Business e-Bulletin Vol.

1, Issue 1, 2009, 33-47

REVIEW OF THE LITERATURE OF BALANCED SCORECARD AND PERFORMANCE MEASUREMENT: THE CASE OF HEALTHCARE ORGANIZATIONS
KHALED MOHAMMED BA-ABAAD

INTRODUCTION
Recently, there is an increasing trend towards implementing balanced scorecard (BSC) as a set of performance indicators (Zelman, Pink, & Matthias, 2003). In the literature review, the feasibility and value of using balanced scorecard to measure performance has been evidenced (Chan & Ho, 2000). Importantly, performance measurement in health care is an important issue both at the individual and the national level since health costs continue to rise and the performance level in these organizations is moving out of control (Hoque & James, 2000). Pressures of costs are faced by individuals, employer, insurance companies and governments. Hospitals move slowly to develop and implement formal performance measurement systems. The primary problems that have inhibited hospitals from making greater progress in this area are culture, organization, and managerial practices that are inconsistent with competitive business, including operating practices that are not cost driven. Some specific reasons why hospital have not been active in this area include the following: many hospital boards are composed of members lacking experience in competitive environments, lack of employee participation, particularly among doctors, and because many individuals regard hospital services as intangible and impossible to measure. Medical staff relations and quality of care are important attributes of hospital performance that can be difficult to measure, interpret, and compare with other health care organizations (Zelman, Pink, & Matthias, 2003). It is argued that the key to achieving the aimed level of performance is to adopt new approaches to performance and performance measurement (Kaplan & Norton, 1992). Balanced scorecard (BSC) is fundamentally a customized performance measurement system that looks beyond traditional financial measures and is based on organization strategy. This paper attempts to discuss balance scorecard as an approach to performance measurement. To this end, this paper is divided into seven sections. The first section defines performance measurement system. Next, trends, issues and challenges in assessing performance measurement are presented. Then, a discussion on performance measurement in healthcare organizations is highlighted. Balance scorecard framework and function, and measuring performance at healthcare organizations are presented next. This paper then concludes the whole discussion on balance scorecard.

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DEFINITION OF PERFORMANCE MEASUREMENT SYSTEM

According to Pink et al. (2001), performance measurement can be addressed at three different levels namely the individual performance measures, the performance measurement system (PMS) and the relationship between the PMS and its environment. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines a performance measurement system as a system composed of: A set of process and/or outcome measures of performance, Processes for collecting, analyzing and disseminating these measures from multiple organizations, and An automated database which, together can be used to facilitate improvement in healthcare organizations. Radnor and Lovell (2003a) explain the term performance measurement system as a means of gathering data to support and coordinate the process of making decisions and taking action throughout the organization. The measurement system is a crucial element in ensuring the successful implementation and execution of strategies identified by the organization in achieving their strategic goals (Fitzpatrick, 2002; Radnor & Lovell, 2003a). Meanwhile, Pink et al. (2001) see performance measurement as the process of quantifying past action, focusing on both efficiency and effectiveness of the action taken. According to Chang and Young (1995), performance measurement provides organization with focus, direction, a common understanding and knowledge for making better business decision besides providing feedback on the organizational improvement efforts. Because performance measurement is always linked to a goal or an objective, it gives the management the means to maintain control and monitor the progress of the organizations towards achievement of their overall vision (Aidemark, 2001), through the successful implementation of the strategy chosen. However, with the rapid changes in the modern businesses environment, many organizations have become dissatisfied with the traditional backward looking performance measurement systems by identifying their shortcoming and arguing for change (Aidemark, 2001). Eventually, the new situation causes the old systems to be inefficient and no longer effective and thus becoming inappropriate to the organizations. This creates new challenge for senior executives in assessing the performance measurement.
TRENDS, ISSUES AND CHALLENGES IN ASSESSING PERFORMANCE MEASUREMENT

The viability and survival of todays business organizations are very much influenced by the new strategies adopted in the highly dynamic environments that facilitate their businesses. Eccles (1991) argues that these new strategies and competitive realities require new measurement systems because traditional systems that stress on the financial indicators can no longer justify the need of the modern business entities. He explains that globalization, growing competition, increased public sophistication and active

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consumerism have all contributed to the shifting of the performance measurement systems manifest towards the non-financial indicator themes such as customer satisfaction and service quality. To be successful and competitive, organizations require a more holistic and balanced approach in measuring their performance that not only display yesterday consequences as shown by the financial indicators but also capable of predicting future performances through utilization of the non-financial measures which are known to be forward-looking (MacStravic, 1999). As the trend of advancement in the performance measurement moves towards this direction, concern and recognition on the existing trade-offs issue between different measures, for example between quality and cost (Morisawa, 2002) and between short-term financial return and long-term competitive position, need to be addressed by the management in a more explicit manner due to the impact on the nature of the businesses. At the same instance, the practice of strategic management begins to spread rapidly into modern business entities as more managers acknowledge the importance of being able to communicate their business strategies across to the other organizational members for the purpose of alignment and attainment of the business strategic goals and objectives. Because measurement provides the link between strategies and actions, the type of performance measurement system is a barrier to organizational development if inappropriate measures are applied. This is because such measures tend to lead to actions, which are incongruent with the strategies no matter how well they are formulated or communicated through the organizations (Oliveira, 2001). Therefore, the challenge for most management leaders is to examine the entire data and reports and weed out the inappropriate measures from the appropriate ones (Chang & Young, 1995), so that these appropriate measures can provide and strengthen the link between actions and strategies in order to achieve organizational strategic goals and overall vision (Amaratunga et al., 2000). Simply put, assessing performance measurement system is a vital task as measuring the right variables. This, according to Brown (1996), will ensure the future success of the organizations. As a result, there is an increasing awareness among todays well-trained managers on the need to search for an integrated performance measurement system that can both strategically measure the financial and operational aspects of their businesses, which are seen as truly essential in creating healthy and balanced organizations (Birch, 2000). While the need to take up the challenge in assessing the performance measurement is real and the potential solution is available, changes to the existing performance measurement system are often difficult and slow. Finding the appropriate modern approaches that can help them to accomplish their tasks in addressing the weakness and limitation in their existing systems is not without problems. Usually the management teams have had their fair share of dilemma, for example when the leaders introduce a new performance measurement approach to the organizations without really going into the details of understanding the process of populating the new measurement framework. Such action will definitely defeat their original

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purpose of getting a more effective and efficient performance measurement system because without understanding the process, the new framework will have no practical value to them (Pink et al., 2001).
PERFORMANCE MEASUREMENT IN THE HEALTHCARE ORGANIZATION

Performance measurement of an organization has always been a hot topic because of the critical role the measurement plays in quality and productivity improvement of the organization (Oakland, 1993, cited in Sinclair & Zairi, 1995). Pink et al. (2001) identify seven evidence-based reasons on why performance measurement has gained so much attention from the management world, namely: the changing nature of work increasing competition specific improvement initiatives national and international quality awards changing organizational roles changing external demands and the power of information technology Basically, these reasons can be used to explain why performance measurement in various industries including those of healthcare go through the process of change, which creates the necessities and needs for a wider range of performance measures for their organizations. Lately in the local healthcare sector, explicit quality in this field has become an important issue for both government and private hospitals in the wake of development whereby funds and resources are shrinking and mounting pressure comes from government and taxpayers for these organizations to adopt a greater accountability and transparency towards the services provided to the public (Chee, 1990; Suleiman, 1996). This type of development demands that the existing performance measurement in the hospitals concerned should change according to the volatile environments in order to maintain its role in improving quality and productivity of the organizations. Traditionally, healthcare organizations such as government hospitals have practice of leaving the formal performance measurement systems in the charge of the administrative departments, whose focus are mainly on the accounting activities such as margins, cost and expenses allocations. Because of this, early measurement systems in these organizations tend to reflect only the financial side of their performance, which gives the picture of the organizational fiscal conditions such as meeting the allocated budget bottom-line, revenues and expenditures and asset-employment efficiency of the healthcare institutions. They do not monitor nor bother to emphasize the non-financial measures that are important to the organizations like the process or the outcomes of patient care deliveries (Stewart & Lokamy III, 2001). However, with the changing operating environment in the healthcare sector, this financially focused performance-measurement systems have slowly

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become obsolete. Increased competition in the industry and the existence of continual pressure from the stakeholders of the healthcare organizations, force these institutions to look for alternative ways of adding values to their services while cutting down the cost of service-care deliveries to their customers and patients (Castandeda-Mendez, 1996). What these organizations do is to embark on the journey to look for specific improvement initiatives, especially in the form of continuous quality improvement effort such as the implementation of Total Quality Management (TQM), industrial benchmarking and participation of hospital accreditation programs. These initiatives are further strengthened by a large number of organizations interest in hunting the national and international quality awards that are widely acknowledged by the public, such as the Baldrige Awards in USA and European Foundations for Quality Management Awards. These prestigious awards are given to winning organizations in recognition of their substantial improvement in their business performances and contribute positively in boosting the reputation of the winners and increase their competitiveness (Deming, 1986). For healthcare providers, they have newly established Baldridge Healthcare Criteria to refer to in measuring their own performance excellence and meeting up the challenge of healthcare cost containment (Chow-Chua & Goh, 2002). As McAdam and Baillie (2002) point out, the introduction of these quality awards has driven many organizations to carry out internal audit exercises, which require them to be able to measure and record a wide range of attributes that lead to the demand of the development of sophisticated performance measurement. All of this brings towards more the reasons why the managements of these organizations have to give more attention towards the improvement of the non-financial measures such as service quality and effective clinical outcomes by establishing the needs to address their current performance shortfalls. Under the formal financially focused performance measurement systems practiced by healthcare organizations, the evaluation, according to Walker (1996), creates three major deficiencies in measuring the hospitals and integrated delivery systems performances. They are namely: 1. Any effort to improve financial performances will be less effective without taking into consideration the physicians clinical decisions because they influence the clinical activities, which are the primary cost drivers at these institutions. 2. Physicians are likely to resist the management effort in controlling cost by improving productivity and reducing resource utilization if the issues of patient satisfaction and service quality are not dealt with. 3. Separate evaluation processes are internally focused that reflect the evaluators point of views only and dismiss external views from organizations stakeholders, thus affecting the effectiveness of the measurement systems. Eventually the deficiencies call for a major treatment as the organizational roles and the external demands in the healthcare

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organizations change. Performance measurement can no longer be done separately under the function of the administrative or the physicians, as it tends to be an integral part of the performance management system (Pink et al., 2001). It also needs to include the views of government agencies involved, private taxpayers and patients as these external stakeholders become more assertive and demanding for higher accountability and transparency from the healthcare organizations. This demand is further driven by the power of information technology that allows the stakeholders to have an easy access to the data and performance reports of the organizations concerned. From shared database to information sharing, the information technology promotes networking, autonomy and higher sense of responsibility among health workers who are becoming more knowledge driven nowadays (Mulyadi, 2001). As a result, the effectiveness in the performance measurement systems at these organizations must be able to indicate the extent of which customers or patients requirement are met, while the efficiency measures must show how the organizations utilize their resources to provide customers/patients satisfactions (Pink et al., 2001). Hence, the demand for integrated performance measurement systems begins, with the continuing search for more relevant, integrated, balanced, strategic, improvement oriented and dynamic kind of measurement systems (Betitci et al., 2000). One prime example of such measurement systems that happens to address these requirements is the famous balanced scorecard.
BALANCE SCORECARD FRAMEWORK AND FUNCTION

Balanced Scorecard (BSC) is a performance management tool which began as a concept for measuring whether the smaller-scale operational activities of a company are aligned with its larger-scale objectives in terms of vision and strategy. By focusing not only on financial outcomes but also on the operational, marketing and developmental inputs to these, the Balanced Scorecard helps provide a more comprehensive view of a business, which in turn helps organizations act in their best long-term interests. Organizations are encouraged to measure in addition to financial outputs - what influenced such financial outputs. For example, process performance, market share/penetration, long term learning and skills development, and so on. The underlying rationale is that organizations cannot directly influence financial outcomes, as these are "lag" measures, and that the use of financial measures alone to inform the strategic control of the firm is unwise. Organizations should instead also measure those areas where direct management intervention is possible. In so doing, the early versions of the Balanced Scorecard helped organizations achieve a degree of "balance" in selection of performance measures. In practice, early Scorecards achieved this balance by encouraging managers to select measures from three additional categories or perspectives: "Customer," "Internal Business Processes" and "Learning and Growth." In 1993, Robert S. Kaplan and David P. Norton began publicizing the Balanced Scorecard through a series of journal articles. In 1996, they

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published the book The Balanced Scorecard. Since the original concept was introduced, Balanced Scorecards have become a fertile field of theory, research and consulting practice. The Balanced Scorecard has evolved considerably from its roots as a measure selection framework. While the underlying principles were sound, many aspects of Kaplan and Norton's original approach were unworkable in practice. In both firms associated with Kaplan & Norton (Renaissance Solutions Inc. and BSCOL), and elsewhere (Cepro in Sweden, and 2GC Active Management in the UK), the Balanced Scorecard has changed so that there is now much greater emphasis on the design process than previously. There has also been a rapid growth in consulting offerings linked to Balanced Scorecards at the level of branding only. Kaplan and Norton themselves revisited Balanced Scorecards with the benefit of a decade's experience since the original article. The Balanced Scorecard is a performance planning and measurement framework, with similar principles as Management by Objectives, which was publicized by Robert S. Kaplan and David P. Norton in the early 1990s. Implementing Balanced Scorecards typically includes four processes: 1. Translating the vision into operational goals; 2. Communicating the vision and link it to individual performance; 3. Business planning; 4. Feedback and learning, and adjusting the strategy accordingly. The Balanced Scorecard is a framework, or what can be best characterized as a strategic management system that claims to incorporate all quantitative and abstract measures of true importance to the enterprise. According to Kaplan and Norton (1996), The Balanced Scorecard provides managers with the instrumentation they need to navigate to future competitive success (p. 2). Many books and articles referring to Balanced Scorecards confuse the design process elements and the Balanced Scorecard itself. In particular, it is common for people to refer to a strategic linkage model or strategy map as being a Balanced Scorecard. Although it helps focus managers' attention on strategic issues and the management of the implementation of strategy, it is important to remember that the Balanced Scorecard itself has no role in the formation of strategy. In fact, Balanced Scorecards can comfortably co-exist with strategic planning systems and other tools. The grouping of performance measures in general categories (perspectives) is seen to aid in the gathering and selection of the appropriate performance measures for the enterprise. Four general perspectives have been proposed by the Balanced Scorecard: * Financial perspective; * Customer perspective; * Internal process perspective; * Innovation and learning perspective. The financial perspective examines if the companys implementation and execution of its strategy are contributing to the bottom-line improvement of the company. It represents the long-term strategic objectives of the organization and thus it incorporates the tangible outcomes

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of the strategy in traditional financial terms. The three possible stages as described by Kaplan and Norton (1996) are rapid growth, sustain and harvest. Financial objectives and measures for the growth stage will stem from the development and growth of the organization which will lead to increased sales volumes, acquisition of new customers, growth in revenues etc. The sustain stage on the other hand will be characterized by measures that evaluate the effectiveness of the organization to manage its operations and costs, by calculating the return on investment, the return on capital employed, etc. Finally, the harvest stage will be based on cash flow analysis with measures such as payback periods and revenue volume. Some of the most common financial measures that are incorporated in the financial perspective are EVA, revenue growth, costs, profit margins, cash flow, net operating income etc. The customer perspective defines the value proposition that the organization will apply in order to satisfy customers and thus generate more sales to the most desired (i.e. the most profitable) customer groups. The measures that are selected for the customer perspective should measure both the value that is delivered to the customer (value position) which may involve time, quality, performance and service and cost and the outcomes that come as a result of this value proposition (e.g., customer satisfaction, market share). The value proposition can be centered on one of the three: operational excellence, customer intimacy or product leadership, while maintaining threshold levels at the other two. The internal process perspective is concerned with the processes that create and deliver the customer value proposition. It focuses on all the activities and key processes required in order for the company to excel at providing the value expected by the customers both productively and efficiently. These can include both short-term and long-term objectives as well as incorporating innovative process development in order to stimulate improvement. In order to identify the measures that correspond to the internal process perspective, Kaplan and Norton propose using certain clusters that group similar value creating processes in an organization. The clusters for the internal process perspective are operations management (by improving asset utilization, supply chain management, etc), customer management (by expanding and deepening relations), innovation (by new products and services) and regulatory & social (by establishing good relations with the external stakeholders). The innovation and learning perspective is the foundation of any strategy and focuses on the intangible assets of an organization, mainly on the internal skills and capabilities that are required to support the valuecreating internal processes. The innovation and learning Perspective is concerned with the jobs (human capital), the systems (information capital), and the climate (organization capital) of the enterprise. These three factors relate to what Kaplan and Norton claim is the infrastructure that is needed in order to enable ambitious objectives in the other three perspectives to be achieved. This of course will be in the long term, since an improvement in the learning and growth perspective will require certain expenditures that

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may decrease short-term financial results, whilst contributing to long-term success. According to each perspective of the Balanced Scorecard, a number of key performance indicators (KPIs) can be used such as: Financial * Cash flow * ROI * Financial Result * Return on capital employed * Return on equity Customer * Delivery Performance to Customer - by Date * Quality Performance to Customer - by Quality * Customer satisfaction rate * Customer Loyalty * Customer retention Internal Business Processes * Number of Activities * Opportunity Success Rate * Accident Ratios * Overall Equipment Effectiveness Learning & Growth * Investment Rate * Illness rate * Internal Promotions * Employee Turnover * Gender Ratios
MEASURING PERFORMACE AT HEALTHCARE ORGANIZATIONS

The research on organization performance measurement system especially in the healthcare sector has generated a great amount of interest from both the practitioners and academicians alike in this field. Much attention has been focused on improving existing system particularly on finding ways to achieve effective and efficient healthcare measurement that help to prevent unnecessary cost overruns to the limited healthcare budget allocated to these organizations by the authorities concerned. While the results of earlier studies do bear significance to the practices of current healthcare management, most of them are carried out in the western environment, focusing on the US based healthcare organizations and those of the Canadians. Stewart and Lokamy III (2001) had strongly recommended healthcare organizations in the US to adopt an integrated performance measurement system if these organizations wished to become successful and competitive in the industry. However, no particular integrated performance measurement system was mentioned in their study. On the other hand, Kaplan and Norton (1996) had persistently promoted an integrated performance measurement system called the BSC and emphasized the need to rely on this system by

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various profit and non-profit organizations including hospitals if they wanted to thrive in their industries. Although evidence of many successful BSC applications could be found across different industries and service organizations, practice of the approach was still considered relatively new in the healthcare field. Melioness (2000) study proved that BSC method could be successfully applied to improve the overall organizational performance of Dke Children Hospital (DCH) with significant improvement to the hospitals financial status, which at that time was running an increasing annual operating loss from 4 million dollars in 1992 to 11 millions in 1996. Driven by the need to create changes in the organization in order to turnaround this performance, the Chief Medical Director of the pediatric hospital in Dunham came up with a new mission statement and effort to realign strategies with goals guided by the BSC method. The end result of the strategic and systematic performance measurement approach was the encouraging outcome in both financial (e.g. improved net margin and reduction of cost per case) and non-financial performances of the organization (e.g. better scores of patient satisfaction and reduction of average length of stay at the hospital). Although implementation of BSC at the hospital had been successful, Meliones (2000) warned that the whole process had not been an easy task. Effective communication, high commitment from the upper managements, employees active participation and understanding of the approach were needed to make the new performance measurement system works. Different study on another hospital that had adopted the BSC approach had also produced a favorable result. Monterfiore hospital was reported to show improvement in its capacity to serve its patient, recruitment of human resources and in the internal business process, which foster greater accountability and promote empowerment among hospital employees (Kaplan & Norton, 2001). Further evidence of BSC application in the healthcare setting was also documented in several other studies that contributed to the knowledge and understanding of the growing popular system with healthcare providers. Curtright et al. (2000), for example, designed a performance measurement system for the Mayo Clinic in Minnesota based on the BSC concept with effort to identify and monitor the key performance indicators of the organization and reported its overall goals achievement. Their experience in the implementation process of the BSC system had shown some resemblance to those faced by the management of Duke Children Hospital. The whole process could be described as continuous, iterative and time consuming while at the same time, required a sustained commitment from the senior managements and the support of a good information system. In a study carried out by Kershaw and Kershaw (2001), they developed a BSC framework to implement a new strategy for a problematic hospice unit at St. Elsewhere Hospital that had been showing a list of poor performances, which produced a chronically low patient census, high employee turnover rate and poor referral rate from physicians working at the hospital. Their study demonstrated how BSC could help a hospital links this strategy to the daily activities of its employee that ultimately made a

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difference in deciding the fate of the organization in todays dynamic healthcare industry. Nonetheless the development of BSC required customization because every organization has its own strategy and thus in need of specific strategic measurement system that could measure the performance of the institution concerned. Generally, Brown (1996) suggested a range of 15 to 20 measures as an ideal number of measures to monitor in any measurement system in order to avoid information overload. These limited measures should at the same time capable of giving the senior management a balanced, fast and comprehensive overview of the organization performances. Inamdar and Kaplan (2002) tried to capture the executives views from nine selected healthcare providers that were implementing BSC at their organizations in an effort to examine the extent of BSC successful application in the healthcare sector. Their survey provided insight into issues related to the adoption of BSC by the organization concerned. The result of the survey indicated that nearly all organizations that adopted this approach had a welldefined vision, mission and strategy prior to launching their BSC project. The factor that motivated them to take the proactive approach came from external forces including financial pressure, competition, consumerism, regulatory reporting, information management, industry consolidation and existing new technology. A summary of guidelines for BSC implementation and the theme of benefits from the approach application were included in the findings of the survey. According to MacStravic (1999, cited in Chan & Ho, 2000), there were at least six benefits that could be gained by healthcare providers from a true BSC approach, namely increased customer insight, refocused internal operations, energized internal stakeholders, strengthened customer acquisition efforts, strengthened customer relations and increased loyalty and returned of value. Before that, Chan and Ho (2000) had also conducted a similar study to assess the extent of BSC initiatives at Canadian hospitals when the concept was still considered quiet new to these healthcare providers. They studied the hospitals executives perceptions regarding BSC, identified factors that drive the management to undertake BSC initiatives and attempted to discover reasons on why BSC program failed. The result showed that executives from the hospitals that implemented BSC and those that did not had a similar understanding on the concept but the former were more definite in their response. The implementer had a more positive attitude towards the BSC and strongly believed that BSC could contribute and provide links to their mission and strategy with objective measures. On the whole, the finding of the study implied that most executives of these organizations agreed that the level of BSC implementation at their organizations were moderate and quite successful. The study cited lack of technical know-how and management commitment as the major reasons for failure in the implementation of BSC project at the participating organizations. Apart from these issues, there was also effort made by some researchers to seek combination of various performance measurement models with that of BSC to achieve better performance and quality improvement to their organization. Chow-Chua and Goh (2002) argued that

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the common traditional tools used to manage quality like TQM lacked performance monitoring facet, whereas the familiar Donabedians quality matrix only provided visual tool for assessment without defining the specific linkage between cause and effect like the BSC. To capture and understand the dynamic relationship between performance, continuous improvement and quality of service, they presented a knowledge based performance measurement framework for hospital by selecting Singapore Quality Award (SQA).

DISCUSSION AND CONCLUSION

It can be concluded that the concern of hospital management for performance measurement has increased largely to overcome the pressures made by the interest groups. The BSC was found to be effective for underlining existing problems and identifying opportunities for improvements. The BSC also revealed the hospitals contribution to performance improvement of each countrys total health system. Although scorecards may appear as a fad in the healthcare field, they have in fact earned a permanent place in strategic planning. A successful performance measurement system should follow a few important principles and take account of the unique characteristics of healthcare. Application of these measurement methods along with some creativity, initiative, and cooperation among hospital employees, customers, and consumers can improve the management and delivery of health care at reduced cost and without loss of quality.

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KHALED MOHAMMED BA-ABAAD (Master of Science [International Accounting]) College of Business Universiti Utara Malaysia email: khmab1975@yahoo.com

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