splitting the total sample into two groups based on the time they agreed to be interviewed (Armstrong and Overton 1977). A comparison of the two groups revealed no significant differences, supporting the assumption that respondents were not different from non-respondents.
1. Our company provided standard products to all of 12345 Our company provided only made-to-order our customers products and services to customer groups or individual customers 2. We invoiced our customers using a set price list 12345 Our products were priced based on the mod- ifications that were required by customers 3. We utilised long product runs in manufacturing 12345 We utilised short products runs in manufacturing or produced in single unit batches 4. Our manufacturing line employees performed 12345 Our manufacturing-line employees were fre- standard tasks in completing the production/ quently required to perform unique tasks or assembly of products alter products 5. Our manufacturing materials inputs did not vary 12345 Our manufacturing-materials inputs varied greatly with production runs greatly with production runs or were spe- cially ordered for particular production runs 6. Customers ordered our products from established 12345 Customers often asked for modification in descriptions or catalogues without product products when ordering or they ordered modification products specifically modified for their market segment 7. We manufactured products and placed them in 12345 We manufactured products after they were inventory for later sale ordered
market creates a positive opportunity for us (inversed); and (3) we have a strong preference for high-risk projects with chances of high return (inversed). Firm size was adopted as the first control variable, which referred to the number of full-time employees. It was measured by a five-point scale (from 1 less than 50 to 5 more than 1000). Firm age was the second control variable. Because technological turbulence, market turbulence, and competitive intensity all affect firm performance (e.g. Jaworski and Kohli 1993), they were controlled as well. Their measures were adopted from Jaworski and Kohli (1993) and Zhou (2006). Technological turbulence ( 0.762) was measured by the following: (1) our industry is characterised by rapidly changing technology; (2) the rate of technology obsolescence is high in our industry; (3) it is difficult to forecast the technological changes in the next three years; and (4) technological changes provide big opportunities in our industry. Market turbulence ( 0.825) was measured by the following: (1) the volume and/or composition of demand are difficult to predict; (2) the evolution of customer preference is difficult to predict; (3) our demand fluctuates drastically from week to week; and (4) new demands in the market are significant difference from existing one. Competitive intensity ( 0.833) was measured by the following: (1) price competition is a hallmark of our industry; (2) any action that a company takes, others can make a response swiftly; (3) one hears of a new competitive move almost every day; and (4) competition in our industry is cut-throat.Downloaded by [London South Bank University] at 17:50 02 November 2017
1 2 3 4 5 6 7 8 9 10
1. Firm age 1 2. Firm size 0.360** 1 3. Technological turbulence 0.037 0.018 1 4. Market turbulence 0.044 0.112 0.428** 1 5. Competitive intensity 0.057 0.008 0.509** 0.340** 1 6. Efficiency/flexibility strategy 0.017 0.071 0.352** 0.284** 0.341** 1 7. Individualism/collectivism 0.055 0.018 0.398** 0.190** 0.298** 0.267** 1 8. Power distance 0.039 0.064 0.286** 0.194** 0.339** 0.475** 0.223** 1 9. Uncertainty avoidance 0.047 0.049 0.462** 0.244** 0.382** 0.507** 0.400** 0.273** 1 10. Firm performance 0.135* 0.196** 0.098 0.094 0.078 0.044 0.016 0.075 0.051 1 Means 10.15 1.49 3.30 3.02 3.70 2.79 3.86 3.17 2.62 2.33 SD 12.04 0.91 0.74 0.85 0.71 0.71 0.53 0.80 0.77 0.73
Note: p < 0.10; *p < 0.05; **p < 0.01; ***p < 0.001. Model 2 compares the R2 change with Model 1, Models 3a, 3b, 3c, and 4 with Model 2.
low power distance, and high uncertainty avoidance. The findings enrich our knowledge of the proper match between manufacturing strategy content and organisational culture. Second, this study contributes to the manufacturing strategy research. Extant research indicates that firms taking efficiency strategies have different organisational and operational requirements from firms operating flexibility strategies, and there is a significant diversity in organisational culture as well (Filley and Aldag 1980, Lowson 2001). Because the internal consistency between manufacturing strategy and organisational characteristics is one of the most important research topics in the manufacturing strategy research (Voss 1995), the strategic fit between manufacturing strategy, and organisation culture, and business performance is an important research issue (Dangayach and Deshmukh 2001, p. 911). This study joins in a part of a series of recent work on such an issue. Thus, it has substantial contributions to the manufacturing strategy research. Third, this study is of importance to the organisational culture literature. The organisational culture literature indicates that it is critical for a firm to match its organisational culture with manufacturing strategy, because an ill-suited organisational culture can reduce the firms effectiveness and disable the firm from perceiving all its operational options, which, in turn, can prevent it from choosing options consistent with operational necessities (McLaughlin and Fitzsimmons 1996, Pun 2001). However, the precise nature of cultures significance is ambiguousDownloaded by [London South Bank University] at 17:50 02 November 2017
and a question unanswered is: what are the associations between organisational culture and manufacturing strategy (Metters et al. 2010)? By investigating how efficiency/flexibility strategy and organisational culture interactively affect firm performance, this study enriches our knowledge of the influence of organisational culture on the performance implication of manufacturing strategy, which contributes to the organisational culture literature. Finally, this study improves our understanding of the values of manufacturing strategy and organisational culture. Although the performance implications of both manufacturing strategy and organisational culture have been empirically tested, there are also significant performance differences among firms taking the same manufacturing strategy or have similar organisational cultures (e.g. Newman and Nollen 1996, Corbett 2008). Because manufacturing strategy and organisational culture are highly related, studies that examine either manufacturing strategy or organisational culture alone can hardly explain such phenomena in that they suffer the omitted variable biases (Bates et al. 1995, Metters et al. 2010). This study finds that the proper combination of manufacturing strategy and organisational culture has synergistic effects on firm performance, whereas the improper combination impedes firm performance. Thus, a possible explanation for the phenomena is that the joint effect of manufacturing strategy and organisational culture on firm performance leads to the diversity in performance. Overall, the findings not only provide a possible explanation as to why there are significant performance differences among firms taking the same manufacturing strategy or have similar organisational cultures, but also enrich our knowledge of the values of manufacturing strategy and organisational culture.
efficiency/flexibility strategy, other kinds of manufacturing strategy have been identified. Future studies should pay attention to them to paint a more comprehensive picture of the match between manufacturing strategy and organisational culture. Finally, there are several other taxonomies of organisational culture, such as clan, efficiency, hierarchy, and innovative cultures. Future studies need to investigate the match between them and a manufacturing strategy to further improve our understanding of such an issue.
Acknowledgements We gratefully acknowledge the suggestions and comments received from the reviewers and the editor. We thank the Humanities and Social Sciences Research Foundation from the Ministry of Education of China (11YJC630184) and the Philosophic and Social Science Foundation from the Education Department of Jiangsu Province, China (2011SJD630012) for the generous financial support. All views expressed are those of the authors and not those of the sponsoring organisations.
NotesDownloaded by [London South Bank University] at 17:50 02 November 2017
1. Because there are several literature reviews on manufacturing strategy, we review relevant research in this study only briefly. For a more comprehensive literature review, see Leong et al. (1990), Swink and Way (1995), Voss (1995), and Dangayach and Deshmukh (2001). 2. Bozarth and McDermott (1998) provide an excellent literature review on this issue, and Leong et al. (1990), Swink and Way (1995), Voss (1995), and Dangayach and Deshmukh (2001) all pay attention to it. Thus, we have not reviewed the literature on such an issue in this article. 3. For a more comprehensive literature review on manufacturing objectives, see Leong et al. (1990) and Dangayach and Deshmukh (2001). 4. Rosenzweig and Easton (2010) have provided a much more comprehensive literature review on the relations among manufacturing objectives. Thus, we have not focused much attention to this issue in this study.
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She then said, "Who took our declarative rights away?" before chuckling it away and concluding, "It is what it is."
Rousey has another match at Elimination Chamber, namely a Raw Women's Championship defense against Ruby Riott that she is a heavy favorite to win.
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TMA House of DelegatesSheraton DallasRemarks of incoming President Michael E. Speer, MD
Over the past several months, more and more people have come up to me and asked,"Michael, what is your number 1 goal as TMA President?"
My answer is simple. My primary goal as your President is to increase physician membership in TMA.
Why? Because the more physician boots on the ground and the more physician voices in the air when discussing medical issues with mothers, fathers, grandfathers, grandmothers, aunts, cousins and … by the way … legislators, the more we are heard, and respected. The level of that respect translates directly into what we can do for our patients … for our practices … for our profession.
By being members of TMA, physicians have accomplished much in practice viability and in advocacy. By representing all physicians in Texas, TMA is the voice for the specialists and for the primary care physicians. Our issues, no matter your area of practice, are astoundingly similar: We want better outcomes for our patients. We want to be treated as professionals, not as hourly workers on an assembly line.
What have we, what has TMA, done for us lately? What have we done lately to advance that agenda? Let me remind you of several examples just over the past decade:
Currently, we are nearly 46,000 members strong. I want 50,000. That's right … 50,000.
But why should your colleagues join? I have given you a lot of reasons. Let me focus on one.
Tort reform alone has decreased our medical liability premiums by one-third to one half since its passage. This is true whether you are paying as a sole practitioner or you are in a very large group that is self-insured. If your policy cost you $15,000 a year per physician back in 2002, you currently save a minimum of $5,000 a year, every year!
TMA and county society dues are a fraction of that number. Each of us knows of at least one non-member physician … probably a whole lot more than that. Therefore, I challenge you and every TMA physician to go out and multiply.
Personally, I am prepared to meet any and all non TMA physicians … one-on-one, in pairs, or in large groups … anywhere across this great state of ours. I will visit as many of you this year as possible. You may see me at your specialty meeting … in your home town … or both. By this time next year, we should all be on a very comfortable, first-name basis.
But I do not want just numbers. I want strength … I want strength for us and for our patients.
Yes, when I appear at the Capitol to testify in support of an item in our Healthy Vision 2020 agenda, I want the head-turning, eye-opening impact that the 50,000 number has. But I also want legislators to put down their papers and pay attention to what we're saying. And, after we are done speaking, I want them to come up to me, to you, and ask how they can help us accomplish what we want.
That's it.
Thank you for the privilege.
List of TMA presidents since 1853
TMA President's main page
May 17, 2017
What could a TMA Membership mean for you, your practice, and your patients
Michael J. Darrouzet takes over as TMA chief executive. Read More
Presidents of the Texas Medical Association Read More
Just like every physician, I want to be the best doctor for my patients. There is the obvious way – as a capable di-agnostician and clinician. While a necessary and valuable role, as clinicians we only impact one person at a time. To have a bigger impact on the health of our communities we must take medicine outside of the exam room and engage in health care advocacy. Read More
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The December issue follows a group of UTMB medical students thrown into extreme situations in order to learn how to practice extreme medicine. The two-week course was offered through the school's preventive medicine department. Plus, read about the medical and economic ripple effects of Texas' uninsured rate, the worst in the nation.
Read the Latest Issue


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Background: Tramadol induced disorder is a new problem.
Objective: To explain the efficacy of low dose of clonidine, baclofen and ibuprofen (NSAID) in the treatment of severe and chronic tramadol dependency (2000 mg daily).
Method: To evaluate the usefulness of non-narcotic drugs in the management of severe tramadol withdrawal symptoms.
Results: Clonidine 0.3 mg, baclofen75 mg and ibuprofen 1200 mg per day is very effective in the management of severe tramadol withdrawal symptoms and craving.
Discussion: Our findings indicates that low dose of clonidine, baclofen and ibuprofen (NSAID) is beneficial in the treatment of severe tramadol dependency. This is a fascinating result.
Conclusion: To our knowledge dramatic effects combination of clonidine, baclofen and ibuprofen in these situations has not been published yet, and this finding is a considerable addition to the literature.
Published on: Oct 28, 2015 Pages: 41-43
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Ennio Duranti
University of Siena, Italy
Archives of Renal Diseases and Management
Chien-Chang Liao
Taipei Medical University, Taiwan
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Jiexiong Feng
Huazong University of Science and Technology, China
Open Journal of Pediatrics and Child Health
Francesco Marotta
ReGenera R&D International for Aging Intervention & San Babila Clinic, Milano, Italy
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Dr. Pierre Guertin
Laval University, Canada
Archive of Gerontology and Geriatrics Research
William CS Cho
Queen Elizabeth Hospital, Hong Kong
International Journal of Immunotherapy and Cancer Research
Richard Hogston
Leeds Beckett University, UK
Archives of Community Medicine and Public Health
Hamza Mujagic
Former member of MGH, USA
International Journal of Immunotherapy and Cancer Research
Samy I. McFarlane
State University of New York, Downstate Medical Centre, Brooklyn, New York, USA
International Journal of Clinical Endocrinology and Metabolism
Giampiero Capobianco
Sassari University, Italy
Archive of Urological Research


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Compare the advantages and disadvantages of a three-dimensional monitor using a varifocal mirror with a stereoscopic system.1788
Determine the result of performing two successive block transfer into the same area of a frame buffer using the binary arith operations.1094
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Poker versions are performed exactly where a "high hand" or a "reduced hand" could be the finest preferred hand. Quite simply, when enjoying a poker variant with "minimal poker" the most effective hand is 1 which contains the bottom cards (and it can get further more challenging by like or not which includes flushes and straights etc. from "superior hand poker"). So when the "the greater part" of poker video game variations are performed "superior hand", exactly where the very best substantial "straight, flush and so forth.
Poker games change in the amount of playing cards dealt, the quantity of shared or "Group" playing cards, the quantity of cards that continue being concealed, and also the betting strategies.
When calculating the utmost increase authorized, all preceding bets and calls, such as the intending raiser's phone, are initial included for the pot. The raiser may perhaps then increase the past bet by the total volume of the pot. In no-Restrict poker, a player may wager their overall betting stack at any position that they're allowed to generate a guess. In all video games, if a participant doesn't have adequate betting chips to completely match a guess, they may go "all-in", making it possible for them to point out down their hand for the amount of chips they've remaining.
One or more gamers are usually required to make pressured bets, typically either an ante or a blind wager (in some cases equally). The supplier shuffles the cards, the player around the chair to their proper cuts, plus the seller specials the right amount of playing cards on the players one by one, beginning Using the player to his / her remaining.
Excluding First pressured bets, funds is just placed in the pot voluntarily by a player who both thinks the guess has constructive predicted worth or who is trying to bluff other gamers for numerous strategic factors.
A participant who matches a guess may additionally "raise" (increase) the guess. The betting round ends when all gamers have either known as the very last wager or folded. If all but 1 participant folds on any round, the remaining player collects the pot devoid of currently being required to expose their hand. If more than one participant stays in contention once the last betting spherical, a showdown normally takes location where the palms are exposed, and the player Along with the winning hand usually takes the pot.
Poker has enhanced in recognition considering the fact that the start from the twentieth century and has absent from being largely a leisure activity confined to smaller groups of lovers to a commonly popular action, both of those for individuals and spectators, together with on the internet, with quite a few Expert players and multimillion-greenback Event prizes.
Cards could possibly be dealt possibly face-up or confront-down, based on the variant of poker currently being performed. Once the initial deal, the primary of what can be several betting rounds begins. Among rounds, the players' palms acquire in a way, often by getting dealt more playing cards or replacing cards Beforehand dealt. At the end of Every round, all bets are collected into your central pot.
For more details on guidelines for the most common poker variants, see List of poker fingers and List of poker variants.
The player with the most effective hand in accordance with the poker variant remaining played wins the pot. A poker hand comprises five cards; in variants the place a participant has more than five cards available to them, only the very best five-card blend counts. Variants[edit]
Poker is a family members of card online games that mixes gambling, system, and various capabilities. All poker variants entail betting being an intrinsic part of Perform, and decide the winner of every hand in accordance with the combinations of gamers' playing cards, no less than many of which continue being concealed right until the tip in the hand.
K. nowadays. Straight arms of 5 playing cards are sometimes used like a last showdown, but poker is nearly always performed in a more elaborate form to allow for additional technique.
Poker was designed sometime during more info the early nineteenth century in The us. Given that These early beginnings, the sport has developed to become a particularly well-liked pastime throughout the world.
A complete hand is dealt to every participant, and players guess in one spherical, with raising and re-elevating allowed. This can be the oldest poker loved ones; the basis of the sport as now played was a video game known as Primero, which advanced into the game 3-card brag, a extremely popular gentleman's sport round the time with the American Groundbreaking War and however loved from the U.
This informative article should really involve a much better summary of Heritage of poker. See Wikipedia:Summary style for info on ways to thoroughly incorporate it into this short article's major text. (April 2018)
In the January 2015 posting[five] posted in Science, a group of researchers primarily through the University of Alberta introduced that they "basically weakly solved" heads-up Restrict Texas Hold 'em with their advancement of their Cepheus poker bot.
Consequently, though the outcome of any certain hand appreciably consists of opportunity, the lengthy-run anticipations in the players are based on their steps decided on on The idea of probability, psychology, and sport concept.
A different game Together with the poker name, but that has a vastly distinctive manner of Enjoy, is referred to as Acey-Deucey or Purple Puppy poker. This sport is more comparable to Blackjack in its layout and betting; Every participant bets from the home, and after that is dealt two playing cards. For your player to earn, the third card dealt (after a chance to raise the guess) have to have a value in-concerning the primary two.
This can be what makes bluffing doable. Bluffing is actually a primary element of poker, one that distinguishes it from other vying online games and from other games that use poker hand rankings.
Payout is based on the chances that this is achievable, according to the real difference in values of the very first two playing cards. Other poker-like games played at casinos from the house include things like three card poker and pai gow poker. Laptop programs[edit]
The authors claimed that Cepheus would get rid of at most 0.001 big blinds for each video game on typical in opposition to its worst-circumstance opponent, and also the approach is thus so "close to ideal" that "it cannot be overwhelmed with statistical significance inside a life time of human poker actively playing".[six] See also[edit]
In casual Perform, the appropriate to offer a hand typically rotates One of the players and is also marked by a token called a vendor button (or buck). Within a On line casino, a property vendor handles the playing cards for each hand, although the button (normally a white plastic disk) is rotated clockwise among the players to indicate a nominal vendor to find out the purchase of betting. The cards are dealt clockwise across the poker table, one by one.
Often known as "flop poker", Local community card poker is often a variation of stud poker. Gamers are dealt an incomplete hand of experience-down cards, then quite a few experience-up Neighborhood cards are dealt to the center of your desk, Just about every of that may be utilized by one or more from the gamers to help make a five-card hand. Texas maintain 'em and Omaha are two nicely-recognized variants of the Group card relatives.
At the conclusion of the last betting spherical, if multiple player continues to be, You will find a showdown, through which the players expose their Earlier hidden playing cards and Consider their hands.
In Newest poker online games the initial round of betting starts with one or more of your players creating some method of a pressured bet (the blind or ante). In typical poker, Every single player bets based on the rank they think their hand is truly worth when compared to another gamers. The action then proceeds clockwise as Just about every player consequently should possibly match (or "contact") the most prior wager, or fold, losing the amount guess up to now and all even further involvement inside the hand.
Other game titles that use poker hand rankings might Also be referred to as poker. Movie poker is only one-player video recreation that capabilities much like a slot equipment; most video poker devices Participate in draw poker, in which the participant bets, a hand is dealt, and the player can discard and exchange playing cards. Payout is depending on the hand resulting after the draw and the player's Preliminary wager.
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Poker versions are performed exactly where a "high hand" or a "reduced hand" could be the finest preferred hand. Quite simply, when enjoying a poker variant with "minimal poker" the most effective hand is 1 which contains the bottom cards (and it can get further more challenging by like or not which includes flushes and straights etc. from "superior hand poker"). So when the "the greater part" of poker video game variations are performed "superior hand", exactly where the very best substantial "straight, flush and so forth.


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text: ioeric updated this revision to Diff 130766. ioeric marked 16 inline comments as done. ioeric added a comment. - Addressed review comments. - Check windows vs unit paths in tests. - Properly check absolute paths. Repository: rCTE Clang Tools Extra https://reviews.llvm.org/D41946 Files: clangd/CMakeLists.txt clangd/URI.cpp clangd/URI.h unittests/clangd/CMakeLists.txt unittests/clangd/URITests.cpp -------------- next part -------------- A non-text attachment was scrubbed... Name: D41946.130766.patch Type: text/x-patch Size: 16598 bytes Desc: not available URL: <http://lists.llvm.org/pipermail/cfe-commits/attachments/20180120/8082c70c/attachment-0001.bin>


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Although there are many who enjoy shopping online, others have concerns about shopping
online and do not enjoy this type of shopping.
For these shoppers, there are many concerns that prevent the shopper from feeling completely comfortable shopping online.
Some of these concerns include identity theft, the difficulty of generating returns, and misrepresentation of products.
This article discusses these concerns and provides information on how to help shoppers avoid online shopping risk and feel more comfortable about online shopping.
Shoppers who put these concerns are likely to find that they actually enjoy the convenience of shopping online.
Concerns about identity theft
Concerns about identity theft are one of the most common concerns for those who think about shopping online.
Identity theft is a very real concern because unscrupulous individuals who gain
sensitive information about an online shopper can do great damage to the financial situation and credit score of individuals.
Although it is usually possible to correct problems that occur as a result of identity theft, the process of making these corrections is usually lengthy and difficult.
In addition, there are some problems that result from identity theft that can not be corrected especially if identity theft is not detected for some time.
While identity theft is a real concern, online shoppers are not quite prone to
identity theft in most cases. However, an online shopper should know how to determine whether the information they provide online is safe or not.
This is important because while the risk of identity theft associated with online shopping through a secure Web site is relatively small, this risk is significantly greater when the site is not secure.
For this reason, online shoppers must carefully check the web address for any Web site where they provide sensitive information.
Sites that start with https: // instead of http: // indicate that the information is sent through a secure server.
Most reputable online retailers will provide a safe shopper site, but some small online retailers may not offer this safety.
If the server is not secure, the shopper should think of contacting customer service to place the order instead of sending information through the insecure website.
Dealing with proceeds
Another problem that many online retailers face is the potential for problems caused by the need to return items purchased online.
In most cases, the return process with online retailers is very simple and no more difficult than returning items to a normal store.
In fact, online retailers who have a traditional shopper shop online often allow you to return to these sites instead of recharging the item to an online retailer.
However, returns are not always that easy.
In some cases, the shopper is financially responsible for the cost of recharging the item to an online retailer.
This can be expensive if the item is oversized and can require a high price insurance
if the item is expensive.
Online shoppers with concerns about the RETAIL RETURN POLICY
should carefully review these policies and ask if they have any questions about the process before making a purchase.
Misleading description of the product
One recent concern among many potential online shoppers about online shopping is that they face misleading product descriptions. This may include descriptions of products that are unintentionally or unintentionally vague. The concern in this case is that the shopper will buy a wrong item or an item not described by the online retailer and the buyer will have difficulty returning the item if necessary. Although this problem may occur, there are simple steps that the consumer can take to avoid this problem. The simplest solution to this problem is to contact customer service to clarify information about online products. This allows the consumer to speak directly to a representative from the online retailer and check whether the product being sold suits his or her needs. Based on this information, the consumer can decide whether or not to make the purchase.
تقوم بتزويد الخدمة لكلا من رواد الأعمال والأفراد واضعين نصب أعيننا توفير
تجربة دفع رائعة للتاجر المصحوبة بمميزات التسويق الرقمي والتحليلات، حيث تتنوع وسائل الدفع الرقمي،
فإن نظام التشغيل يقبل بطاقات الصراف الآلي وبطاقات الإئتمان و المحافظ الرقمية علي حدٍ سواء،
مما يتيح الفرصة لتوفير خدماتنا لفئة الغير متعاملين مع البنوك بحرية.
ودفع فواتيرهم بالطريقة المفضلة لديهم من خلال الهاتف أو الجهاز اللوحي أو الحاسب الشخصي.


text:
Are you experiencing flea infestation at home even if your pet is getting the right treatment? You may need to contact an expert in flea control Muirlea to help you protect your pet and your home from these annoying bugs.
In flea control, the flea pupae should be your main concern. Here are some facts to know about flea pupae:
Liquid flea treatment may not effectively kill the pupae consistently. When you apply liquid treatment using a growth regulator and adulticide, it may kill the fleas and the larva that is crawling around. The growth regulator may affect the development of the existing eggs once they are exposed and they won't be able to develop normally into adults. The problem, however, is the pupae which are still developing. They may take another four to eight weeks to hatch out.
Oftentimes, people do all the wrong things when dealing with a flea problem such as segregating the cat or dog from which the source of the infestation. Since pupae are motivated to hatch when there is activity around them, keep people and pets active in the rooms where the flea problem is common. The adult fleas are not interested in making you their next meal and are happy to stay with your pet. If you decide to remove the pet from the room where the flea problem is worst, they may leave the pupae cocoons with them and since your pet is not there anymore, you may have a flea problem in your room soon.
Call for expert pest control service. Your pest control expert will apply effective flea treatment to control the eggs and eliminate them on all places they could be hiding.


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Sudan's ex-President Omar al-Bashir moved to prisonAfrica, Headlines Wednesday, April 17th, 2019
(BBC) Sudan's former President Omar al-Bashir has been moved to Kobar maximum security prison, days after he was deposed in a military coup.
Reports say the ex-leader has until now been detained at the presidential residence under heavy guard.
He is reportedly being held in solitary confinement and is surrounded by tight security.
Months of protests in Sudan led to the ousting and arrest of the long-time ruler on Thursday.
Uganda's Minister for Foreign Affairs Henry Oryem Okello told Reuters news agency the country would consider offering the deposed leader asylum if he applied, despite an arrest warrant issued by the International Criminal Court (ICC).
As an ICC member, Uganda would have to hand over Mr Bashir if he arrived in the country. The ICC has not yet commented.
Until now, Mr Bashir's whereabouts since his removal were unknown. The coup leader at the time, Awad Ibn Auf, said Mr Bashir was being detained in a "safe place". He himself stood down soon afterwards.
Lt Gen Abdel Fattah Abdelrahman Burhan was then named as head of the transitional military council, to become Sudan's third leader in as many days.
Demonstrators have vowed to stay on the streets until there is an immediate move to civilian rule.
Who is Omar al-Bashir?
Mr Bashir led Sudan for close to 30 years.
He is accused of organising war crimes and crimes against humanity in Sudan's western Darfur region, for which the ICC issued an arrest warrant.
After months of protests – starting in response to a rise in living costs and morphing into calls for the government to resign – Sudan's military toppled Mr Bashir in a coup on Thursday.
The transitional military council was set up in the wake of his removal and has said it will stay in place for a maximum of two years until a civilian government can be put in place.
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Short URL: http://newnigerianpolitics.com/?p=52372


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The Scottish Government has announced that the process of appointing Scotland's second most senior judicial office is under way, now that the First Minister has established a selection panel to make recommendations for a new Lord Justice Clerk.
The process of appointing the new Lord Justice Clerk follows the recent appointment of Lord Carloway to the office of Lord President.
The Lord Justice Clerk, who provides support to the Lord President and is deputy chair of the Board of the Scottish Courts and Tribunals Service, also chairs the newly created Scottish Sentencing Council.
On the selection panel are:
The post is being advertised from today, with applications welcome until Sunday 7 February.
The advert can be accessed via the Scottish Government website.
Sheriff Principal job application
Tuesday, 26 November, 2019
New judges appointed
Wednesday, 20 November, 2019
New Evidence & Hearings Suite
Monday, 18 November, 2019
Dale Vince and Others
Wednesday, 9 October, 2019
Judicial Institute for Scotland Annual Report published
Monday, 7 October, 2019
Stay up-to-date with us