This course is designed for people in private, public or nonprofit sector organisations who have responsibility for building, implementing and maintaining a balanced scorecard or other performance management system. Expires by 6 Sep Expires by 4 Oct From 5 Oct Expires by 11 Oct Expires by 8 Nov From 9 Nov Other studies have also used PGF to understand implementation of a change process [ 6 , 29 , 30 ].
Syntheses of findings from similar multi-method studies have been reported in the literature of organizational studies [ 31 , 32 ]. The importance of organizational support context with regard to financial and non-financial incentives and prior work experience on quality care initiatives were highlighted as potential facilitating factors for BSC implementation.
Such organizational support has also emerged as a critical factor in other studies [ 33 ]. Units I and II predominantly participatory culture as assessed through the quantitative survey considered non-financial incentives to be equally strong motivators for implementing the BSC. In contrast, Units III and IV predominant culture type: bureaucratic and goal-oriented strongly linked BSC implementation to financial gains, and it was observed and quoted during interviews that taking time out of clinical activity and investing in BSC implementation was a potential financial loss and distraction from pre-conceived goals.
Similar context with emphasis on generating revenue has also been noted in other hospital-based studies [ 34 ]. BSC contextual barriers that surfaced in all units included clinical workload, lack of national performance management initiatives to provide benchmarks for comparison, an inability of leadership to communicate a clear BSC agenda, a lack of designated human resources, and ill-defined staff roles in BSC implementation.
Paucity of comparable indicators from peer health units in the four BSC quadrants has also been reported from a recent study in Ontario's public health units [ 35 ]. Moreover, role awareness has also been cited as an important method of avoiding territorial conflicts in other settings [ 36 ]. Similar challenges in BSC implementation have been discovered in healthcare provider organizations in the United States.
They include acceptance towards implementation, maintaining simplicity, and staff commitment [ 37 ]. During the interviews in Units III and IV, it was clear that there was difficulty in tracking BSC indicators because data were not readily available and accessible in the required formats. These results resonate with the findings of a nested qualitative study in England [ 38 ]. Deficiency of good quality data, unclear program direction, and a low level of awareness have also been identified as implementation barriers in a case study of nursing in Canada [ 39 ].
Due to these issues with data acquisition, Unit III, for instance, decided to bank on existing clinical quality indicators to initiate BSC implementation. Another study also concluded that the BSC could build on existing frameworks [ 40 ]. A multi-method study of organizations in Norway has come up with similar recommendations to start small [ 31 ]. Additionally, staff and faculty in our study perceived that BSC indicators such as employee and patient satisfaction were non-clinical in nature and therefore not of direct concern.
They perceived that it was the role of hospital managers to keep track of the information, while the clinician's role was to concentrate on direct patient care. Such barriers between professional domains have also been noted in France [ 32 ]. Axelsson describes territorial barriers between professionals and administrators to be a classic concern within organizations [ 36 ]. Furthermore, during staff meetings of Units III and IV, it was observed that beepers and cell phones were a constant source of distraction. Clinicians in these two units seemed more interested in attending to calls from their clinics as opposed to focusing on BSC reporting.
This context explains the competing priorities due to which these two units lagged behind in implementation compared to Units I and II. Another contextual observation was that if employees were appropriately sensitized to the BSC benefits, it translated into a positive impact on implementation. Moreover, the designated employees in Unit IV had anxieties and fears that this new requirement of BSC-based performance reporting would be very time consuming.
Unit IV therefore remained in a preparatory phase without entering actual implementation. A similar lack of understanding about the benefits of the BSC has been observed in Germany [ 41 ]. Strategies found useful in setting up a process of change and facilitating BSC implementation process included: providing designated human resources for monitoring of BSC indicators; ownership from all employees; communicating a clear agenda to implement the BSC; encouraging non-financial incentives; and reporting of BSC indicators in routine unit meetings.
Other studies have also reported the importance of having open channels of communication within a workforce [ 42 ]. Unit II did not pose any objections to viewing the scorecard as a new initiative. Both Units I and II had two personnel each assigned for working on the BSC throughout the observed month implementation period, and there was less emphasis on generating revenue.
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It is noteworthy that despite the perceived need for change to improve standards of care, Unit IV lagged behind as it encountered most of the implementation barriers and was unable to successfully employ any of the above strategies. It is also essential to mention that Units I and II handle a large patient load on an outpatient basis and provide non-invasive diagnostic and therapeutic services. Units III and IV provide outpatient and inpatient services and are responsible for more invasive investigations with an emphasis on revenue generation and the maintenance of clinical volumes.
Recent studies in Italy have also concluded that introducing the BSC to improve management of day-care surgery and gastroenterology endoscopy units has the potential to optimize services [ 44 , 45 ]. The BSC performance was closely linked with the prevalent culture internal context and the changes brought about in a unit's climate content as part of the implementation process.
It has been mentioned that context greatly influences the how and what dimensions of PGF, and it is difficult to demarcate boundaries between the three dimensions. Culture is seen as a common base for values and understanding of principles within a professional organization [ 29 ].
Other studies on improving hospital performance have recognized the importance of human relation dimensions [ 32 ]. The culture types in the quantitative survey Figure 2 matched the KIs opinion regarding the unit's culture and concomitantly what was observed during meetings of the unit.
The purpose of this study was not to bring about a cultural transformation, but rather to understand how existing unit culture influenced the implementation process and what changes if any emerged in a unit's dynamics while implementing the BSC. Unit III's relatively bureaucratic style prevented an early BSC implementation; the leadership of the unit appeared interested, but seemed very disparaging in assigning tasks to their staff and faculty.
The culture of the unit gradually started showing signs of teamwork once the BSC continued to appear on the agenda of their regular meetings. Towards the end of the implementation period, the designated employees of Unit III took on the responsibility and ownership for BSC-based performance reporting in their monthly unit meetings. The importance of having such frequent formal and informal meetings with employees and managers is a sign of a participatory culture and has been shown to bring about support for improvement efforts and implementation initiatives [ 46 ].
In Unit IV, there was neither a fixed schedule nor a proper agenda for meetings; this lack of cohesive management and resistance to change impaired BSC implementation. It is noteworthy to mention here that the assessment of culture typology is based on cross-sectional survey conducted earlier. At the outset, stakeholders were informed that this survey would highlight their readiness for quality improvement implementation based on the contextual information they provided about their unit.
The same survey was used to understand the cultural typology of the four study units in which BSC implementation later began. Although some emerging signs of change were noted, no cause-and-effect relationship between the BSC and organizational culture is implied in either direction. During observations and interviews, stakeholders knew that the process of BSC implementation was being studied without a specific reference to the role of culture in the implementation process.
This study was not without limitations. It is based in just one private academic hospital in Pakistan and therefore findings are mostly relevant to this case. At least five other private tertiary hospitals in the country are comparable to the study hospital in terms of skilled manpower, diagnostic and curative facilities, and information technology infrastructure. Nevertheless, the study hospital is distinctive in the LIC setting because of its state-of-the-art facilities and international accreditation and certifications.
Applicability of our findings to an audience outside non-academic settings should therefore be carefully interpreted. Due to logistic reasons and a short observation period, hardcore BSC outcomes improvement of clinical indicators, patient and employee satisfaction, etcl. Similar shortcomings have also been noted in a recent study of BSC implementation in three acute care hospitals in a HIC setting [ 41 ]. Despite these limitations, the involvement of four hospital units in the BSC application and the study of the context of implementation was a unique experience with catalytic validity.
The latter implies that our results are not merely descriptive, but part of a continuous process of change and, based on current experience, have the potential to guide future BSC implementation efforts. Such approaches have been considered very helpful in understanding how and why certain activities produce certain effects during an observational follow-up period [ 47 ]. The strategies used to increase trustworthiness of the findings Additional File 5 in this study included theory-guided data collection and analysis. It is important to note, however, that the author of this article and the study subjects worked for the same organization.
Given the lack of expertise in the field, in some participant observation meetings the researchers were also partial facilitators; this has the potential of introducing an observation bias and affecting team dynamics. It is possible that Units I and II showed greater enthusiasm because of the presence of the researchers in their meetings Hawthorne effect.
Much influence of the Hawthorne effect however, seems unlikely because Units III and IV consistently lagged behind despite facilitation by the researchers. Later, these observations were corroborated by interviews to increase the objectivity and neutrality of results. For the purpose of this case study, the three PGF dimensions were used to guide the contextual and process analysis, and to look for patterns, identifying gaps in the BSC implementation.
The purpose was not to confirm or refute the PGF theoretical model. Therefore, findings have not been described under the umbrella of the classical PGF factors. Future research tracking contexts over a longer period of time could examine the impact of the entire PGF or alternative strategic change frameworks across a variety of organizations with theoretical explanation building.
Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming barriers related to BSC implementation. Similar drivers and blockers of performance management implementation have been reported from a synthesis of five case studies in the United Kingdom [ 48 ]. Moreover, it was realized 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.
Other studies have also pointed out the need to foster BSC champions, not rushing the BSC's introduction, creating a receptive organizational culture and integrating the scorecard with existing management processes [ 49 ]. Journal for Healthcare Quality.
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Schalm C: Implementing a balanced scorecard as a strategic management tool in a long-term care organization. Download references. We are grateful to Shafaq Ambreen for her secretarial assistance and to all the faculty and staff of the hospital who contributed as study participants or were part of the BSC implementation team. Without their support this study would not have been possible. Correspondence to Fauziah Rabbani. FR designed, planned, executed, analyzed, and wrote all drafts of the manuscript. SL assisted in conducting the interviews, data transcription, qualitative analysis and worked on several revisions of the manuscript.
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FA and WJ guided the larger institutional mandate on taking the BSC-related work forward and in reviewing draft manuscripts critically. AA assisted in thematic content analysis of the qualitative data and MP facilitated the quantitative analysis and triangulation aspects of data. MB and GT critically reviewed the methodology, design, concept and data from the study and gave detailed feedback on several draft manuscripts.
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