Reviewing the Application of the Balanced Scorecard with Implications for Low‐Income Health Settings

Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
Journal for Healthcare Quality (Impact Factor: 1.4). 09/2007; 29(5):21-34. DOI: 10.1111/j.1945-1474.2007.tb00210.x
Source: PubMed


High-income countries (HICs) are increasingly making use of the balanced scorecard (BSC) in healthcare. Evidence about BSC usage in low-income countries (LICs) is deficient. This study assessed feasibility of BSC use in LICs. Systematic review of electronic databases shows that the BSC improved patient, staff, clinical, and financial outcomes in HICs. To translate the experience of BSC use in HICs to their use in LICs, the applicability parameters of the National Committee for Quality Assurance were applied. Despite contextual challenges, pilot testing of BSC use can be undertaken in selected LICs. Committed leadership, cultural readiness, quality information systems, viable strategic plans, and optimum resources are required.

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    • "These data were later analyzed, reported, and published. The first report [13] assessed the feasibility of using the BSC in the context of LICs and identified a team-oriented participatory (clan) organizational culture as a prerequisite for implementation. Subsequent studies [14,15] determined cultural readiness prior to BSC implementation and used group consensus methods to design a BSC for a tertiary care private hospital in Karachi, Pakistan. "
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    ABSTRACT: 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. 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. 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. 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.
    Implementation Science 03/2011; 6(1):31. DOI:10.1186/1748-5908-6-31 · 4.12 Impact Factor
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    • "In the context of low income countries (LICs), however, we know little about successful models to promote greater management effectiveness at the hospital level (Hartwig et al., 2008). Evidence about BSC usage in LICs is deficient mainly due to lack of committed leadership, cultural readiness, quality information systems, viable strategic plans, and optimum resources (Rabbani et al., 2007). Simple dissemination of written guidelines in LICs is proving to be often ineffective (Rowe et al., 2005) and health managers face significant challenges in developing and managing appropriate systems (Green and Collins, 2003). "
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    ABSTRACT: Balanced Scorecards (BSC) are being implemented in high income health settings linking organizational strategies with performance data. At this private university hospital in Pakistan an elaborate information system exists. This study aimed to make best use of available data for better performance management. Applying the modified Delphi technique an expert panel of clinicians and hospital managers reduced a long list of indicators to a manageable size. Indicators from existing documents were evaluated for their importance, scientific soundness, appropriateness to hospital's strategic plan, feasibility and modifiability. Panel members individually rated each indicator on a scale of 1-9 for the above criteria. Median scores were assigned. Of an initial set of 50 indicators, 20 were finally selected to be assigned to the four BSC quadrants. These were financial (n = 4), customer or patient (n = 4), internal business or quality of care (n = 7) and innovation/learning or employee perspectives (n = 5). A need for stringent definitions, international benchmarking and standardized measurement methods was identified. BSC compels individual clinicians and managers to jointly work towards improving performance. This scorecard is now ready to be implemented by this hospital as a performance management tool for monitoring indicators, addressing measurement issues and enabling comparisons with hospitals in other settings.
    International Journal of Health Planning and Management 01/2010; 25(1):74-90. DOI:10.1002/hpm.1004 · 0.97 Impact Factor
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    ABSTRACT: Organizational culture is a determinant for quality improvement. This paper aims to assess organizational culture in a hospital setting, understand its relationship with perceptions about quality of care and identify areas for improvement. The paper is based on a cross-sectional survey in a large clinical department that used two validated questionnaires. The first contained 20 items addressing perceptions of cultural typology (64 respondents). The second one assessed staff views on quality improvement implementation (48 faculty) in three domains: leadership, information and analysis and human resource utilization (employee satisfaction). All four cultural types received scoring, from a mean of 17.5 (group), 13.7 (developmental), 31.2 (rational) to 37.2 (hierarchical). The latter was the dominant cultural type. Group (participatory) and developmental (open) culture types had significant positive correlation with optimistic perceptions about leadership (r = 0.48 and 0.55 respectively, p < 0.00). Hierarchical (bureaucratic) culture was significantly negatively correlated with domains; leadership (r = -0.61,p < 0.00), information and analysis (-0.50, p < 0.00) and employee satisfaction (r = -0.55, p < 0.00). Responses reveal a need for leadership to better utilize suggestions for improving quality of care, strengthening the process of information analysis and encouraging reward and recognition for employees. It is likely that, by adopting a participatory and open culture, staff views about organizational leadership will improve and employee satisfaction will be enhanced. This finding has implications for quality care implementation in other hospital settings. The paper bridges an important gap in the literature by addressing the relationship between culture and quality care perceptions in a Pakistani hospital. As such a new and informative perspective is added.
    International Journal of Health Care Quality Assurance 07/2009; 22(5):498-513. DOI:10.1108/09526860910975607
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