PONE-D-22-07840Management Practices in Hospitals: A Public-Private ComparisonPLOS ONE

Dear Dr. lucifora,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please find below other specific comments on the paper.

Please submit your revised manuscript by Jul 19 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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PLOS ONE

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Additional Editor Comments :

Dear Authors, thank you for submitting the paper to PLOS ONE.

The topic is really interesting and useful for the progress of healthcare management studies.

However, the expert reviewers raised several concerns which prevent from publication on PLOS ONE in its current form, especially for a lack of an adequate literature review on public administration and management field, and on the specific characteristics of healthcare organizations and management. Moreover, there is a common request to reorganize the structure of the paper, along with several other comments.

My advice is to follow carefully the requests of the two reviewers and submit the paper for a second round of review after these improvements.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Management Practices in Hospitals: A Public-Private Comparison by Claudio Lucifora

Referee Report

The paper addresses a salient issue in health policy and management and has potential intriguing implications. It is also clearly written and easy to follow. However, it has several crucial weaknesses that need to be addressed by the author before becoming publishable. I will present them according to the structure of the paper.

Abstract

The first part of the abstract is not relevant as it is already known that management matters in emergency situation and the paper is based on rather old data. I suggest to radically change the first three lines of the abstract. I would openly state when data were collected as in the last decade there has been major changes in healthcare management in several countries, including Italy. Finally, I find the final part too simplistic and with no reference to the literature about how to improve management in the public sector. In this respect I suggest the author to get a bit more familiar with the public and healthcare management literature. The references show that he is not aware of a scholarly debate in the field of Public Administration and Public Management.

2. Management practices in hospitals

• The reference Chandra and Staiger (2007) appears unrelated to the statement made by the authors by the similar incentive structure in public and private hospital. Indeed, these two types of organizations tend to have different institutional goals; as it is well known private hospitals are mainly dominated by the search of shareholder value while public organizations are expected to pursue the public interest and they are, by definition, directly or indirectly, accountable to politics (see for example the Oxford Handbook on Public Management for an overview (Ferlie et al., 2005). Also, it is unclear how the survey and the authors treated non-profit hospitals, that are organizations that are generally owned by private entities but cannot share profits. It should specified this distinction and, if possible, it should be taken into account in the analysis.

• This sentence at the end of the section: “It is important to stress that what is under investigation here is not the quality of healthcare or the services provided to patients, nor the resilience of hospitals to the coronavirus outbreak, but simply the management practices adopted in public and private hospitals, during normal times, to monitor performance, set targets, and recruit, retain and motivate the personnel. Is very important,” is crucial. Particularly, it is essential that the author explains why he chose these three areas among all possible avoidable dimensions collected in the interviews, including some that are healthcare management specific.

• It should be reported when the data were collected given changes occurring in healthcare system worldwide

• It should reported (and justified) that the survey is based on interviews with clinicians and not managers strictu senso. As far as I understand, they acted as key informant about what happened in their hospitals. Obviously, they reported what perceived through the lenses of the clinical profession (see Numerato et al. 2012) to get a first idea about the relationship between management and medical doctors. It may be also useful to read a very recent paper that, by chance, investigated the same professionals in two Italian regions (Fattore et al, 2022).

• Please provide in the main text more info about the interview. If I remember well they are presented in one of the papers authored by Bloom.

3. Data and descriptive statistics

My preference is for papers that follow a traditional format: introduction, literature review (basically lacking in this paper), methods (including data and statistical methods), results, discussion and conclusions. It facilitates reading the paper.

• Present the statistical analysis of the difference in scores between public and private hospitals

• While Italy is missing in the figure presenting data country by country?

• What’s the meaning of quoting Syverson 2011? Doesn’t this paper refer to management in general? Anyway, it should be explained better why the parallel between the two papers matter

4. Main results

See my comment above about the structure of the paper. The regression model, with its various specifications, is the heart of the paper. The model, although simple, makes sense and it is clearly presented. Still needs some improvements (part in the methods section and part in the result section).

• I would avoid to use the expression management quality as the three indicators measure a part of what management is or can be

• I would avoid the expression management styles because it has a specific and narrower meaning in management studies

• Why the size of the hospitals is defined with two dummies (three classes). Don’t you have the stated size of the hospitals so to use it as a continuous variable? Please explain and justify

• This sentence should be moved in the discussion section where limitations of the study should be openly presented. “Notice that, as previously discussed, some care should be used in interpreting the above results, since large hospitals may well have better procedures, but it could also be the case that better managers are more likely to be hired in larger organization. These different hypotheses, however, cannot be disentangled in our setting”.

4.1 Robustness Check

I am not convinced by the Heckman model specification where the presence of competitor is used as IV. As rightly stated, the exclusion restriction assumption is unlikely to be respected. Why the level of competition is not simply used as control variable? In this respect, how competition is measured? Anyway, the part of the model presented in the discussion needs to presented earlier (in the method and results sections). More info are also needed to understand the variables to characterize hospitals; which are they? Are data reported by the key informants or collected from institutional sources (e.g., official eb sites)?

4.2 Discussion

This and the following sections are very scant with too few references and over simplifications. In the following I present some points of reflections.

• Larger hospitals are more difficult to be managed and thus require, in addition to others, the three elements considered by the authors. Smaller hospitals can perform well even with more basic management systems because informal relations, direct supervision by CEO and other top managers is easier, and organizational procedures and routines are more simple

• A large literature show that private and public management differences are substantial. Is it useful to use the same dimensions to measure management quality in the public and private sector? This was for sure the wish of the extreme New Public Management literature (see for example (Osborne and Gabler, 1992). For a critique to NPM see (Hood and Dixon, 2015). Maybe, looking for a co-author in the field of management and/or specifically in public management could make the difference, because she/he could put the empirical results of the study in the cultural context of disciplines that are debating these issues for decades.

Overall, this paper is potentially interesting and covers issues where there are relevant empirical gaps. However, as it stands is not publishable by PLOSE ONE. It needs a radical revision.

I do hope that my suggestions can help improve the paper.

References

Fattore G, Numerato D, Salvatore D. Do Policies affect Management? Evidencce from a survey of clinicians in the Italian NHS. Health Service Management Research. 2022.

Ferlie E, Lynn L, Pollitt C edr. The Oxford Handbook of Public Management. Oxford University Press. 2007.

Hood C, Dixon R. A Government that worked better and costs less? Oxford University Press. 2015.

Numerato D, Salvatore D, Fattore G. The impact of management on medical professionalism: A review. Sociology of Health and Illness 2012; 34 (4): 626-644.

Osborne D, Gaebler T. Reinventing Government. New York. Penguin Press. 1992

Reviewer #2: Overall comments

The paper explores how management practices in healthcare sector varies across seven OECD countries according to hospital size, public-private ownership and level of competition. The paper is consistent with the contemporary shared interest in the study of healthcare management and the topic pertains to scope and aims of the journal. Author’ contributions can be relevant because the study employs a large hospitals sample covering seven OECD countries and it properly employs the chosen methodologies. Therefore, I generally found the article interesting and with a good potential to contribute to the literature. Nevertheless, there is still some work to be done as several major issues strongly prevent the paper to be published. The following part of the review will provide some specific comments about each section of the paper.

1. Introduction

I would suggest to deeply revise and re-articulate the introduction. Indeed, while in the first paragraph the introduction provides some interesting arguments to motivate the practical relevance of the topic, by suggesting that management practices are key determinants of healthcare performance and efficiency, I would suggest the authors to better elaborate the review of previous studies on the determinants of ‘management practices’, especially for what concerns the ownership structure and identity. This would help the author to identify and develop the related research gap, to motivate the research questions so as to explain how his study could contribute to the literature on the topic. I think this is a major point that might prevent the article’s contribution to the literature and to the journal.

2. Management practices in hospitals

While reading this section my wait was to read a section concerning previous studies on management practices above all in terms of determinants. Actually, the section represents a brief description of items employed to measure “management practices” in the study, as well as to explain that they represent key determinants of performance (that is not the authors’ aim, as declared in the introduction). I would suggest moving the content of this section to the section 3, that I would suggest to entitle “3. Methodology”, to articulate as later discussed. In doing so, I would suggest to add a new section 2 devoted to the literature review on organizational determinants of management practices (especially in terms of ownership structure). As previously stated, I think that the lack of previous studies assessment is a major point that might prevent the article’s contribution to the literature and to the journal.

3. Data and descriptive statistics and 4. Main results

As previously stated, I would suggest to add a new section “3. Methodology” to articulate as follows:

3.1 Management practices in hospitals

This section would include the content of the previous version of section 2

3.2 Data and analysis

This section would include some of the text included in the section “3. Data and descriptive statistics” and section “4. Main results”.

More specifically I would suggest to separate the analysis of the employed methodology from the descriptive and regression results, that I would suggest to include within a new section entitled “4. Findings” articulated as follows: “4.1 Descriptive findings”, “4.2 Regression results”, “4.3 Robustness Checks”.

While section 3 (and related subsections) should describe the sample, the method, variables and analysis, section 4 (and related subsections) should describe descriptive findings, results coming from more advanced statistical analysis and robustness checks.

Finally, still concerning section 3 and specifically with regard to the regression analysis, I would suggest enlarging the list of control variables in order to include more controls that could influence the reported findings. For example, I would suggest the authors to control for (i) type of hospitals (general hospitals, teaching hospitals, research hospitals); (ii) hospital performance (e.g. quality and efficiency) (as it might possible that the adoption of management practices is more likely to occur within better performers); (iii) characteristics of served population; (iv) hospital complexity.

4.2 Discussion

I would suggest separating the discussion from the findings within a new section “5. Discussion”. I also think that actually the section is a little bit rare and this is due to the scarce assessment of previous studies on the literature background on the topic.

5. Concluding Remarks

I would suggest the authors to better reflect about the academic implications. Moreover, they could better explain in which way their article provides contribution to the theory. Authors should also reflect on the limitations of the study and provide them.

I hope that these comments can help the authors to better develop their study and to bring out its full potential. I wish them good luck with their research!

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Giovanni Fattore

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Management Practices in Hospitals Lucifora.docx

PONE-D-22-07840R1Management Practices in Hospitals: A Public-Private ComparisonPLOS ONE

Dear Dr. lucifora,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please find below the Academic Editor comments. 

Please submit your revised manuscript by Mar 03 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Anna Prenestini, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear authors,

the reviewers' decisions are polarized. Reviewer 1 is completely satisfied with your improvements.

On the contrary, reviewer 2 raises again some concerns about your methodology and, in particular, the lack of use of some suggested control variables.

I read carefully the justifications by the author and some of them convinced me to assign minor revisions.

However, I suggest an effort in order to use at least the typology of hospitals (mainly the difference between teaching and research hospitals and other hospitals) as a control variable. It may be really interesting.

Otherwise, specify why you decided not to use this control variable.

Kind regards.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: No

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Overall, I think that the structure of the paper and its theoretical positioning is improved as the author(s) have addressed most of my suggestions. Indeed, most of efforts have been done in terms of improvement of the assessment of prior studies on the topic. However, I think that the paper is still lacking in what concerns the methodology as the regression models still suffer of the use of more control variables. This can prevent the strength and the generalizability of the results.

In the previous review I suggested the authors to include more control variables such as (i) type of hospitals (general hospitals, teaching hospitals, research hospitals); (ii) hospital performance (e.g. quality and efficiency) (as it might possible that the adoption of management practices is more likely to occur within better performers); (iii) characteristics of served population; (iv) hospital complexity. Indeed, in the previous draft of the paper, the authors only used the hospital size as control variable. However, in this new version of the paper, hospital size and country dummies remain the only control variables. The authors answered to the comment that they have discussed the possible implication of omitting these variables. I think that the results in this version could be not strong and generalizable.

On the basis of this, I would suggest again the authors to enrich the regression model in order to make their research more robust. I think that the article is interesting and with a good potential, but this issue can strongly prevent the contribution of the paper to the literature.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Giovanni Fattore

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Management Practices in Hospitals: A Public-Private Comparison

PONE-D-22-07840R2

Dear Dr. lucifora,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Anna Prenestini, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Congratulations on the improvement of the paper. Now it is ready for publication on PLOS One.

Reviewers' comments: