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Balanced
Adaptation of the balanced scorecard
scorecard model to measure model

performance of the departments

at Dr Zainoel Abidin Regional 365

General Hospital, Banda Aceh Received 18 September 2018

Revised 2 April 2019
Accepted 16 June 2019
Ashiva Martunis, Ritha Dalimunthe, Khaira Amalia and
Juanita Juanita
Faculty of Public Health, University of North Sumatra, Medan, Indonesia
Hendra Syahputra
Department of Knowledge Management, Islamic University of Ar-Raniry,
Banda Aceh, Indonesia
Muhammad Adam
Department of Management, Faculty Economic and Business,
Syiah Kuala University, Banda Aceh, Indonesia, and
Masyudi Masyudi
Faculty of Public Health, Riau University, Pekanbaru, Indonesia

Abstract
Purpose – This paper aims to determine the performance of the departments at Dr Zainoel Abidin Regional
General Hospital, Banda Aceh, Indonesia, in 2016, based on the targets and realization of their work programs
using balanced scorecard.
Design/methodology/approach – This study adopted qualitative and quantitative approaches.
Findings – The overall results of the performance appraisal using the balanced scorecard approach seen
from the financial, internal business, customer and training and learning perspectives are good. Dr Zainoel
Abidin Regional General Hospital has provided good services, and performance of its departments have
generated the expected outcome, realized by the Hospital.
Originality/value – The novelty of the present study lies in its research model, where human resources
(transformational leadership, organizational commitment and resource uniqueness) and financial management
(business plans, budget and performance).
Keywords Performance management, Performance, Balanced scorecards, Hospital, Modelling
Paper type Research paper

1. Introduction
Performance of a company is an outcome generated by a company within a certain period
Journal of Modelling in
with reference to the predetermined standard. Thus, assessment of a company’s performance Management
means a process or system to assess the implementation of work abilities of a company Vol. 15 No. 2, 2020
pp. 365-379
(organization) based on certain standards (Kaplan and Norton, 1996). At the beginning, the © Emerald Publishing Limited
1746-5664
balanced scorecard was used to improve the executive performance appraisal system. In its DOI 10.1108/JM2-09-2018-0149
JM2 early use, executive performance was measured only from the financial aspect. Then, this
15,2 evolved into four perspectives which were then used to measure the whole performance of an
organization: financial, customer, internal business process and learning and growth.
The main objective of performance appraisals is to encourage employees to attaint
organizational goals and meet the predetermined standards of behavior so as to produce actions
and outcomes the organization desires. The forms of these standards of behavior can be either
366 policies of the management or formal plans outlined in the organization’s budget (Mulyadi,
2000). Performance appraisals are an important factor for the current and future organizational
environment and the existing performance appraisal methods which only consider financial
performance still have weaknesses; that is why the effective performance appraisal should be
able to translate the missions, visions and strategies of an organization into operational
objectives and performance parameters, both financial and non-financial (Gaspersz, 2003).
Balanced scorecard (BSC) is a performance measurement method which is applied to
private organizations to balance between financial and nonfinancial aspects. However, in
this case, the financial measure of BSC application to non-profit public sector organizations
is quite different from private organizations (Taufik et al., 2018).
The use of balanced scorecard as a method to conduct performance appraisals is indeed
more common in business companies that produce goods. But, it can also be applied to
hospitals running the business of service provision, for example, Peel Memorial Hospital
Vancouver Canada and Mayo Clinic in the USA. Both hospitals have adopted frameworks to
conduct performance appraisals and evaluation and applied them into the strategic planning
of their respective organization to improve their own performance (Maheshwari et al., 2000).
The same view also comes from Chow et al. (1998) who recommends adoption of balanced
scorecard to conduct performance appraisals in health organizations.
Dr Zainoel Abidin Regional General Hospital as one of class-A general hospitals owned by
the provincial government of Aceh has programs that provide added value for its customers,
employees, and the public and supports the growth of regional and national economy. To
determine the success of the programs it runs, performance of those program needs to be
assessed. The performance appraisals undertaken to the departments at Dr Zainoel Abidin
Regional General Hospital still focused on assessing the success of a program based on the
aspects of finance and services. Thus, it is necessary to have a performance appraisal system
that is able to measure performance more accurately and comprehensively and one of the
options is to implement balanced scorecard. The balanced scorecard is not only a performance
appraisal tool, but it further develops into a strategic management system that helps translate
and communicate an organization’s visions and missions and gains feedback from learning. It
is vital to carry out performance appraisals of the departments at Dr Zainoel Abidin Hospital
for optimally improving the public health status and in the near future, it is expected that this
hospital undertakes not only curative and rehabilitative efforts but also preventive and
promotive efforts to improve hospital benefits without neglecting its social function.
Study by Taufik et al. (2018) aims at measuring the performance of hospitals in Pasuruan
based on four BSC perspectives (financial perspective, customer perspective, internal business
process perspective, and learning and growth perspective). This study was conducted at the
hospital using secondary data in the form of financial reports and non-financial reports.
The object of this research was the hospitals in Pasuruan. The results showed that the
performance of the three hospitals in Pasuruan in using BCS gauge is good. This reflects that
the three hospitals in Pasuruan always strive to realize the achievement of vision, mission and
goals as one of the optimal public health services in Pasuruan and surrounding areas.
This research aims to determine the performance of the departments at Dr Zainoel
Abidin Hospital in 2016, based on the targets and realization of their work programs using
balanced scorecard. Novelty of the present research lies in its research model, where human Balanced
resources (transformational leadership, organizational commitment and resource scorecard
uniqueness) and financial management (business plans, budget and performance).
Several previous studies have found partial relationship between variables such as:
model

service performance and financial performance by Duncan and Elliott (2004),
Camarero (2007), Liang et al. (2009), Keisidou et al. (2013);

customer performance and financial performance by Chotekorakul and Nelson 367
(2013), Eklof et al. (2017), Moon and Choi (2014);

growth and learning performance and internal business process performance by Lee
et al. (2011), Kotey and Anderson (2006), Bititci et al. (2011), Liu and Tsai (2007),
Jusoh et al. (2008), Tung et al. (2011);

growth and learning performance and performance of hospital departments by
Potter et al. (1994), Chen et al. (2006), Halkjær and Lueg (2017), Capkun et al. (2012);

performance of hospital departments and target realized work program by Bakar
et al. (2009), Bhat et al. (2016), Al-Hyari et al. (2016), Warburton et al. (2004); and

performance of hospital departments and performance appraisal of hospital departments
by Coates (1996), Wilson and Western (2000), Pantouvakis and Mpogiatzidis (2013).

2. Literature review
2.1 The financial perspective
In this research, performance appraisals viewed from the financial perspective were
undertaken using economic, efficiency, and effectiveness ratios by using the value-for-money or
3E instrument developed by Mardiasmo (2002). This instrument consists of 3Es. First is the
economic ratio, i.e. a ratio that describes how economical the use of the budget is, which also
includes careful or efficient management and no waste. According to Ahmad et al. (2010), the
economic ration is measured by comparing the target budget and spending realization.
The second one is the efficiency ratio, i.e. the ratio that describes the comparison between the
amount of spending and revenue realization. Therefore, in the event that the target to be
achieved by a public policy is in fact very simple while the costs incurred through the policy
process is too large compared to the outcome achieved, this means that the activities of that
policy are not feasible to be implemented (Dunn, 2003). The third one is the effectiveness ratio, i.
e. the ratio which has something to do with whether an alternative achieves the expected
outcome or the objective of a particular action or not (Dunn, 2003). Thus, parameters for
effectiveness can be defined as particular standards to be fulfilled in attainment of goals and
objectives. Having no access to financial services is a costly matter. Indeed, a person with no
access to a bank account would have to go to every retail establishment and stand in line to pay
his/her bills and may even have to pay extra fees for paying in cash (Jouti, 2018).

2.2 The internal business perspective

The internal business perspective refers to the ability of the hospital to carry out work
activities according to plan. In this research, the internal business processes analyzed
included the increased/decreased number of outpatient and inpatient visits.

2.3 The customer perspective

The customer perspective has something to do with the ability of the hospital to provide
quality health services to the public who use its services. In this research, an analysis was
JM2 undertaken to the satisfaction index of the patients. These data on customer satisfaction
15,2 were based on the secondary data, which were obtained from a survey conducted by the
hospital management to measure the extent to which customers were satisfied with
the health services provided by the hospital. Consumer satisfaction measures the average
customer satisfaction by giving a score to the answer indicated on the questionnaire in
accordance with the level of perceived satisfaction. Servitization have definition in which the
368 development of processes and capabilities is considered, a natural expected outcome of a
servitization strategy would therefore consist of the level or contribution toward the
development of processes and capabilities of servitized firms from customers’ perspective
(used in this research to measure servitization).

2.4 The growth and learning perspective

The growth and learning perspective constitutes efforts made by the hospital management
to improve the quality of human resource performance. In this research, the activities
analyzed were employee satisfaction and the frequency of education and training intended
to develop human resources in the field of health and use of technology.

2.5 Measurement using balanced scorecard

This refers to the analysis whose data can be calculated to be interpreted quantitatively,
which include performance appraisals based on the balanced scorecard expressed in the
form of a total score. This method was used to determine the score of each indicator of the
four balanced scorecard perspectives. A higher performance appraisal score indicates that
such a performance appraisal is more suitable compared to the others and can be
recommended as a measurement tool that can be applied by hospitals in the future (Aurora,
2010). In balanced scorecard, an appraisal is conducted through balanced measurement
between one perspective and another according to the benchmarks of each perspective.
According to Mulyadi (2001), balance is used as a criterion to measure the extent to which
the strategic objectives achieved are balanced in all perspectives.

3. Methodology
This research adopted qualitative and quantitative approaches. The research population
consisted of 1,516 employees working at 38 polyclinics (profile of Zainal Abidin Hospital,
2012). The research sample consisted of 28 polyclinics. This research was conducted at
Dr Zainoel Abidin Hospital in Banda Aceh from August to November 2016. The data
collection techniques used included interviews, observation, and documentation. The main
data needed to do performance appraisals to the departments at Dr Zainoel Abidin Hospital
in this research can be classified as follows: financial data, consisting of data on the
economic, efficiency and effectiveness ratios; data on outpatient visits; data on inpatient
visits; data on patient satisfaction; data on employee satisfaction; and data on employee
education, training and development.
The data analysis in the balanced scorecard analysis to do performance appraisals to the
departments at Dr Zainoel Abidin Hospital was performed through identification of the four
perspectives, i.e. financial, customer, internal business process and learning and growth
perspectives of the departments at Dr Zainoel Abidin Hospital. If the four perspectives
measured generate a good score, it means that the performance of the departments at
Dr Zainoel Abidin Hospital is good. The mechanism for the performance appraisals of the
departments at Dr Zainoel Abidin Hospital is illustrated in Figure 1.
 Balanced
scorecard
FINANCIAL PERFORMANCE model
SERVICE PERFORMANCE

CUSTOMER PERFORMANCE
369
GROWTH AND LEARNING INTERNAL BUSINESS
PERFORMANCE PROCESS PERFORMANCE

PERFORMANCE OF TARGET REALIZED

HOSPITAL DEPARTMENTS GAP WORK PROGRAM

PERFORMANCE APPRAISAL OF Figure 1.

HOSPITAL DEPARTMENTS Research scheme

4. Result and discussion

4.1 The financial perspective
It indicated the ability of the departments at Dr Zainoel Abidin Hospital in Banda Aceh in
achieving financial conditions. In this research, the financial analysis was performed using
the economic, efficiency, and effectiveness ratios by using the value-for-money or 3E
instrument developed by Mardiasmo (2002). The results are presented in Table I.
As seen in Table I, on the average there was a gradual improvement in the three financial
perspectives in all polyclinics between 2014 and 2015. In terms of economy, most polyclinics
reached the economic target (the ratio in 2014 = 75.57 and in 2015 = 76.28). Among 28
polyclinics, only the heart surgery polyclinic did not reach the economic target (the ratio in
2014 = 114.09 and in 2015 = 122.70). As for the efficiency and effectiveness ratios, 12
polyclinics proved positively efficient and effective (the ratio > 100), namely, dental and
mouth polyclinic, inpatient thalassemia ward, pediatric inpatients ward, neurological
inpatients ward, cardiologic and pulmonary inpatients ward, ICU ward, ICCU ward, PICU
ward, NICU ward, VIP service ward and operational room polyclinic.

4.2 The internal business perspective

The internal business perspective refers to the ability of the departments at Dr Zainoel
Abidin Hospital in Banda Aceh to carry out work activities according to plan. The internal
business processes analyzed included the increased/decreased number of outpatient and
inpatient visits and the result is presented in Table II.
Based on the information presented in Table II, it is revealed that of 28 hospital
departments, there is a significant increase between the targeted visits and the actual visits
in most departments.
JM2 2014 2015
15,2 Departments Economic efficiency Effectiveness Economic efficiency Effectiveness

Surgical Polyclinic 69.5 89.1 82.8 74.8 94.8 90.0

Internal Disease and Endocrine 68.3 37.9 85.2 73.4 40.3 92.6
Polyclinic
Obstetric Polyclinic 71.4 47.4 83.7 76.8 50.4 90.9
Pediatrics Polyclinic 71.4 84.2 82.8 76.7 89.5 90.0
370 Neurology Polyclinic 71.7 28.3 82.8 77.1 30.1 90.0
Cardiology Polyclinic 73.4 61.3 82.8 78.9 65.2 90.0
Eye Polyclinic 77.0 50.5 84.4 82.8 53.7 91.7
Hearing and Otolaryngology 77.0 49.2 82.8 82.8 52.3 90.0
Polyclinic
Pulmonary Polyclinic 71.7 84.5 82.8 77.1 89.9 90.0
Skin and Sexual Disease Polyclinic 73.8 96.3 82.8 79.3 102.4 90.0
Endoscopy Polyclinic 77.8 35.9 85.9 83.7 38.1 93.4
Anesthesia Polyclinic 70.6 67.9 82.8 75.9 72.3 90.0
Emergency Unit 82.4 91.9 78.6 88.6 97.8 85.5
Dental and Mouth Polyclinic 69.8 163.8 78.6 75.1 174.3 85.5
Heart Surgery Ward 114.1 171.0 167.4 122.7 182.0 182.0
Eye/THT Inpatients Ward 81.8 50.5 49.4 87.9 53.7 53.7
Inpatient Thalassemia Ward 71.7 126.3 123.6 77.1 134.4 134.4
Maternity Ward 78.6 59.7 58.5 84.6 63.6 63.6
Pediatric Inpatients Ward 77.8 136.2 133.3 83.6 144.9 144.9
Male Surgical Ward 75.9 37.6 36.7 81.6 39.9 39.9
Neurological Inpatients Ward 79.3 155.0 151.7 85.2 164.9 164.9
Cardiologic and Pulmonary 76.3 265.8 260.1 82.1 282.8 282.8
Inpatients Ward
ICU Ward 78.9 161.9 158.5 82.1 157.4 157.4
Table I. ICCU Ward 50.8 208.4 204.0 83.8 134.8 134.8
The achievements of PICU Ward 76.4 147.9 144.8 82.7 132.6 132.6
NICU Ward 77.9 126.7 123.9 79.1 219.3 219.3
the three financial
VIP Service Ward 76.9 124.6 121.9 82.7 120.9 132.6
perspectives in 2014 Operational Room polyclinic 73.5 206.1 201.8 79.1 199.9 219.3
and 2015 Mean 75.57 105.9 110.52 76.28 110.09 118.6

4.3 The customer perspective

The customer perspective has something to do with the ability of the hospital to provide
quality health services to the public who use its services. In this research, an analysis was
undertaken to the satisfaction index of the patients. The results are presented in Table III.
Based on the information presented in Table III, it is revealed that of 28 hospital
departments, 20 of them (71.4 per cent) were considered to have provided satisfying services
according to patients and the remaining 8 departments (28.6 per cent) have not, namely,
internal disease and endocrine polyclinic, cardiology polyclinic, hearing and otolaryngology
polyclinic, dental and mouth polyclinic, heart surgery ward, inpatient thalassemia ward,
pediatric inpatients ward and NICU ward.

4.4 The growth and learning perspective

The growth and learning perspective constitutes efforts made by the hospital management
to improve the quality of human resource performance. In this research, the activities
analyzed were employee satisfaction and the frequency of education and training intended
to develop human resources in the field of health and use of technology. Results of the
employee satisfaction measurement are presented in Table IV.
As seen in Table IV, on the average, there is an increase in the employee
satisfaction score by 3.8 (i.e. from 85.3 to 89.1). However, the employee satisfaction
Department Target Realization (%) of realization
Balanced
scorecard
Surgical Polyclinic 19.278 21.206 90.91 model
Internal Disease and Endocrine Polyclinic 12.968 14.136 91.74
Obstetric Polyclinic 6.302 7.059 89.28
Pediatrics Polyclinic 7.925 8.638 91.75
Neurology Polyclinic 9.116 10.210 89.29
Cardiology Polyclinic 6.551 7.206 90.91 371
Eye Polyclinic 7.426 8.242 90.10
Hearing and Otolaryngology Polyclinic 7.675 8.673 88.49
Pulmonary Polyclinic 4.635 4.959 93.47
Skin and Sexual Disease Polyclinic 8.631 9.667 89.28
Endoscopy Polyclinic 3.197 3.485 91.74
Anesthesia Polyclinic 2.157 2.416 89.28
Emergency Unit 2.419 2.613 92.58
Dental and Mouth Polyclinic 2.545 2.851 89.27
Heart Surgery Ward 784 1.012 77.47
Eye/THT Inpatients Ward 369 405 91.11
Inpatient Thalassemia Ward 210 231 90.91
Maternity Ward 200 220 90.91
Pediatric Inpatients Ward 252 277 90.97
Male Surgical Ward 720 1.470 48.98
Neurological Inpatients Ward 715 1.362 52.50
Cardiologic and Pulmonary Inpatients Ward 799 1.463 54.61
ICU Ward 854 1.778 48.03
ICCU Ward 294 329 89.36
Table II.
PICU Ward 920 1.575 58.41
NICU Ward 728 1.367 53.26 Results of the
VIP service Ward 348 389 89.46 calculation of visits
Operational room polyclinic 328 367 89.37 to departments in
Mean 81.91 2016

scores in seven polyclinics gradually decrease, namely, skin and sexual disease
polyclinic (from 87.5 to 86.5), endoscopy polyclinic (from 87.5 to 86.5), dental and
mouth polyclinic (from 72.4 to 70.4), heart surgery ward (from 87.5to 84.5), maternity
ward (from 75.4 to 72.4), pediatric inpatients ward (from 96.3 to 90.7) and ICU ward
(from 96.3 to 87.5).
The researcher obtained information about the access to employee training attended each
year for each department from secondary data in the form of the hospital annual report for
2015 as shown in Table V.
Table V above presents data on the percentage of employees of the hospital departments
having access to training in 2015, where there are 19 departments with a mean higher than
82.2 per cent and 9 departments with a mean lower than the mean of the hospital, namely, by
72 per cent.

4.5 Performance based on balanced scorecard

Determining results of performance appraisals using the approach of balanced scorecard
was undertaken using an analysis whose data can be calculated by measuring performance
of each perspective. After the data had been processed, a score was given, to determine if the
performance of the whole aspects of the company is good, fair, or poor. The results are
presented in Table VI.
JM2 Department Target Realization Remark
15,2
Surgical Polyclinic 80.00 92.90 Target Achieved
Internal Disease and Endocrine Polyclinic 80.00 75.40 Target Not Achieved
Obstetric Polyclinic 80.00 98.20 Target Achieved
Pediatrics Polyclinic 80.00 94.60 Target Achieved
Neurology Polyclinic 80.00 98.20 Target Achieved
372 Cardiology Polyclinic 80.00 70.40 Target Not Achieved
Eye Polyclinic 80.00 94.95 Target Achieved
Hearing and Otolaryngology Polyclinic 80.00 70.40 Target Not Achieved
Pulmonary Polyclinic 80.00 92.90 Target Achieved
Skin and Sexual Disease Polyclinic 80.00 96.40 Target Achieved
Endoscopy Polyclinic 80.00 90.70 Target Achieved
Anesthesia Polyclinic 80.00 95.50 Target Achieved
Emergency Unit 80.00 92.90 Target Achieved
Dental and Mouth Polyclinic 80.00 74.40 Target Not Achieved
Heart Surgery Ward 80.00 73.40 Target Not Achieved
Eye/THT Inpatients Ward 80.00 98.90 Target Achieved
Inpatient Thalassemia Ward 80.00 70.40 Target Not Achieved
Maternity Ward 80.00 96.30 Target Achieved
Pediatric Inpatients Ward 80.00 70.40 Target Not Achieved
Male Surgical Ward 80.00 98.20 Target Achieved
Neurological Inpatients Ward 80.00 94.60 Target Achieved
Cardiologic and Pulmonary Inpatients Ward 80.00 92.90 Target Achieved
ICU Ward 80.00 87.55 Target Achieved
ICCU Ward 80.00 98.20 Target Achieved
PICU Ward 80.00 92.90 Target Achieved
Table III. NICU Ward 80.00 72.40 Target Not Achieved
Results of the survey VIP service Ward 80.00 87.55 Target Achieved
on patient Operational Room polyclinic 80.00 91.10 Target Achieved
satisfaction in 2015 Mean 80.00 88.00 Target Achieved

Table VI above describes performance of the hospital departments based on performance

appraisal using the approach of balanced scorecard, where the overall performance fall into
the good category with a mean by 0.88, because the total score is higher than 0.50,
performance of the outpatient department falls into the good category. However, there are
several departments whose performance according to balanced scorecard is lower than the
mean of the hospital, namely, internal disease and endocrine polyclinic, obstetric polyclinic,
pediatrics polyclinic, neurology polyclinic, cardiology polyclinic, eye polyclinic, hearing and
otolaryngology polyclinic, pulmonary polyclinic male surgical ward, maternity ward,
cardiologic and pulmonary inpatients ward and eye/THT ward.

5. Discussion
The revenue obtained by the departments of Dr Zainoel Abidin Hospital fluctuated in 2015
with the effectiveness ratio by 76.28 per cent. Based determination of the budget and realization
to determine the indicators of effectiveness, the effectiveness ratio of Dr Zainoel Abidin
Regional General Hospital remains not effective. This can be seen from the effectiveness ratio
that is far below 100 per cent. Because the financial performance of an institution is said to be
effective if the value generated is higher than 100 per cent (x > 100 per cent) for this
effectiveness ratio. The internal business perspective was measured using the number of
outpatient and inpatient visits. It is known that the number of outpatient and inpatient visits
Department Scores
Balanced
scorecard
2014 2015 model
Surgical Polyclinic 78.5 87.5
Internal Disease and Endocrine Polyclinic 87.5 98.2
Obstetric Polyclinic 92.75 98.2
Pediatric Polyclinic 70.4 72.4
Neurology Polyclinic 91.1 91.1 373
Cardiology Polyclinic 87.5 97.5
Eye Polyclinic 70.4 78.5
Hearing and Otolaryngology Polyclinic 87.5 98.2
Pulmonary Polyclinic 87.5 97.4
Skin and Sexual Disease Polyclinic 87.5 86.5
Endoscopy Polyclinic 87.5 86.5
Anesthesia Polyclinic 91.1 98.2
Emergency Unit 87.5 92.9
Dental and Mouth Polyclinic 72.4 70.4
Heart Surgery Ward 87.5 84.5
Eye/THT Inpatients Ward 87.5 91.1
Inpatient Thalassemia Ward 87.5 92.9
Maternity Ward 75.4 72.4
Pediatric Inpatients Ward 96.3 90.7
Male Surgical Ward 87.5 94.6
Neurological Inpatients Ward 96.3 98.2
Cardiological and Pulmonary Inpatients Ward 70.4 72.4
ICU Ward 96.3 87.5
ICCU Ward 70.4 72.4
PICU Ward 87.5 92.9
NICU Ward 87.5 96.4 Table IV.
VIP service Ward 90.7 92.9 Employee
Operational Room (COT) 87.5 95.5 satisfaction scores
Mean 85.3 89.1 years 2014 and 2015

tended to increase every year. Such an increase implies that users perceived that the services
provided by Dr Zainoel Abidin Regional General Hospital got increasingly better every year so
that the number of both outpatient and inpatient visits tended to increase every year.
The customer perspective was measured using the level of patient satisfaction. Patient/
customer satisfaction refers to a customer’s level of satisfaction after comparing his/her
needs, expectations, and desires with the reality he/she gets when using a product
(Gaspersz, 2002). Many surveys on hospital patient satisfaction had been conducted to
assess services, but they in fact did not reveal things which patients actually complained
about or which disturbed them (Piechert JW, 1998). Patient satisfaction surveys often focus
on those patients who are satisfied. Meanwhile, those patients who feel dissatisfied or
aggrieved often refuse to bother filling in survey sheets and this leads to the absence of
documented information and, eventually, the absence of follows-up. The reason why a
patient files a lawsuit against a doctor or hospital officer is the absence of satisfactory
responses in relation to the doctor and the hospital (Mineo et al., 2005).
Based on results of the research in 2015 at the hospital on the level of patient satisfaction
using secondary data and questionnaires adopted from the Letter of Decision of the Minister
of State Apparatus of the Republic of Indonesia No. KEP- 25/M.PAN/2/2004 dated February
24, 2004, in the departments of Dr Zaineol Abidin Regional General Hospital, there are 14
indicators to measure patient satisfaction: straightforward service procedures, suitable
JM2 Department Target Realization Remark
15,2
Surgical Polyclinic 75.00 96.00 Target Tercapai
Internal Disease and Endocrine Polyclinic 75.00 84.00 Target Tercapai
Obstetric Polyclinic 75.00 84.00 Target Tercapai
Pediatrics Polyclinic 75.00 72.00 Target Not Achieved
Neurology Polyclinic 75.00 72.00 Target Not Achieved
374 Cardiology Polyclinic 75.00 72.00 Target Not Achieved
Eye Polyclinic 75.00 84.00 Target Achieved
Hearing and Otolaryngology Polyclinic 75.00 96.00 Target Achieved
Pulmonary Polyclinic 75.00 84.00 Target Achieved
Skin and Sexual Disease Polyclinic 75.00 72.00 Target Not Achieved
Endoscopy Polyclinic 75.00 84.00 Target Achieved
Anesthesia Polyclinic 75.00 84.00 Target Achieved
Emergency Unit 75.00 84.00 Target Achieved
Dental and Mouth Polyclinic 75.00 84.00 Target Achieved
Heart Surgery Ward 75.00 96.00 Target Achieved
Eye/THT Inpatients Ward 75.00 96.00 Target Achieved
Inpatient Thalassemia Ward 75.00 84.00 Target Achieved
Maternity Ward 75.00 96.00 Target Achieved
Pediatric Inpatients Ward 75.00 84.00 Target Achieved
Male Surgical Ward 75.00 84.00 Target Achieved
Neurological Inpatients Ward 75.00 84.00 Target Achieved
Cardiologic and Pulmonary Inpatients Ward 75.00 72.00 Target Not Achieved
ICU Ward 75.00 72.00 Target Not Achieved
ICCU Ward 75.00 72.00 Target Not Achieved
Table V.
PICU Ward 75.00 72.00 Target Not Achieved
Measurement results NICU Ward 75.00 72.00 Target Not Achieved
of the access to VIP service Ward 75.00 84.00 Target Achieved
employee training in Operational room polyclinic 75.00 84.00 Target Achieved
2016 Mean 75.00 82.29 Target Achieved

service requirements, clarity and certainty from the officer in charge of service provision,
discipline of the officer who provides services, officers’ sense of responsibility, officers’
abilities, speed of the service, equal treatment with regard to service provision, politeness
and friendliness, fairness of the service, consistency between the fee paid and the one
charged, accuracy of the service, convenience of the service and security of the service.
Measuring customers’ level of satisfaction with the health service provided by the
hospital. Consumer satisfaction measures the average customer satisfaction by providing a
score to responses indicated in the questionnaire based on the level of perceived satisfaction.
The scores given are 1: very dissatisfied; 2: not satisfied; 3: neither satisfied nor dissatisfied;
4: satisfied; and 5: very satisfied.
Results of the survey in 2015 conducted at Dr Zainoel Abidin Regional General Hospital
generated the average percentage of patient satisfaction by 71.4 per cent. Based on the table
above, the level of patient satisfaction of most work units in outpatient and inpatient
departments is higher than the target set by the hospital, namely, by 70 per cent (20 work units
generate the level of patient satisfaction greater than 70 per cent (i.e. 71.4 per cent), while 8 of
them generate the level of patient satisfaction lower than 75 per cent (i.e. 28.6 per cent). Thus,
these results indicate that patients at Dr Zainoel Abidin Regional General Hospital fall into the
category of “satisfied with the hospital’s performance.”
The learning and growth perspective was measured based on employee satisfaction, and
employee education and training. Argue that employees have a unique contribution to
 Score indicator performance
Balanced
Department balanced scorecard*) Mean Score scorecard
model
1 2 3 4 5 6 7 BLC BLC
Surgical Polyclinic 74.08 94.08 90.00 90.91 92.90 87.05 96.00 89.29 0.89
Internal Disease and Endocrine Polyclinic 73.04 40.03 90.00 91.74 75.40 98.02 84.00 78.89 0.78
Obstetric Polyclinic 76.08 50.04 90.00 89.28 98.20 98.02 84.00 83.66 0.83
Pediatrics Polyclinic 76.07 89.05 90.00 91.75 94.60 72.04 72.00 83.64 0.83 375
Neurology Polyclinic 77.01 30.01 90.00 89.29 98.20 91.01 72.00 78.22 0.78
Cardiology Polyclinic 78.09 65.02 90.00 90.91 70.40 97.05 72.00 80.50 0.80
Eye Polyclinic 82.08 53.07 91.07 90.10 94.95 78.05 84.00 81.90 0.82
Hearing and Otolaryngology Polyclinic 82.08 52.03 90.00 88.49 70.40 98.02 96.00 82.43 0.82
Pulmonary Polyclinic 77.01 89.09 90.00 93.47 92.90 97.04 84.00 89.07 0.89
Skin and Sexual Disease Polyclinic 79.03 102.04 90.00 89.28 96.40 86.05 72.00 87.83 0.88
Endoscopy Polyclinic 83.07 38.01 93.04 91.74 90.70 86.05 84.00 80.94 0.94
Anesthesia Polyclinic 75.09 72.03 90.00 89.28 95.50 98.02 84.00 86.27 0.86
Emergency Unit 88.06 97.08 85.05 92.58 92.90 92.09 84.00 90.25 0.90
Dental and Mouth Polyclinic 75.01 174.03 85.05 89.27 74.40 74.04 84.00 93.69 0.93
Heart Surgery Ward 88.06 182 93.04 77.47 73.40 84.05 96.00 99.15 0.99
Eye/THT Inpatients Ward 87.09 53.07 53.07 91.11 98.90 91.01 96.00 81.46 0.81
Inpatient Thalassemia Ward 77.01 134.04 134.04 90.91 70.40 92.09 84.00 97.50 0.97
Maternity Ward 84.06 63.06 63.06 90.91 96.30 72.04 96.00 80.78 0.81
Pediatric Inpatients Ward 83.06 144.09 93.04 90.97 70.40 90.07 84.00 93.66 0.94
Male Surgical Ward 81.06 39.09 39.09 48.98 98.20 94.06 84.00 69.21 0.69
Neurological Inpatients Ward 85.02 164.09 93.04 52.50 94.60 98.02 84.00 95.90 0.96
Cardiologic and Pulmonary 82.01 93.04 93.04 54.61 92.90 72.04 72.00 79.95 0.80
Inpatients Ward
ICU Ward 82.01 157.04 157.04 48.03 87.55 87.05 72.00 98.67 0.99
ICCU Ward 83.08 134.08 134.08 89.36 98.20 72.04 72.00 97.55 0.97
PICU Ward 82.07 132.06 132.06 58.41 92.90 92.09 72.00 94.51 0.95
NICU Ward 79.01 93.04 219.03 53.26 72.40 96.04 72.00 97.83 0.97
VIP service Ward 82.07 120.09 132.06 89.46 87.55 92.09 84.00 98.19 0.98 Table VI.
Operational Room polyclinic 79.01 93.04 93.04 89.37 91.10 95.05 84.00 89.23 0.89
Mean 80.37 94.55 99.39 81.91 87.95 88.58 82.29 87.86 0.88
Performance of the
departments
Notes: Description *) 1. Economic ratio 2. Efficiency ratio 3. Effectiveness ratio 4. Number of Patient visits according to the
5. Patient satisfaction index 6. Employee satisfaction 7. Education and training balanced scorecard

satisfaction perceived by patients and their family. Lyons and Valentine (1997) states that
service and employee behavior are factors that are very influential on patient satisfaction.
The implementation of a survey to measure employee satisfaction at Dr Zainoel Abidin
Regional General Hospital has been set out in the hospital’s regulations and is undertaken
every year. This was done by distributing questionnaires to the employees of Dr Zainoel
Abidin Regional General Hospital. There were five indicators to measure employee
satisfaction: contentment with the job, relationships between employees, career
advancement (promotion), compensation/reward (incentives) and supervision from the
immediate superior. The average employee satisfaction can be measured by assigning a
score to the response indicated in the questionnaire in accordance with the level of perceived
satisfaction. The scores given are 1: very dissatisfied; 2: not satisfied; 3: neither satisfied nor
dissatisfied; 4: satisfied; and 5: very satisfied.
Results of a survey in 2015 conducted by the management of Dr Zainoel Abidin Regional
General Hospital by distributing questionnaires to employees generate the average
percentage of employee satisfaction by 82.2 per cent. Employees are said to be satisfied if the
JM2 average percentage is greater than 80 per cent. In most outpatient and inpatient
15,2 departments, the level of satisfaction of the employees exceeds the target by 75 per cent (the
employee satisfaction in 19 work units (82.2 per cent) is higher than 75 per cent, while the
employee satisfaction in 9 work units (11.8 per cent) is lower than 75 per cent). This means
that the employees of Dr Zainoel Abidin Regional General Hospital can be considered
satisfied with the performance of Dr Zainoel Abidin Regional General Hospital.
376 Kaplan and Norton (1996) states that it is vital for a business organization to pay attention
to its employees, monitor their welfare, and improve their knowledge because as knowledge
of the employees increases, their level of participation will also increase. In this research, the
activities analyzed were the frequency of education and training intended to develop human
resources in attainment of the three perspectives and objectives of the company.
Based on results of the research in relation to access to training and education using
secondary data, it is revealed that it is quite easy for employees of Dr Zainoel Abidin
Regional General Hospital to attend education and training activities intended for employee
development. This implies that the majority of employees working in the hospital stated
that the education and training activities they attended in 2014 did not meet the target by 50
per cent of the total employees of each work unit. According to the information presented in
the table, in 2015, more than 75 per cent of the employees in a total of 27 work units (71 per
cent) and less than 75 per cent of the employees in a total of 11 work units (29 per cent)
attended education and training activities. In general, the chance of employees to attend
education and training activities at the hospital is 82 per cent on the average.
Based on results of the interviews with the management of Dr Zainoel Abidin Regional
General Hospital, it is revealed that throughout 2014 and 2015, the number of training
activities/seminars it held which were useful for its employees remained inadequate, despite
their usefulness to help develop the abilities and skills of its employees. The higher the skills
owned by employees is, the better the quality of services provided is and, likewise, more
innovations can be made at Dr Zainoel Abidin Regional General Hospital so as to attract the
interest of many people to continue treatment in the hospital, even these innovations may
also attract new patients. The higher the number of patients and prospective patients is, the
higher the revenue of the hospital is, where the revenue itself will be reallocated to fund any
activities that support service provision activities at Dr Zainoel Abidin Regional General
Hospital such as conducting training/seminar for its employees and learning how to use the
latest and most sophisticated equipment and tools to support its service quality. In addition,
employees of the hospital also need to create comfort for both prospective patients and their
families by showing hospitality while providing service to them.
Furthermore, it is revealed that the total performance score using the approach of
balanced scorecard for Dr Zainoel Abidin Regional General Hospital is equal to 5.6 out of 7
performance parameters. Thus, the mean is equal to 5.6./7 = 0.80. Having obtained the mean,
the next step is to make a scale to assess the total score to determine whether the performance
of Dr Zainoel Abidin Regional General Hospital is “poor,” “fair” or “good.” By using the scale,
the performance of Dr Zainoel Abidin Regional General Hospital can be determined.
The results above illustrate that the majority of work units of the inpatient department at Dr
Zainoel Abidin Regional General Hospital, overall, based on results of the performance
appraisal using the approach of balanced scorecard, fall into the good category with a mean by
0.88, which is higher than 0.50, meaning that the performance of the work units of the inpatient
department fall into the good category. Nevertheless, there are two work units, namely, ICU
ward and the PICU ward, which generate a total performance score based on balanced
scorecard by less than 0.50. This means that the performance of the ICU Ward and the PICU
Ward of Dr Zainoel Abidin Regional General Hospital falls into the “fairly good” category.
6. Conclusion Balanced
Based on results of the analysis, it can be concluded that the overall results of the scorecard
performance appraisal using the balanced scorecard approach seen from the financial,
internal business, customer, and training and learning perspectives are good. Dr Zainoel
model
Abidin Regional General Hospital has provided good services and performance of its
departments have generated the expected outcome and is realized by the Hospital.
The research limitation lies in the variables under study, which relate to strategic
management and human resource management of the hospital (especially the
377
transformational leadership, organizational commitment, implementation of resource
uniqueness and performance) and financial management of the hospital (especially
implementation of business plans, budget and performance).

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Corresponding author
Ashiva Martunis can be contacted at: ashiva.uinaceh.jp@gmail.com

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