The Evolution of Balanced Scorecard in Healthcare: A Systematic Review of Its Design, Implementation, Use, and Review

During the last few years, the interest in performance measurement increased within the healthcare sector. Due to the COVID-19 pandemic, healthcare systems needed to boost performance measurement systems to become more resilient and improve their capability in monitoring key performance indicators. Since the 1990s, the Balanced Scorecard (BSC) model has been widely used among private and public organizations as it is the most adopted model to measure performance. The current paper aims at understanding the evolution of BSC in healthcare. The systematic literature review has been carried out by searching keywords according to PRISMA guidelines. By analyzing papers through one classification of BSC adoption phases, the results reveal that studies focused mainly on the BSC design process, rather than BSC implementation, use, or review. However, there is no agreement about the perspectives to be adopted in healthcare. Concerning BSC implementation and use, on one side especially leadership, culture and communication enable the BSC implementation. On the other side, monitoring and strategic decision-making are the most widespread objectives for using BSC. Concerning BSC review, however, the paper highlights a need for additional research. Finally, the paper provides further research opportunities concerning the phases suitable for implementing a BSC in healthcare.

Barriers to adopt the Health Promoting Hospitals (HPH) initiative in Iran: The Q method derived perspectives of front line practitioners

OBJECTIVE

This study aimed to investigate prospects of a sample of Iranian front line health care professionals about their perceived barriers to implement the HPH initiative.

METHODS

The six stages Q methodology was applied to systematically envisage divergent perspectives of the 33 health professionals (7 physicians, 2 managerial and 24 nurses) working in the 10 educational hospitals in Iran.

RESULTS

Analysis of the study participants' viewpoints (the Q-sorts) resulted in a five factor solution (accounted for 48% of the total variance) to endorse main barriers of the HPH implementation in the typical Iranian hospitals. The health professionals' dominant biomedical approach and their deficit commitment to health promotion programs, inappropriate decision-making mechanisms and insufficiency of the organizational infrastructure in the Iranian national health system (INHS) were among the important emanated factors to sustainably maintain the HPH program.

CONCLUSION

The identified barriers reflect the spheres that need to be focused in interventions to facilitate the successful implementation of the HPH initiative in Iran and other developing countries.

PRACTICE IMPLICATIONS

Despite the existent consensus about overall merits of the HPH to fulfill best interests of hospitalized patients, major challenges deems to exist for operability of this beneficial undertaking in Iran.

Advancing towards contemporary practice: a systematic review of organisational performance measures for non-acute health charities

Background

Organisational performance measurement is a recognised business management tool and essential for survival and success. There is a paucity of methodological studies of organisational performance measurement relating to non-acute healthcare charities and this study is the first to suggest a set of evidence-informed organisational performance measures for the sector.

Methods

This study was designed using a two-staged approach. A systematic review of peer-reviewed journal literature between 2003 and 2016 was conducted according to the twenty-seven (27) point checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) complemented by a thematic analysis of eligible data using a cutting and sorting technique to generate a set of common measures of organisational performance for non-acute health charities.

Results

Not one study was found relating to organisational performance of non-acute healthcare charities however four records met eligibility criteria relating to non-acute or primary healthcare services with charitable fundraising capability. Three were case studies of specific organisations that related their approach to organisational performance measurement, while the fourth compared a case study organisation to a public service. Three different organisational performance frameworks and 20 organisational performance measures were used across the four studies.

Conclusions

The study concluded that (1) demonstration of organisational performance is relevant to non-acute health charities; (2) organisational performance measurement is feasible in this sector; (3) an evidence-based organisational performance measurement framework for the sector has not yet been developed nor has an existing organisational performance measurement framework been adapted for the sector, although the Balanced Scorecard is likely to be an effective option and (4) five leading measures – Quality of Service; Finance; Stakeholders (Customers and Clients); People and Culture; and Governance and Business Management; could be used to determine organisational performance in these sectors. Finally, ‘Mission and Purpose’ could be explored as a potential measure. Further research to understand why there is such limited published organisational performance evidence for the sector could be useful. Case studies of organisational measurement strategies of successful non-acute healthcare charities and research into important factors for organisational performance implementation in the sector may contribute to greater uptake and knowledge dissemination.

Effective factors in implementation and development of health promoting hospitals: a systematic review

One of the requirements for the implementation of Health Promoting Hospitals (HPHs) is comprehensive integration of health promotion (HP) activities and programs in hospital quality management system. Therefore, this systematic review was conducted utilizing a comprehensive European Foundation for Quality Managment (EFQM) model to determine appropriate criteria for the implementation and development of HPH. This systematic review considered the published literature on factors affecting the implementation and development of HPH during 1997–2016. Twenty-three articles were finalized for further investigation. EFQM was used as guidance for the investigation and analysis of studies conducted in relation to HPH. Regarding our results, real need analysis and accurate assessment of needs, attention to infrastructure factors, HPH standardization, promotion of self-care, knowledge enhancement and patient and staff skills training, improvement of quality indicators, continuous participation of HPH committee, designing HP interventions, paying attention to clinical outcome, equity in health, promoting a healthy work environment, continuity and cooperation etc. are among the factors contributing to HPH implementation and development. In case of having high capacity for successful HPH implementation, comprehensive HPH capacity building and resource development are not possible unless they are performed based on one of the framework emphasized by World Health Organization (WHO) such as EFQM.

An assessment of implementation and evaluation phases of strategic plans in Iranian hospitals

Objectives:

To assess the implementation and evaluation phases of strategic plans in selected hospitals.

Methods:

We conducted a cross-sectional study of implementation and evaluation of strategic plan in 24 hospitals in 2015, using a questionnaire which consisted of two separate sections for strategic implementation and strategic evaluation. Data were analyzed with SPSS version 18.

Results:

Nearly one-third of hospitals claimed that they allocate their budget based on priorities and strategic goals. However, it turned out that although goals had been set, no formal announcements had been made. Most of the hospitals stated that they used measures when evaluating the plan. For hospital staff, clarifying the hospital’s priorities was the most important advantage of a strategic plan.

Conclusion:

There is no clear definition for strategic management in Iranian hospitals, which results in chaotic implementation and control of strategic planning.

Using a Scorecard to Demonstrate Clinical Nurse Specialists’ Contributions

Clinical nurse specialists (CNSs) have the expertise to influence change at the patient, nurse, and system levels. They are clinical experts who understand the challenges of the current health care environment: decreasing costs, ensuring high-quality care, and achieving outcomes. Evidence has demonstrated CNSs’ influence on improving patient outcomes. Although CNSs often lead the work, they can be invisible when the outcomes are presented. A scorecard to display this work could be invaluable to the CNS role, as it would bring transparency to the evidence-based work done. This article describes the development of a CNS scorecard in a 627-bed tertiary hospital.

Strategic planning, implementation, and evaluation processes in hospital systems: a survey from Iran

BACKGROUND & AIM

Strategic planning has been presented as an important management practice. However, evidence of its deployment in healthcare systems in low-income and middle-income countries (LMICs) is limited. This study investigated the strategic management process in Iranian hospitals.

METHODS

The present study was accomplished in 24 teaching hospitals in Tehran, Iran from September 2012 to March 2013. The data collection instrument was a questionnaire including 130 items. This questionnaire measured the situation of formulation, implementation, and evaluation of strategic plan as well as the requirements, facilitators, and its benefits in the studied hospitals.

RESULTS

All the investigated hospitals had a strategic plan. The obtained percentages for the items "the rate of the compliance to requirements" and "the quantity of planning facilitators" (68.75%), attention to the stakeholder participation in the planning (55.74%), attention to the planning components (62.22%), the status of evaluating strategic plan (59.94%) and the benefits of strategic planning for hospitals (65.15%) were in the medium limit. However, the status of implementation of the strategic plan (53.71%) was found to be weak. Significant statistical correlations were observed between the incentive for developing strategic plan and status of evaluating phase (P=0.04), and between status of implementation phase and having a documented strategic plan (P=0.03).

CONCLUSION

According to the results, it seems that absence of appropriate internal incentive for formulating and implementing strategies led more hospitals to start formulation strategic planning in accordance with the legal requirements of Ministry of Health. Consequently, even though all the investigated hospital had the documented strategic plan, the plan has not been implemented efficiently and valid evaluation of results is yet to be achieved.

Balanced scorecard: application in the General Panarcadian Hospital of Tripolis, Greece

PURPOSE

The purpose of this paper is to discuss the application of the balanced scorecard (BSC) in the Greek public health sector.

DESIGN/METHODOLOGY/APPROACH

The basic balanced scorecard theory has been adopted in the characteristics and individualities of the Greek public health system. The theoretical model developed was applied in the General Panarcadian Hospital of Tripolis (GPHT) in Greece. GPHT is a representative paradigm of a big regional Greek public hospital. It has about 300 beds and many clinics and specialties (internal medicine, cardiology, general surgery, intensive care unit, artificial kidney unit, etc.). Strategic management was performed for almost three years. The BSC model was formulated in an appropriate software program. The problems (both technical and managerial) faced during a three-year period along with the results of this management approach are presented in the current paper. The paper highlights some important gaps in the Greek public health system, while proposing actions to be taken.

FINDINGS

The BSC theory can be very successful under certain conditions.

ORIGINALITY/VALUE

Special attention is given to the peculiarities of the Greek public health situation. The paper presents for the first time a real life example of applying BSC in the Greek public health sector.

Configuring balanced scorecards for measuring health system performance: evidence from 5 years' evaluation in Afghanistan

BACKGROUND

In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008.

METHODS AND FINDINGS

Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p<0.0001); provider satisfaction (65.4-79.2, p<0.01); capacity for service provision (47.4-76.4, p<0.0001); quality of services (40.5-67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0-52.6). The financial domain also showed improvement until 2007 (84.4-95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004.

CONCLUSIONS

The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts. Please see later in the article for the Editors' Summary.

Understanding the context of balanced scorecard implementation: a hospital-based case study in Pakistan

Background

As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital.

Methods

Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs and reporting of performance based on the BSC during administrative meetings. Pettigrew and Whipp's context (why), process (how) and content (what) framework of strategic change was used to guide data collection and analysis. Data collection methods included quantitative tools (a validated culture assessment questionnaire) and qualitative approaches including key informant interviews and participant observation.

Results

Method triangulation provided common and contrasting results between the four units. A participatory culture, supportive leadership, financial and non-financial incentives, the presentation of clear direction by integrating support for the BSC in policies, resources, and routine activities emerged as desirable attributes for BSC implementation. The two units that lagged behind were more involved in direct inpatient care and carried a considerable clinical workload. Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming implementation challenges in two clinical units that were relatively ahead in BSC implementation. It was noted that, rather than seeking to replace existing information systems, initiatives such as the BSC could be readily adopted if they are built on existing infrastructures and data networks.

Conclusion

Variable levels of the BSC implementation were observed in this study. Those intending to apply the BSC in other hospital settings need to ensure a participatory culture, clear institutional mandate, appropriate leadership support, proper reward and recognition system, and sensitization to BSC benefits.