Competing values in healthcare: balancing the (un)balanced scorecard

Facing a complex environment driven by two decades of dramatic change, healthcare organizations are adopting new strategic frameworks such as the Balanced Scorecard (BSC) to evaluate performance (Kaplan and Norton 1992). The BSC was not originally developed as a performance management tool, however. Rather, it was designed as a tool to communicate strategy and, as such, provides little guidance when actual outcomes fall short of desired outcomes. In addition, although the BSC is an improvement over exclusively financial measures, it has three conceptual limitations that are especially problematic for evaluating healthcare organizations: (1) it underemphasizes the employee perspective, (2) it is founded on a control-based management philosophy, and (3) it emphasizes making trade-offs. To address these limitations, we propose using the Competing Values Framework (CVF), a theoretically grounded, comprehensive approach to understanding and improving organizational and managerial performance by focusing on four action imperatives: competing, controlling, collaborating, and creating. The CVF pays particular attention to the employee perspective, is consistent with a commitment-based management philosophy, and emphasizes transcending apparent paradoxes to identify win-win solutions. Rather than focusing on customer satisfaction or employee satisfaction, the CVF looks for ways to satisfy customers and employees while still addressing financial constraints and growth opportunities. The CVF also can be used to assess both the culture of the organization and the competencies of individual managers, thereby providing a clear link between strategy and implementation.     

Establishing a balanced scorecard measurement system for integrated care organizations in China

To address, among other issues, the regional and international challenges of the heavy health care burden caused by an aging population, integrated care organizations (ICOs) were proposed at the end of the 20th century for health care delivery. However, the implementation of ICOs has not progressed smoothly, and the current results have not eliminated the imbalance of medical service capabilities among hospitals of different levels. To make up for the deficiency in the current evaluation system at ICOs and offer suggestions for improved sustainable health planning and management, this study establishes a balanced scorecard based on a comprehensive measurement system valid for a Chinese ICO by surveying the staff at the West China Hospital ICO. This study collected valid responses from 216 professional staff members at the ICO via questionnaires. K‐means clustering and the coefficient of variation method were used to evaluate the weights of the first‐ and second‐level indicators. The results show the importance ranking of the core perspectives of the ICO balanced scorecard in the following order: patient, internal process, learning and growth, and financial. The weight‐based analysis identified the importance ranking of all indicators and pointed to the areas that require close attention in future ICO planning and management.     

Applying the balanced scorecard to local public health performance measurement: deliberations and decisions

Background  

All aspects of the heath care sector are being asked to account for their performance. This poses unique challenges for local public health units with their traditional focus on population health and their emphasis on disease prevention, health promotion and protection. Reliance on measures of health status provides an imprecise and partial picture of the performance of a health unit. In 2004 the provincial Institute for Clinical Evaluative Sciences based in Ontario, Canada introduced a public-health specific balanced scorecard framework. We present the conceptual deliberations and decisions undertaken by a health unit while adopting the framework.     

The balanced scorecard: a potent tool for energizing and focusing healthcare organization management

The current environment for healthcare organizations contains many forces demanding unprecedented levels of change. These forces include changing demographics, increased customer expectations, increased competition, and intensified governmental pressure. Meeting these challenges will require healthcare organizations to undergo fundamental changes and to continuously seek new ways to create future value. This article provides explanation of a potent new management tool-the balanced scorecard-that can be used by healthcare organizations to meet these challenges. The article also presents the opinions of many high-level healthcare administrators that the balanced scorecard can be highly beneficial to healthcare organizations. It also summarizes these administrators' suggestions regarding the goals and measures that can make up an effective scorecard for a hospital as a whole, as well as for a specific subunit of a hospital. Interestingly, while no published report of balanced scorecard implementations in healthcare organizations exists, a number of administrators stated that they had fully implemented systems similar to the scorecard. These actions can be considered support for the scorecard's potential usefulness; at the same time, they suggest that some sharing of experiences will likely be available in the future. As all administrators are well aware, moving from concept to practice is often difficult. While the article includes some suggestions for scorecard development and implementation, each organization must engage in the full range of activities, from defining its mission to the selection of goals and strategies, and develop its own unique scorecard to assist progress toward the selected goals. As a starting point, Table 3 provides a timeline of some general events that may be common to all organizations during this process.     

Use of the balanced scorecard in health care

Since Kaplan and Norton published their article proposing a balanced scorecard, the concept has been widely adopted by industry and health care provider organizations. This article reviews the use of the balanced scorecard in health care and concludes that the balanced scorecard: (1) is relevant to health care, but modification to reflect industry and organizational realities is necessary; (2) is used by a wide range of health care organizations; (3) has been extended to applications beyond that of strategic management; (4) has been modified to include perspectives, such as quality of care, outcomes, and access; (5) increases the need for valid, comprehensive, and timely information; and (6) has been used by two large-scale efforts across many health care organizations in a health care sector, which differ, namely in the units of analysis, purposes, audiences, methods, data, and results.     

A balanced scorecard for health services in Afghanistan

The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13,843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.     

平衡计分卡在医院绩效评估中的应用

绩效评估对医院的经营管理有着重要的意义，但是许多医院在评估绩效时过分依赖财务性绩效指标．平衡计分卡避免了依赖单一的财务指标来衡量组织绩效的缺点，它从财务、客户、内部流程和创新学习4个方面综合考核组织的绩效。成功设计与应用平衡计分卡对医院在激烈的市场竞争中生存和发展有重要促进作用。     

平衡计分卡与妇幼保健机构绩效评价和绩效管理

本文对绩效、绩效评估和绩效管理的概念进行了介绍,阐述了平衡计分卡理论的框架、理念及应用现状。在对我国妇幼保健机构的功能定位以及存在的相关问题进行分析的基础上,对平衡计分卡理论和方法在妇幼保健机构绩效评价和绩效管理中应用的可行性和适用性进行了分析探讨,旨在为我国妇幼保健机构的绩效评价和绩效管理实践提供借鉴和参考,促进妇幼保健机构的规范化发展。     

应用平衡计分卡实施医院战略管理

平衡计分卡是企业中使用的一种新的绩效管理工具，它超越了传统的仅从财务角度来衡量企业绩效的测评方法，从财务、客户、内部运营和革新与学习4个方面来全面考察企业。平衡计分卡也可以应用于医疗卫生领域，帮助医院可持续性地改善绩效，以实现医院愿景和战略目标。作者介绍了平衡计分卡的概念、创建步骤和原则以及其在医院战略管理中的应用，为医院发展寻找一条新的途径。     

Creating a balanced scorecard for a hospital system

In 1999, hospitals in Ontario, Canada, collaborated with a university-based research team to develop a report on the relative performance of individual hospitals in Canada's most populated province. The researchers used the balanced-scorecard framework advocated by Kaplan and Norton. Indicators of performance were developed in four areas: clinical utilization and outcomes, patient satisfaction, system integration and change, and financial performance and condition. The process of selecting, calculating, and validating meaningful indicators of financial performance and condition is outlined. Lessons learned along the way are provided. These lessons may prove valuable to other finance researchers and practitioners who are engaged in performance measurement endeavors.     

New opportunities for provider/insurers. Catholic healthcare organizations are well positioned for direct contracting

Congress and a number of state governments have recently taken steps to encourage the formation of provider/insurer networks and other forms of "direct contracting" by providers with consumers. No group is better positioned than Catholic hospitals and medical centers, with their common heritage, not-for-profit status, and history of community service, to take advantage of direct contracting opportunities. Provider/insurer configurations fall into three categories: self-policing networks that assume full-risk contracts from payers; joint ventures between provider networks and existing insurance companies or HMOs; and provider networks that establish their own insurance capability. Anticipated changes in many states' insurance application processes will make it easier for providers to choose the latter option. The keys to a successful provider/insurer plan are differentiation from other insurance products in the market and a strong, consumer-friendly image. The involvement of physicians is vital, and the majority of physicians on any one hospital's staff should be members of the provider/insurer network. Currently, the Medicare population, rather than the commercial sector, is a good choice for a beginning provider/insurer network to cover. While such networks may be driven by either physicians or hospitals, a joint initiative by physicians and hospitals is preferable. Successful implementation of highly evolved medical management systems and related operational support is also key.     

Continuity and change in preferred provider organizations

This paper presents the results from a national survey of preferred provider organizations (PPOs) that was conducted in 1988. It is based on telephone interviews conducted by the authors with executives in over 170 PPOs in the United States. We compare the survey results with those obtained from similar surveys conducted in 1985 and 1986, allowing us to assess the extent to which PPOs have grown and changed. We found that PPOs have continued to grow at an extremely rapid rate. During the Summer and Fall of 1988, the time in which the survey took place, 37.6 million people were eligible to use PPO benefits, compared to the 16.5 million figure we obtained two years earlier. We did not find, however, that PPOs are moving in the direction of providing more innovative forms of health care cost containment. Most PPOs still rely on discounts from providers and utilization review to achieve savings. There is little trend towards using incentive reimbursement techniques and choosing preferred providers that have shown themselves to be cost-efficient. We conclude that in the coming years PPOs must demonstrate the ability to control rising health care costs. To accomplish this, they will need to put more pressure on providers to use resources more sparingly. Otherwise, they may lose their market share to other forms of managed care.     

Strategic learning in healthcare organizations

There is no definitive blueprint for the healthcare organization involved in strategic learning. However, what distinguishes strategic learning institutions is their acknowledgment that they must discover their own paths and solutions rather than blindly follow a detailed strategic mandate from administration. Answers to their most critical implementation and adaptive questions will not flow down ready-made from above, but will be tailored to meet the requirements of their own particular situation. Strategic learning organizations have certain attributes in common in developing their own answers: They continuously experiment rather than seek final solutions. They favor improvisation over forecasts. They formulate new actions rather than defend past ones. They nurture change rather than permanence. They encourage creative conflict rather than tranquillity. They encourage questioning rather than compliance. They expose contradictions rather than hide them (Weick 1977). Most importantly, strategic learning organizations realize that successful strategic change is best undertaken as a process of learning (O'Sullivan 1999). Healthcare organizations can no longer afford the illusion of traditional strategic planning, with its emphasis on bureaucratic controls from the top to the bottom. They must embrace the fundamental truth that most change occurs through processes of learning that occur in many locations simultaneously throughout the organization. The initial step in discovering ways to improve the capability of healthcare organizations is to adapt continuously while fulfilling their mission. Healthcare leaders must create a shared vision of where an institution is heading rather than what the final destination will be, nurture a spirit of experimentation and discovery rather than close supervision and unbending control, and recognize that plans have to be continuously changed and adjusted. To learn means to face the unknown: to recognize that we do not possess all the answers; to concede that we do not always know what to do; to admit that past actions and solutions may no longer be appropriate, in fact may have been the incubators of today's problems; to question basic assumptions long held about running the institution; and to make ourselves vulnerable to the political dynamics prevalent in all organizations. Hospitals and other healthcare organizations must seek to develop and maintain a continuing state of readiness in which everyone in the organization, from front-line clinician to senior management, is poised to act in anticipation of and in response to unforeseen changes in the environment and to learn from their own experiences in confronting the future.