Development of performance indicators by the Delphi study for foodservice operations in senior welfare centers: application of the balanced scorecard

With the rapid growth of the elderly population, the number of elderly welfare centers has expanded significantly. However, the current regulations and standards for foodservice management in these centers are inadequate. To address this issue, this study aimed to develop objective and integrated performance indicators based on the Balanced Scorecard for foodservice programs in elderly welfare centers. To evaluate the validity and reliability of the performance indicators, two Delphi studies were conducted in April 2017. The Delphi survey included the evaluation of strategic goals, financial perspective, customer perspective, learning and growth perspective, and the internal process perspective. The degree of consensus among experts was assessed using Kendall's W-test. As a result of the study, the study ultimately identified 33 performance indicators from 12 strategic goals in four perspectives, which could be used as an efficient tool to evaluate, supplement, and improve foodservice in elderly welfare centers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10068-023-01468-x.

Keep-or-drop multidimensional control systems in professional organisations: evidence on the use of the balanced scorecard in healthcare

PURPOSE

During the 1990s, Italian healthcare organisations (HOs) underwent a process of corporatisation, and the most innovative HOs introduced the balanced scorecard (BSC) to address the need for broader accountability. Currently, there is a limited understanding of the dynamics and outcomes of such a process. Therefore, this study aims to explore whether the BSC is still considered an effective performance management tool and analyse the factors driving and hindering its evolution and endurance in public and non-profit HOs.

DESIGN/METHODOLOGY/APPROACH

We conducted a retrospective longitudinal analysis of two pioneering cases in the adoption of the BSC: one in a public hospital and the other in a non-profit hospital. Data collection relied on accessing institutional documents and reports from the early 2000s to the present, as well as conducting semi-structured interviews with the internal sponsors of the BSC.

FINDINGS

We found evidence of three main categories of factors that trigger or hinder the adoption and development of the BSC: (1) the role of the internal sponsor and professionals' commitment; (2) information technology and the controller's technological skills; and (3) the relationship between the management and professionalism logics during the implementation process. At the same time, there is no evidence to suggest that specific technical features of the BSC influence its endurance.

ORIGINALITY/VALUE

The paper contributes to the debate on the key factors for implementing and sustaining multidimensional control systems in professional organisations. It emphasises the importance of knowledge-based assets and distinctive internal capabilities for the success of the business. The implications of the BSC legacy are discussed, along with future developments of multidimensional control tools aimed at supporting strategy execution.

A comprehensive bibliometric study of the balanced scorecard

This research provides a deeper knowledge in the Balanced Scorecard (BSC) insight by using the bibliometric technique. The existing gap between the traditional literatura reviews and previous bibliometric studies, is covered as it is the first comprehensive analysis carried out in applying quantity, quality, and structural indicators. Web of Science Core Collection was used as the source of information, considering it the most accurate and suitable data base for these studies. This research covers the wider period-of-time possible, from 1992 to 2020, with a final sample of 771 articles in 466 reviews. Quantity indicators show the high interest that the BSC still has in the scholar's community, pointing out Kaplan and Norton as the most productive authors,and confirming that 'management', 'business' and 'accountability' are its most common field of activity, although others as 'systems' and sustainability' are coming to prominence; 'Balanced Scorecard' appears as the most remarkable keyword. Quality indicators found 32,706 citations, with Kaplan and Norton occupying again top positions as well as 'Harvard Business Review' as the most impacting review both in cited articles and in average. Co-citation analysis reveals the existence of a triple corecluster for articles, based on the theory, literature reviews, and case-studies.

Measuring circularity of a manufacturing organization by using sustainable balanced scorecard

In recent years, circular economy has become a matter of great importance because of its ability to contribute toward economic, environmental, and social aspects of the sustainability. The circular economy approaches help in resource conservation by reducing, reusing, and recycling products/parts/components/materials. On the other hand, Industry 4.0 is coupled with emerging technologies, which support the firms in efficient resource utilization. These innovative technologies can transform the present manufacturing organizations by reducing resource extraction, CO2 emissions, environmental damage, and power consumption and improve it into a more sustainable manufacturing organization. Industry 4.0 along with circular economy concepts greatly improves the circularity performance. However, there is no framework found for measuring the circularity performance of the firm. Therefore, the current study aims to develop a framework for measuring performance in terms of circularity percentage. In this work, graph theory and matrix approach are employed for measuring the performance based on a sustainable balanced scorecard such as internal process, learning and growth, customer and financial with environmental and social perspectives. A case of an Indian barrel manufacturing organization is discussed for the illustration of proposed methodology. Based on "circularity index" of the organization and the maximum possible circularity index, the circularity was found to be 5.10%. It indicates that there is a huge potential for the improvement in the circularity of the organization. An in-depth sensitivity analysis and comparison are also performed to validate the findings. There are very few studies on measuring the circularity. The study developed the approach for measuring circularity, which may be utilized by industrialists and practitioners for improving the circularity.

Evaluating the adoption of cybersecurity and its influence on organizational performance

Cyberattacks negatively impact the performance of enterprises all around the globe. While organizations invest more in cybersecurity to avoid cyberattacks, studies on the factors affecting their overall cybersecurity adoption and awareness are sparse. In this paper, by integrating the diffusion of innovation theory (DOI), technology acceptance model (TAM), and technology-organization-environment (TOE) with the balanced scorecard approach, we propose a comprehensive set of factors that influence cybersecurity adoption and assess the effects of these factors on organizational performance. Data are collected through a survey of IT experts in small and medium-sized enterprises (SMEs) in the United Kingdom, with 147 valid responses. Structural equation modeling based on a statistical package for the social sciences (SPSS) was used to assess the model. The findings identify and confirm the importance of eight factors affecting SMEs' cybersecurity adoption. Moreover, cybersecurity technology adoption is found to positively impacts organizational performance. The proposed framework depicts variables influencing cybersecurity technology adoption and assesses their importance. The outcomes of this study provide a basis for future research and can be adopted by IT and cybersecurity managers to identify the most appropriate cybersecurity technologies that positively impact their company's performance.

Conceptual structure of balanced scorecard research: A co-word analysis

The present research aims to examine the conceptual structure of balanced scorecard (BSC) research from its inception (1992) to the end of 2020. After a review of the BSC literature, co-word analysis and social network analysis are used to analyze the data. The results show that 3742 documents have been published between 1992 and 2020 with 2638 distinctive keywords. The most frequently used keywords are "Balanced Scorecard", "Management", "Performance", "Framework" and "Strategy". Moreover, the article "The Balanced Scorecard: Measures That Drive Performance" with 4253 citations, was the most frequently cited article and "Robert Kaplan" with 16 documents and 8063 citations was the top author in terms of citation count and the number of documents. The United States is the top country with 486 documents and 18,805 citations. In addition, the journal "Total Quality Management and Business Excellence" is the most prolific journal with 50 articles, and the journal "Harvard Business Review" with 7778 citations, is the top journal in the number of citations. "Islamic Azad University of Iran" is the top university in the world with 57 documents. The most common keyword in Asia, Europe, North America, South America, and Oceania is "Balanced Scorecard". The results of this study provide an overview of the state of BSC literature and can enable researchers to identify and develop ideas for future research.

Constructing internal audit quality evaluation index: evidence from listed companies in Jiangsu province, China

Internal audit quality is the foundation for a company's survival and development across the world. As a result, global efforts have been made to develop a scientific and accurate evaluation index for internal audit quality. However, literature shows that existing internal audit quality evaluation indices have many flaws, such as a lack of systematic internal audit evaluation indicators, poor execution, and inability to identify priority areas. To address gaps in the literature, this study intended to construct an internal audit quality evaluation index utilizing the joint approaches of the Balanced Scorecard, Delphi Process, and Analytical Hierarchy Process. A systematic literature review, examination of companies' internal audit guidelines, Balanced Scorecard, and Delphi approaches resulted in a multilevel internal audit quality evaluation index with five dimensions (stakeholder satisfaction, stakeholder contribution, financial results, internal audit process, and learning and growth) and 36 indicators. The Analytical Hierarchy Process revealed that the most prioritized dimension is the internal audit process. The consistency ratio and evaluation feedback from the listed companies' internal auditors, management, and audit committee members revealed that the results are valid and reliable.

The Use of Balanced Scorecards in Mental Health Services: an Integrative Review and Thematic Analysis

Performance management of mental health services (MHS) through quality reporting of strategic indicators and goals is essential to improve efficiency and quality of care. One such method is the balanced scorecard (BSC). This integrative review of peer-reviewed and industry implemented BSCs in MHS aims to inform future development of a more comprehensive mental health–focused benchmarking tool. A two-part systematic literature search consisted of peer-reviewed published literature on MHS specific BSCs utilising the PRISMA guidelines in addition to industry published BSCs available online. A total of 17 unique BSCs were identified. A total of 434 indicators were subject to thematic analysis identifying 11 key themes: prevalence, accessibility, services provided, clinical outcomes, client satisfaction, client involvement, staff motivation, staffing levels, governance and compliance, development, and costs and revenue. These themes represented the measures that MHS believed measured key performance criteria in alignment with their organisational objectives.

The balanced scorecard as a strategic management tool in hospital pharmacies: an experimental study

PURPOSE

A balanced scorecard (BSC) is an applied tool for implementing strategic management in various organizations. Implementing strategic management using the BSC approach has not received much attention in pharmacy departments. This study aims to provide a model for the strategic management of pharmacy departments using the BSC framework.

DESIGN/METHODOLOGY/APPROACH

This experimental study was conducted from 2015 to 2018 in a 300-bed hospital and regional healthcare centers affiliated with the Petroleum Industry Health Organization in Tehran province, Iran. After carefully reviewing the organization's mission and vision, the strategic objectives were determined via the internal matrix and the external matrix (IE matrix), and the strengths-weaknesses-opportunities-threats matrix (SWOT matrix) were examined. Then, six BSC measures and interventions were identified, and each was examined from the perspectives of finance, patient satisfaction, internal processes and learning/growth. Finally, the proposed strategy was evaluated.

FINDINGS

Results showed significant increases in patient satisfaction and gross profit. The observed increase range, from 0.09 to 0.29, indicates more effective operational management for optimal resource utilization. In addition, the pharmacy department was able to save US $539,137 by implementing prepared protocols for expensive medications. Similarly, the pharmacy department saved $442,899 during the two years of our strategic management plan by implementing the standard mechanism for returning unused medications to the pharmacy department after patients were discharged from various treatment units.

ORIGINALITY/VALUE

This study is among the first studies to demonstrate the simultaneous development, implementation and evaluation of the proposed strategy using the BSC in a pharmacy department in a public healthcare center. The BSC application improved the optimal use of resources and reduced costs while increasing patient satisfaction. It appears that the application of such an intervention may be as valuable to public pharmacies as it is to other private centers.

A systematic review: the dimensions to evaluate health care performance and an implication during the pandemic

BACKGROUND

The balanced scorecard (BSC) has been implemented to evaluate the performance of health care organizations (HCOs). BSC proved to be effective in improving financial performance and patient satisfaction.

AIM

This systematic review aims to identify all the perspectives, dimensions, and KPIs that are vital and most frequently used by health care managers in BSC implementations.

METHODS

This systematic review adheres to PRISMA guidelines. The PubMed, Embase, Cochrane, and Google Scholar databases and Google search engine were inspected to find all implementations of BSC at HCO. The risk of bias was assessed using the nonrandomized intervention studies (ROBINS-I) tool to evaluate the quality of observational and quasi-experimental studies and the Cochrane (RoB 2) tool for randomized controlled trials (RCTs).

RESULTS

There were 33 eligible studies, of which we identified 36 BSC implementations. The categorization and regrouping of the 797 KPIs resulted in 45 subdimensions. The reassembly of these subdimensions resulted in 13 major dimensions: financial, efficiency and effectiveness, availability and quality of supplies and services, managerial tasks, health care workers' (HCWs) scientific development error-free and safety, time, HCW-centeredness, patient-centeredness, technology, and information systems, community care and reputation, HCO building, and communication. On the other hand, this review detected that BSC design modification to include external and managerial perspectives was necessary for many BSC implementations.

CONCLUSION

This review solves the KPI categorization dilemma. It also guides researchers and health care managers in choosing dimensions for future BSC implementations and performance evaluations in general. Consequently, dimension uniformity will improve the data sharing and comparability among studies. Additionally, despite the pandemic negatively influencing many dimensions, the researchers observed a lack of comprehensive HCO performance evaluations. In the same vein, although some resulting dimensions were assessed separately during the pandemic, other dimensions still lack investigation. Last, BSC dimensions may play an essential role in tackling the COVID-19 pandemic. However, further research is required to investigate the BSC implementation effect in mitigating the pandemic consequences on HCO.

Relationship between human resources strategies and organizational performance based on the balanced scorecard in a public hospital in Iran: a cross-sectional study

BACKGROUND

Today, due to the complex environment and rapidly changing of health industry, hospitals should optimize their organizational performance to achieve a competitive advantage. One of the important factors for achieving a competitive advantage is effective human resource management through the application of appropriate human resources strategies. This study investigated the relationship between human resources strategies and organizational performance based on balanced scorecard.

METHODS

A cross-sectional study was conducted among clinical and administrative staff in a public hospital in Isfahan province, Iran. All eligible staff entered the study (n=200). Data were collected using two self-reported questionnaires during July 2018. The main questionnaire contained 32 items that investigated human resources strategies (including seven types of strategies) and organizational performance based on the balanced scorecard approach. Data were analyzed via Pearson correlation coefficient and multivariate regression using SPSS/21 software (P<0.05).

RESULTS

In this study, 154 questionnaires were completed and returned (return rate=77%). Human resources strategies and organizational performance were evaluated at the intermediate level. There was a significant positive correlation between human resources strategies and organizational performance (r=0.73, p=0.001). The organizational performance in learning & growth perspective had the highest correlation (r=0.669, p=0.001) with human resources strategies while the financial perspective had the lowest (r=0.455, p=0.001). Multivariate regression analysis showed that all human resources strategies were effective on organizational performance (R=0.998, R2=0.997, ADJ.R2=0.997). Staff training and development strategy (Beta=0. 265, p=0.000), staff compensation & reward strategy (Beta =0.212, p= 0.000) and recruitment strategy (Beta = 0.208, B, P=0.000) had the greatest impact on organizational performance, respectively.

CONCLUSIONS

To improve hospital performance (especially in non financial perspectives), the development of human resources strategies (especially staff training and development strategy, staff compensation & reward strategy, and compensation strategy) can be considered by hospital managers. The findings of this study can be used for developing hospital performance in a similar context.

Exploration on the gap of single- and double-loop learning of balanced scorecard and organizational performance in a health organization

This paper addresses and interprets learning styles, namely, single- and double-loop learning, of BSC implementation in the background of healthcare organizaiton/industry, through which barriers and facilitators are inducted for the BSC for the healthcare industry. Samples of this study are from a community hospital with 290 beds was probed with samples of 34 BSC members interviewed. Based on the qualitative research's grounded theory, the transcript data of this study were analyzed using open, axial, and selective coding through NVIVO 10.0. By using single- and double-loop learning, this study distinguishes between adding and changing a health organization's specific capabilities, routines or abilities. Findings of this study indicated that BSC learning is more likely to improve the efficiency of the strategic management and strengthen the company's existing capabilities and routines; but it is not possible for single-loop learning to develop new capabilities. This study contributes to indicate that single-loop learning can be useful facilitators for organizational learning via affecting the positive performance of the organization, because employees are in favor of following existing routines and rules and allowing the employees to see the meaning of this balanced scorecard. However, employees still do not have the power to make changes they expect, because they do not have the power and right to change. The purpose of this research is to evaluate organizational learning performance via the implementation of the balanced scorecard in order to understand the mechanism's impact on organizational development. In short, this paper contributes practically to depict the process of executing BSC in learning organization in detail, and theoretically to understand the mechanism in optimizing organizational learning effect via BSC implementation through discussion of (1) downward penetration of single-loop learning from organization vision and goals, and upward following and promotion of double-loop learning of sub-units in the form of routines, norms, action plans and others; (2) ways of eliminating the gap by linking organizational member's values with the organization's vision in the form of giving individuals opportunities to make their own interpretation of learning results in the workplace.

Balance with logic-measuring the performance and sustainable development efforts of an NPO in rural Ethiopia

The analysis of performance of Not-for-profit organisations (NPOs) is difficult because there are several objectives and perspectives to NPO performance and accountability, especially if considered sustainably and in long term. This suggests that performance analysis and measurement of NPOs might also involve multiple perspectives, such as in Balanced Scorecard (BSC) or in the Logical Framework (LF) models. This article is a case study of analysing the sustainable development and performance of an NPO in rural Ethiopia. We propose the Logic Balanced Scorecard (LBSC) model that combines elements of BSC and LF. This proposal was preliminarily used and tested in a five-year interventionist accounting case study among eight villages in rural Ethiopia. Advances in performance measurement may help improving the socioeconomic, agricultural and nutritional situation in the area. Further, an improved analysis of performance, sustainability and accountability of NPOs may make development projects easier to plan, follow and assess.

Development of a balanced scorecard as a strategic performance measurement system for clinical radiology as a cost center

Objectives

To develop a goal-oriented indicator system based on the balanced scorecard (BSC) concept, which takes into account the perspectives of the referring physician and patient and emphasizes the focus on the internal processes of the radiology department.

Methods

Development of a BSC occurred in six steps: (Step 1) strengths/weaknesses and opportunities/risks (SWOT-) analysis of the radiology department, (Step 2) setting-specific objectives (model, core values, key objective) followed by the development of 4 perspectives, (Step 3) and definition of strategic issues oriented to the value-added chain of the processes of the radiology department. (Step 4) Creation of a “Strategy Map” with regard to the perspective and their cause–effect relationships. (Step 5) Development of an automated key performance indicator (KPI) cockpit for the monitoring, reporting, and management scorecard.

Results

A total of 10 success factors were identified using SWOT analysis. The core values include high quality in clinical, teaching, and research areas. The radiological value-added chain is composed of three processing steps. 1. registration, 2. examination, and 3. reading/X-ray demonstration. Three action programs were derived: 1. increase competency (e.g., specialist standard), 2. improve referring physician/patient satisfaction, 3. increase productivity. Daily process monitoring was added to the management cockpit as a monitoring scorecard. The scorecard comprises 18 KPIs and is automatically updated every month. The annual management scorecard comprises 10 KPIs.

Conclusions

The BSC makes it possible to implement a strategy for radiology that is strongly oriented toward the requirements of the referring physicians and the demands of patients.

Balanced scorecard in the hospitality and tourism industry: Past, present and future

After its introduction in 1992, the balanced scorecard (BSC) has attracted considerable interest from both scholars and practitioners. This is evidenced by the increasing number of publications addressing BSC and the large number of professional events devoted to it. However, there is little research on BSC in the hospitality and tourism industry. This study aims to contribute towards filling this significant gap through studying 106 top-ranked journal articles on BSC, of which 37 belong to the hospitality and tourism industry. In so doing, the study highlights the research focus that has been placed so far on BSC and examines its trends and the relationships amongst its perspectives. It also provides valuable input to identify gaps currently impeding BSC development in the hospitality and tourism industry, recommends future research opportunities intended to improve understanding and practice of BSC along with building up on emerging research topics like sustainable tourism and new tourism management.

S-MEDUTA: Combining Balanced Scorecard with Simulation and MCDA Techniques for the Evaluation of the Strategic Performance of an Emergency Department

The scope of this paper is to propose a new integrated methodology for the evaluation of the strategic performance of a healthcare organization. In order to find the optimal strategy for an emergency department, we propose the combination of BSC, simulation, and UTASTAR algorithm. Through the simulation model, the stakeholders have the ability to evaluate the effect of their decisions on a number of KPIs that are important for the successful implementation of strategy on the ED. This method is able to provide a set of completed results (e.g., scores, weights, value functions, etc.), which may help the organization to evaluate and revise its strategy.

Performance Evaluation of Community Hospitals in Thailand: An Analysis Based on the Balanced Scorecard Concept

BACKGROUND

Although the concept of the Balanced Scorecard (BSC) was designed for profit-based organisations, the application of the BSC in public and nonprofit organisations (NPOs) could be performed within the NPOs and public health sector, as the conceptual foundation of this system was developed from community hospitals performance.

METHODS

This study used the BSC concept to analyse the 16 key performance indicators and trends of performance during the last five years of 52 community hospitals located in upper southern Thailand in 2017 and tendency of 2013-2017. The instruments included an annual report and a questionnaire. A statistical analysis to determine percentages, means and standard deviations was performed.

RESULTS

The major findings of the community hospitals performance were as follows: Customer perspective: 1. Patient complaint rate of 0.0097% and 2. Outpatient waiting time of 91.89 minutes, Financial perspective: 1. Ratio of total revenue to total expense at 0.9949 and 2. Cost of drugs and materials to total expense at 13.32%, Internal process perspective: 1. Bed turnover at 88.16 and 2. Hospital infection rate of 0.379 times:1,000 patient days, Learning and growth perspective: 1. Staff turnover rate of 4.69% and 2. Number of research studies at 3.77 articles. Trends and performance of hospitals in every perspective of the BSC in the last 5 years showed no differences.

CONCLUSION

The community hospitals offer services such as treatment of common diseases. If the community hospitals could not assist, they will go to referral system by referring patients to secondary and tertiary care respectively.

Bureaucracy and the balanced scorecard in health care settings

PURPOSE

We explore the relationship between the balanced scorecard (BSC) and neo-bureaucracy by investigating whether the operationalization of the BSC incorporates "neo-bureaucratic" ideas and whether the BSC implemented in a Portuguese Local Health Unit (LHU) demonstrates a neo-bureaucratic approach.

DESIGN/METHODOLOGY/APPROACH

We conduct semi-structured interviews with LHU staff and analyse documents to assess whether features of bureaucratic organization were evident in the use of a BSC by the LHU.

FINDINGS

We found nine bureaucratic features evident in the LHU's BSC. These were systematization, rationality, authority, jurisdiction, professional qualification, knowledge, discipline, transparency and accountability. The BSC used at the LHU demonstrated a neo-bureaucratic approach.

ORIGINALITY/VALUE

Our study helps to demystify bureaucracy and overcome prevailing prejudices regarding some of its principles. Health care managers should recognize and endorse neo-bureaucratic principles in developing a BSC. They should recognize the BSC as involving a neo-bureaucratic approach. The BSC is a valuable management tool that hospital managers should find useful in fostering flexibility, collaboration, innovation and adaptation - all of which should help lead to improved healthcare outcomes.

Improving performance evaluation based on balanced scorecard with grey relational analysis and data envelopment analysis approaches: Case study in water and wastewater companies

Various approaches are used to measure the firms' performance. Grey relational analysis is one of the multiple attribute decision-making methods and data envelopment analysis is used to calculate the efficiency. Regarding the importance of water and wastewater companies' services, the present study, evaluates the performance and rank these companies by using grey relational analysis and data envelopment analysis approaches based on balanced scorecard criteria. Besides, balanced scorecard considers all levels of organization. In this research, statistical population includes thirty-five municipal water and wastewater companies in Iran for the year 2017. In order to ascertain grey relational grade, fuzzy normalization method was used then by subtracting normalized numbers from one, reference sequences obtained and in the next step, grey relational coefficient was calculated and finally, grey relational grade was determined by multiplying relative weight from Shannon entropy to relational coefficients. In order to assess companies' efficiency in data envelopment analysis, after ascertaining input and output indices, with the assumption of constant returns to scale and output-oriented viewpoint, the efficiency scores were calculated. Also, to rank efficient units Anderson-Petersen model implemented. Results demonstrated that, grey relational analysis is a more accurate method to measure the performance of water and wastewater companies.

Does the Central Environmental Inspection actually work?

Central Environmental Inspection (CEI) is a particularly important innovative strategy in the transition of environmental governance in China. The first round of CEI for all provincial regions in mainland China has been finished by the end of 2017, but its actual performance remains to be seen. In this study, a multi-dimensional index system was developed under the framework of Balanced Scorecard. Using the content analysis method, we comprehensively evaluated the performance of CEIs in all provinces inspected from the perspectives of target achievement, local rectification, direct effect, and social involvement. The results indicate that CEI has made encouraging progress in the area of environmental governance and the accumulated experiences of the inspections in the early stage greatly boosted the subsequent performance of CEIs. The provincial performance of the central region was significantly higher than that of other regions. For target achievement, the focal points has been basically realized. Despite some neglect of CEI feedback, local environmental governance is experiencing a promising shift from passive to active in general. For social involvement, the CEI has not only promoted the awakening of public environmental consciousness, but also driven public participation in environmental protection. It is notable that the implementation of environmental co-responsibility between Party and governmental officials needs to be further improved. In addition, the shortcomings of each province were identified as well and policy recommendations for existing problems were offered to guide future optimization of local environmental governance and CEI practice.

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan

INTRODUCTION

Weak vaccine delivery systems in countries off-track for routine immunization targets, need in-depth evidence on system level barriers to be critically resourced and monitored. We applied a Balanced Score Card (BSC) approach in a rural underserved district of Pakistan to (i) identify critical areas needing support in the government vaccine delivery system; and (ii) for benchmarking improvements in the vaccine delivery system.

METHODOLOGY

BSC was developed drawing on desk review, government consultations and field testing. 45 immunization indicators were finalized across 8 domains: human resource; vaccine supply; safe vaccination practice; cold chain maintenance; outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Data were collected through health facility assessments, client exit interviews and household vaccination assessment. A composite score was calculated for each domain and banded into unsatisfactory, borderline and satisfactory categories. 5 lowest ranking domains were targeted for 2 years of health systems strengthening (HSS) interventions. Post-intervention assessment tracked progress.

RESULTS

The district obtained a cumulative score of 51% (unsatisfactory) at pre-intervention and improved to 82% (satisfactory) at post-intervention. At pre-intervention, 4 domains scored satisfactory and 4 scored unsatisfactory. Unsatisfactory scores were received for: outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Post intervention 6 of 8 domains scored satisfactory and 2 moved from unsatisfactory to borderline. Highest percentage point (pp) improvements were seen in outreach preparedness (53 pp, p = 0.01), EPI supervision (52 pp, p = 0.01) and verified vaccination volume (46 pp, p = 0.02). 3 domains that were not intervened through HSS interventions had minimal change in scoring - cold chain maintenance (6 pp), safe vaccination practice (12 pp) and vaccine supply (11 pp).

CONCLUSION

BSC served to prioritize interventions towards critical unmet needs for vaccine delivery in the district health system and particularly helped to improve outreach preparedness, EPI supervision and verified vaccination volume.

Performance Management in Healthcare Organizations: Concept and Practicum

Organizational performance can create and sustain competitive advantages for corporations and even improve their sustainability and future prospects. Health care organizations present a sector where performance management is structured by multiple dimensions. The scope of this study is to analyze the issue of performance management in healthcare organizations and specifically the implementation of the Balanced Scorecard (BSC) methodology on organizations providing health services. The study provides a discussion on the BSC development process, the steps that management has to take in order to prepare the implementation of the BSC and finally discusses a practical example of a scorecard with specific strategic goals and performance indicators. Managers of healthcare organizations and specifically those providing services to the elderly and the general population could use the propositions of the study as a roadmap for processing, analyzing, evaluating and implementing the balanced scorecard approach in their organizations' daily operations. BSC methodology can give an advantage in terms of enhanced stakeholder management and preservation within a highly volatile and competitive economic environment.

Important Administrative Aspects of Critical Care Telemedicine Programs

Conceptualizing, designing, implementing, and sustaining a successful critical care telemedicine program is a complex undertaking. All of these steps must be fully accomplished as a joint effort between a host facility and the telemedicine service provider. Important administrative considerations that must be incorporated into planning and execution steps include managing change. We briefly discuss critical aspects of establishing a sustainable business model, and aligning the critical care telemedicine program with institutional vision, goals, and mission. Discussed are important telemedicine provider infrastructure, key personnel considerations, and how a program defines and measures value.

Using benchmarking to assist the improvement of service quality in home support services for older people-IN TOUCH (Integrated Networks Towards Optimising Understanding of Community Health)

Service providers and funders need ways to work together to improve services. Identifying critical performance variables provides a mechanism by which funders can understand what they are purchasing without getting caught up in restrictive service specifications that restrict the ability of service providers to meet the needs of the clients. An implementation pathway and benchmarking programme called IN TOUCH provided contracted providers of home support and funders with a consistent methodology to follow when developing and implementing new restorative approaches for service delivery. Data from performance measurement was used to triangulate the personal and social worlds of the stakeholders enabling them to develop a shared understanding of what is working and what is not. The initial implementation of IN TOUCH involved five District Health Boards. The recursive dialogue encouraged by the IN TOUCH programme supports better and more sustainable service development because performance management is anchored to agreed data that has meaning to all stakeholders.

Strategic planning in Brazilian protected areas: Uses and adjustments

Management plans for protected areas commonly use strategic planning tools in their drafting. It is proposed that the adequate use of the instruments of planning and management of protected areas can improve their strategic competitiveness, providing greater financial and administrative independence, enabling them to be economically sustainable organizations. This study evaluated the application of concepts and strategy formulation, strategy principles and competitiveness, organizational diagnosis, strategic maps, scenarios, and other strategic planning instruments used for conservation management in Brazil. 25 management plans of 25 different protected areas were selected and studied, with special attention to the indicators used in each plan. Results indicate that there is a high suitability for the application of SP tools to the universe of protected areas, although management plans did not take full advantage of these tools. We also found that the broader use of these tools did not guarantee greater managerial effectiveness. We suggest that other governance variables beyond planning strategies must be improved, to ensure a better performance of protected areas.

Balanced performance measurement in research hospitals: the participative case study of a haematology department

Background

The paper aims to review, design and implement a multidimensional performance measurement system for a public research hospital in order to address the complexity of its multifaceted stakeholder requirements and its double institutional aim of care and research.

Method

The methodology relies on a participative case study performed by external researchers in close collaboration with the staff of an Italian research hospital.

Results

The paper develops and applies a customized version of balanced scorecard based on a new set of performance measures. Our findings suggest that it can be considered an effective framework for measuring the research hospital performance, thanks to a combination of generalizable and context-specific factors.

Conclusions

By showing how the balanced scorecard framework can be customized to research hospitals, the paper is especially of interest for complex healthcare organizations that are implementing management accounting practices. The paper contributes to the body of literature on the application of the balanced scorecard in healthcare through an examination of the challenges in designing and implementing this multidimensional performance tool. This is one of the first papers that show how the balanced scorecard model can be adapted to fit the specific requirements of public research hospitals.

Developing an evaluation framework for clinical redesign programs: lessons learnt

Purpose The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme - the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital. Design/methodology/approach The development of the evaluation framework involved three stages - namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme. Findings The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively. Research limitations/implications The evaluation framework is limited by its retrospective application to a clinical process redesign programme. Originality/value This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.

[Usefulness of the budget and the balanced scorecard in managing Primary Care Centres. Impact on staff motivation]

OBJECTIVE

To analyse the utility perceived by managers of centers of primary care about management tools (budget and balanced scorecard), together their impact on human resources motivation.

DESIGN

Qualitative study (case study) based on grounded theory performed between January and June 2014.

LOCATION

Units of Clinical Management of Primary Health (UGCAP) in Metropolitan Health Area of Seville, Spain.

PARTICIPANTS

UGCAP managers and Health Area (CEO) managers.

METHOD

Data were collected through 8 semi-structured interviews using non-probabilistic intentional sampling with representation and sufficiency criteria of discourse. Interviews were recorded, literally transcripted and analysis through in-vivo codes.

RESULTS

Both tools are fully implemented but differently used in primary care centers. Budget is perceived as a coercive management tool, which has been imposed for cost saving; however, it is scarcely adequate for day-by-day management. While balanced scorecard is a more flexible tool that allows identifying financial and welfare problems, budgeting limits heavily reduce the possibility of implementing adequate solutions. The policy of incentives is not adequate either, leading on de-motivation.

CONCLUSIONS

This study shows that budgeting restrictions have led to a significant reduction in autonomy of Spanish Primary Care centers. Management decision making is much centralised, also focused on cost saving over quality of healthcare. As a result, two needs emerge for the future: increasing centers' autonomy and improving staff commitment through training and professional development programs.

Service quality in contracted facilities

PURPOSE

The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework.

DESIGN/METHODOLOGY/APPROACH

Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher's Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities.

FINDINGS

Contracted facilities were generally found to be better than non-contracted facilities in all five BSC domains. Patients' inclination for facility-based delivery at contracted facilities was, however, significantly higher than non-contracted facilities (80 percent contracted vs 43 percent non-contracted, p=0.006).

PRACTICAL IMPLICATIONS

The study shows that contracting out initiatives have the potential to improve MNH care.

ORIGINALITY/VALUE

This is the first study to compare MNH service delivery quality across contracted and non-contracted facilities using BSC as the assessment framework.

Quantitative performance targets by using balanced scorecard system: application to waste management and public administration

This article demonstrates how decision-makers can be guided in the process of defining performance target values in the balanced scorecard system. We apply a method based on sensitivity analysis with Monte Carlo simulation to the municipal solid waste management system in Loulé Municipality (Portugal). The method includes two steps: sensitivity analysis of performance indicators to identify those performance indicators with the highest impact on the balanced scorecard model outcomes; and sensitivity analysis of the target values for the previously identified performance indicators. Sensitivity analysis shows that four strategic objectives (IPP1: Comply with the national waste strategy; IPP4: Reduce nonrenewable resources and greenhouse gases; IPP5: Optimize the life-cycle of waste; and FP1: Meet and optimize the budget) alone contribute 99.7% of the variability in overall balanced scorecard value. Thus, these strategic objectives had a much stronger impact on the estimated balanced scorecard outcome than did others, with the IPP1 and the IPP4 accounting for over 55% and 22% of the variance in overall balanced scorecard value, respectively. The remaining performance indicators contribute only marginally. In addition, a change in the value of a single indicator's target value made the overall balanced scorecard value change by as much as 18%. This may lead to involuntarily biased decisions by organizations regarding performance target-setting, if not prevented with the help of methods such as that proposed and applied in this study.

Determining the causal relationships among balanced scorecard perspectives on school safety performance: case of Saudi Arabia

In the public schools of many developing countries, numerous accidents and incidents occur because of poor safety regulations and management systems. To improve the educational environment in Saudi Arabia, the Ministry of Education seeks novel approaches to measure school safety performance in order to decrease incidents and accidents. The main objective of this research was to develop a systematic approach for measuring Saudi school safety performance using the balanced scorecard framework philosophy. The evolved third generation balanced scorecard framework is considered to be a suitable and robust framework that captures the system-wide leading and lagging indicators of business performance. The balanced scorecard architecture is ideal for adaptation to complex areas such as safety management where a holistic system evaluation is more effective than traditional compartmentalised approaches. In developing the safety performance balanced scorecard for Saudi schools, the conceptual framework was first developed and peer-reviewed by eighteen Saudi education experts. Next, 200 participants, including teachers, school executives, and Ministry of Education officers, were recruited to rate both the importance and the performance of 79 measurement items used in the framework. Exploratory factor analysis, followed by the confirmatory partial least squares method, was then conducted in order to operationalise the safety performance balanced scorecard, which encapsulates the following five salient perspectives: safety management and leadership; safety learning and training; safety policy, procedures and processes; workforce safety culture; and safety performance. Partial least squares based structural equation modelling was then conducted to reveal five significant relationships between perspectives, namely, safety management and leadership had a significant effect on safety learning and training and safety policy, procedures and processes, both safety learning and training and safety policy, procedures and processes had significant effects on workforce safety culture, and workforce safety culture had a significant effect on safety performance.

Impact on the performance of health workers adopted performance-related contracts in the provision of basic public health service at village and township levels

BACKGROUND

This paper focus on the impact on the performance of health workers at village and township levels in the provision of a government stipulated package of basic public health service, which adopted the performance-related contracts mode.

METHODS

The concept of balanced scorecard was adopted and developed to gather the 11 evaluation indicators distributed in four quadrants. These were implemented using on-site questionnaire and interview design. Four thousand and twenty-one respondents at 30 administrative villages including 2674 respondents at 20 pilot villages and 1347 at 10 control villages were investigated. Meanwhile, 62 administration officials from three counties and nine townships were interviewed.

RESULTS

Eight of 11 evaluation indicators were obviously better in pilot counties than in Control County, The remaining three indicators respectively represented that equal, inferior to control county, and could not clear judge.

CONCLUSION

The performance of health workers at village and township levels in the provision of basic public health service in pilot counties, which adopted the performance-related contracts mode, is better than before and control county.

Performance evaluation of Al-Zahra academic medical center based on Iran balanced scorecard model

BACKGROUND

Growth and development in any country's national health system, without an efficient evaluation system, lacks the basic concepts and tools necessary for fulfilling the system's goals. The balanced scorecard (BSC) is a technique widely used to measure the performance of an organization. The basic core of the BSC is guided by the organization's vision and strategies, which are the bases for the formation of four perspectives of BSC. The goal of this research is the performance evaluation of Al-Zahra Academic Medical Center in Isfahan University of Medical Sciences, based on Iran BSC model.

MATERIALS AND METHODS

This is a combination (quantitative-qualitative) research which was done at Al-Zahra Academic Medical Center in Isfahan University of Medical Sciences in 2011. The research populations were hospital managers at different levels. Sampling method was purposive sampling in which the key informed personnel participated in determining the performance indicators of hospital as the BSC team members in focused discussion groups. After determining the conceptual elements in focused discussion groups, the performance objectives (targets) and indicators of hospital were determined and sorted in perspectives by the group discussion participants. Following that, the performance indicators were calculated by the experts according to the predetermined objectives; then, the score of each indicator and the mean score of each perspective were calculated.

RESULTS

Research findings included development of the organizational mission, vision, values, objectives, and strategies. The strategies agreed upon by the participants in the focus discussion group included five strategies, which were customer satisfaction, continuous quality improvement, development of human resources, supporting innovation, expansion of services and improving the productivity. Research participants also agreed upon four perspectives for the Al-Zahra hospital BSC. In the patients and community perspective (customer), two objectives and three indicators were agreed upon, with a mean score of 75.9%. In the internal process perspective, 4 objectives and 14 indicators were agreed upon, with a mean score of 79.37%. In the learning and growth perspective, four objectives and eight indicators were agreed upon, with a mean score of 81.11%. Finally, in the financial perspective, two objectives and five indicators were agreed upon, with a mean score of 67.15%.

CONCLUSION

One way to create demand for hospital services is performance evaluation by paying close attention to all BSC perspectives, especially the non-financial perspectives such as customers and internal processes perspectives. In this study, the BSC showed the differences in performance level of the organization in different perspectives, which would assist the hospital managers improve their performance indicators. The learning and growth perspective obtained the highest score, and the financial perspective obtained the least score. Since the learning and growth perspective acts as a base for all other perspectives and they depend on it, hospitals must continuously improve the service processes and the quality of services by educating staff and updating their policies and procedures. This can increase customer satisfaction and productivity and finally improve the BSC in financial perspective.