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The practice of the Balanced Scorecard in health care services

Beata Kollberg
Industrial Marketing, Department of Management and Engineering, Linkoping University, Linkoping, Sweden, and

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Received March 2010 Revised September 2010 Accepted October 2010

Mattias Elg
Quality Technology and Management, Department of Management and Engineering, Linkoping University, Linkoping, Sweden
Abstract
Purpose The purpose of this paper is to identify the main characteristics of the Balanced Scorecard (BSC) practice in health care services Design/methodology/approach The paper uses a case study approach focusing on three health care organisations in Sweden using the BSC. The focus is upon different management levels in a hierarchical branch in each organisation. Findings The paper concludes that the BSC is used as a tool for improving internal capabilities and supporting organisational development. More specically, the BSC is used as a tool by management and employees in discussions, information dissemination, knowledge creation, follow-up and reporting processes. Instead of using the BSC as a tool to implement and communicate strategy formulated by management it is used as a tool for opening up the organisation and providing a foundation for an improvement dialogue, which consequently increases the demands on management. Research limitations/implications The paper contributes to changing the focus in existing research away from the design and construction of the BSC towards its use in managerial work. Practical implications The paper emphasises important aspects in using the BSC in a health care context that will help managers in improving performance measurements. Originality/value The paper shows that the use of the BSC includes several aspects, such as the purpose of the system, implementation process, actions taken and the expected contribution. Keywords Balanced Scorecard, Performance measures, Health care, Case studies, Health services, Sweden Paper type Research paper

Introduction The Swedish health system has, during the last decade, experienced an extensive reorganisation involving cost reduction, downsizing and decentralisation initiatives. In order to improve the follow-up process from the units and to focus the organisation on measures other than economic measures, several county councils have started implementing the Balanced Scorecard (BSC). Even though the BSC prevails as the dominant performance measurement system in private industry (Bhagyashree et al., 2006) and the number of case studies reported in the context of health care has
The authors gratefully acknowledge help and insightful comments from Assistant Professor Johan Holtstrom, Linkoping University.

International Journal of Productivity and Performance Management Vol. 60 No. 5, 2011 pp. 427-445 q Emerald Group Publishing Limited 1741-0401 DOI 10.1108/17410401111140374

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increased (Kollberg and Elg, 2006; Schmidt et al., 2006; Kocakulah and Austill, 2007; Chan, 2009, Aidemark and Funck, 2009) practitioners have nevertheless started questioning its usefulness and effects in regard to managerial work. This article discusses several aspects in using the BSC in work practice in order to support health care managers in improving performance measurement. Many authors in the performance measurement eld seem to be technically focused in the sense that they are occupied in the study of measure construction and the design of performance measurement systems (see, for example, Toni and Tonchia, 2001; Tangen, 2004; Courty et al., 2006). In addition, authors seem to focus upon developing and promoting prescriptive models of performance measurements (see, for example, Kaplan and Norton, 2001; Neely et al., 2002; Olve et al., 2003), which often draw attention away from the implications of these frameworks in work practice. Hence, the overall encompassing problems for managers of how to effectively realise and implement performance measurement systems in their own contexts has been overlooked in research. The purpose of this paper is to identify the main characteristics of the BSC practice in health care services. The research question of interest derived from this purpose is: how are public health care organisations using the BSC in their work practice? In Kollberg and Elg (2006) we explored the use of the BSC in health care by describing the use from different angles. This paper extends the aim of the previous work by identifying the specic characteristics of the BSC practice that may explain the use in the health care context. The research is based on three case studies conducted in 2002-2004, which are presented in Kollberg (2003), Elg and Persson (2003) and Kollberg (2004). During the last decade there have been a growing number of publications on the implementation of performance measurement systems (Bourne et al., 2000; Kaplan and Norton, 1996; Radnor and Lovell, 2003). This study focuses on the latter part of the implementation process by analysing how the BSC is being used in work practice (see also Elg, 2001; Bititci et al., 2002; Zelman et al., 2003; Aidemark and Funck, 2009); it aims to contribute to widening the use perspective by including aspects such as the purpose of the system, measures, implementation process, actions taken and the experienced contribution. In order to familiarise the reader with the health care context we briey describe the Swedish public health care services in the following section before presenting the theoretical framework used for analysing the practice of the BSC in health care. The authors methodological considerations are then presented and discussed, followed by an examination of the case study results in relation to existing theories and prior research. Finally, we draw some conclusions and discuss the managerial implications. The empirical context Health care organisations are often described as professional organisations in which the medical profession has the main inuence on health care (Mintzberg, 1993; Etzioni, 1966). According to Ouchi (1979), health care organisations rely heavily on ritualised, ceremonial forms of control, which makes measurement of individual performance hard to accomplish. The health care organisation can be described on the basis of three domains (Kouzes and Mico, 1979): (1) the policy domain; (2) the management domain; and (3) the service domain.

Each domain operates on different and contrasting principles, success measures, structural arrangements, and work modes, and they can be seen as conicting with each other. Ostergren and Sahlin-Andersson (1998) take a similar approach and describe the health care organisation as three separate worlds: (1) the professional; (2) the administrative; and (3) the political. Furthermore, Wikstrom (2006) describes the complex leadership in health care services as separate and hierarchical logics, including the administrative logic, strategic logic and employee logic. According to Gustafsson (1987), Swedish health care is characterised by an inherent conict derived from the meeting of the strong, traditional control of the professional hierarchy and the relatively new administrative management. The differing domains, logics or worlds have different demands when it comes to management control and how to measure performance. The health care system in Sweden is highly decentralised compared to other countries (SKL, 2005) as health services are nanced and managed by the 20 county councils and regions and 290 municipalities within their respective areas. However, the Swedish government and parliament have the main responsibility for health policy on a national level. Over the years the state has gradually shifted nancial and provider responsibilities to the county councils and the municipalities, resulting in greater decentralisation. The Adel Reform of 1992, which can be seen as a major step towards decentralisation, gave municipalities the statutory responsibility for elderly and disabled citizens (Henriksen, 2002). Today, services related to residential care, excluding physician services, are managed by municipalities, and municipalities can also enter contracts with county councils to provide home care. Swedish health care services are mainly tax-nanced, through county and municipal taxes. The county councils also charge patient fees, accounting for 2.7 per cent of their revenues (SKL, 2005). Between them the county councils and municipalities are the main providers of health care: private providers deliver approximately 10 per cent of all health services. All counties can contract with private providers, and this is mainly done within primary care. Swedish health care is relatively unied compared to other countries, with county councils and municipalities serving as nanciers and dominant providers. Theoretical framework The following sections discuss how BSC is dened in the literature and looks at recent studies in the eld of performance measurement. We also discuss and identify from a theoretical perspective important aspects in the analysis of the practice of the BSC. The Balanced Scorecard In 1992 Robert S. Kaplan and David P. Norton introduced the Balanced Scorecard (BSC) in order to provide organisations with the opportunity to balance their nancial measurements with non-nancial measurements (Kaplan and Norton, 1992). In addition, the BSC is intended to provide executives with a comprehensive framework that translates the companys vision and strategy into a coherent set of performance measurements (Kaplan and Norton, 1993, 1996). Accordingly, the objectives and

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measures on a BSC should be derived from the organisations vision and strategy so as to become a new tool for managing strategy (Kaplan and Norton, 2001). Research on performance measurement systems, such as the BSC, has mainly focused on the design of different types of performance measurement systems (see, for example, Neely et al., 1995, Kaplan and Norton, 1996, Neely et al., 1997, Bititci et al., 1997, Olve et al., 1997). In this research area measurement frameworks are said to require specic key characteristics in order to help organisations to identify an appropriate set of measures to assess their performance (Kennerley and Neely, 2002). For instance, performance measures should be derived from strategy (Anthony and Govindarajan, 2001; Neely et al., 1995), monitor a balanced picture of the organisation (Kaplan and Norton, 1992; Keegan et al., 1989), be multi-dimensional in such that they reect all areas of performance (Epstein and Manzoni, 1997), encourage congruence of goals and actions (Epstein and Manzoni, 1997; Bititci et al., 1997), and monitor past and future performance (Fitzgerald and Moon, 1996, Olve et al., 2003). During the last decade there have been a growing number of publications on the implementation of performance measurement systems (Bourne et al., 2000, Radnor and Lovell, 2003). Even more recently the increased use of performance measures in managerial work has led to in-depth research in how organisations deal with these measurements and use the information collected (Elg, 2001, Bititci et al., 2002, Zelman et al., 2003, Kollberg, 2007, Aidemark and Funck, 2009). The attention has moved from verifying that measurements are used in management teams to analysing how measurements are being used to support management control. The practice of the BSC in health care From the literature we have identied several aspects that are important in the investigation of the practice of the BSC in health care. First, it is relevant to understand the purpose for which organisations implement the BSC. The literature indicates that the BSC primarily serves as a system to improve health care quality (Funck, 2009), and support long-term survival (Zelman et al., 2003). However, it also seems to be used as a system to reduce goal uncertainty in the organisation (Aidemark, 2001), enhance customer focus (Rahm et al., 2002) create a common language on how to improve health care (Hallin and Kastberg, 2002), and support strategy implementation (Atkinson, 2006). The former aims to monitor organisational outcomes and correct faults from standards of performance and thereby ensure the achievement of organisational strategies and goals, while the latter aims to dene, communicate, and reinforce basic values, purpose, and direction for the organisation in order to encourage opportunity-seeking behaviour. Second, we analyse the measures included in the BSC. According to Kaplan and Norton (1996), the BSC should include a wide range of performance measures in order to represent all dimensions of the organisation. In a health care context, the BSC takes into account patients, health care processes and professional staff learning, a process reinforces a move from traditional, bureaucratic control (Aidemark, 2001). The multi-dimensional thinking promoted in the BSC is also emphasised by Andersson et al. (2000). In health care it is essential to measure and follow-up medical activities (e.g. number of diagnoses, operations and treatments, time for care and the patients physical status) as well as administrative activities (e.g. efciency, rationality, productivity, conformity, waiting times and care times, economic measures).

The implementation process of the BSC is another important aspect in this study. In particular we are interested in identifying the central factors that have made people use the BSC. Chavan (2009) presents a case study of Australian organisations implementing the BSC and concludes that the approach may require changes in the organisational culture. BSC furthermore requires understanding, commitment and support from not only the top management but all the people in the organisation. Othman (2006) suggests that successful implementation of the BSC requires that organisations develop and communicate a causal model of their strategy. Based on a case study at a medical clinic in Sweden over a period of ten years, Aidemark and Funck (2009) identify three explanatory factors for the sustainability of the BSC: (1) decentralisation of the measures within the process perspective; (2) the management interest, demand and support of the BSC; and (3) the exibility of the design and use of the BSC. Based on a literature review, Zelman et al. (2003) conclude that the BSC is a relevant framework, but emphasise the importance of modifying the concept to t the organisations own conditions. Rahm et al. (2002) also emphasize that the BSC should be developed and adapted in local departments in order to succeed with the implementation. Finally, we are interested in analyzing the actions taken based on the information from the BSC. Bhagyashree et al. (2006) nd that the BSC is the dominant performance measurement system in industry, but that implementations often fail due to difculties in translating the measurements into concrete action. In this study we focus on two parts: (1) who is taking action; and (2) the type of actions (such as strategy reformulation, improvement initiatives, discussions or information dissemination). In this respect it is also interesting to understand perceptions of the contribution of the BSC. Empirical studies have identied several contributions, such as reduced goal uncertainty (Aidemark, 2001), improved communication processes (Aidemark, 2001; Hallin and Kastberg, 2002; Rahm et al., 2002), increased consensus about the health care goal (Aidemark, 2001), increased customer focus (Rahm et al., 2002), and encouraging politicians, professionals and administrators to focus on the whole organisation instead of its parts. Based on a literature review Funck (2009) suggests six functions of the BSC: (1) management control; (2) strategic management tool; (3) information and communication tool; (4) quality management tool; (5) benchmarking tool; and (6) complementary budgeting tool. Table I summarises important aspects in analysing the BSC in practice and presents specic questions for the analysis.

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Aspect Purpose

Analysis question Is the purpose of the BSC: To dene, communicate, and reinforce basic values, purpose, and direction for the organisation? To monitor organisational outcomes and correct faults from standards of performance? Do the measures in the BSC emphasise patients, health care processes and/or professional staff? Do the measures reect the whole organisation, both administrative and medical activities? Which factors are important to consider in the implementation of the BSC? What actions are taken in the organisation based on the information from the BSC? Which people in the organisation are taking action? What contributions do people gain from using the BSC in their work practice?

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Measures Implementation Actions Contribution

Table I. Important aspects in the analysis of the BSC

Method This research project began in autumn 2001 and aimed to increase the knowledge of how the BSC was used in those health care organisations that have come far in its implementation. Since the BSC was a relatively new concept in the health care services at the time and had not been thoroughly investigated, a multiple and embedded case study design was selected as the research strategy (Yin, 1994). In addition, a multiple case study design may further enhance the transferability of results to other cases. Case selection The selection of suitable cases was primarily based on what could be learnt in relation to the purpose (Stake, 1994). In addition, three other criteria were considered in the selection process: (1) the design of the BSC included nancial and non-nancial measures derived from a vision and strategy and were categorised into perspectives originating from the framework by Kaplan and Norton (1992); (2) according to people familiar with the health care context, the BSC was used in the organisations; and (3) the organisations belong to different county councils in Sweden. The second criterion concerns the use of the BSC in the organisations. Kaplan and Norton (1996) suggest that it takes about 25-26 months for a company to make BSC a routine part within the management process, although depends very much on the organisations background, history and current situation. Therefore, people who are familiar with the health care context were questioned about organisations that had implemented the BSC. In addition, before selecting a case, managers in the organisations were asked if they made use of the BSC in their work. In order to facilitate the prediction of results in the comparative analysis, organisations with a focus on elective care were selected. The unit of analysis was identied as a hierarchical branch expecting to strive towards one vision in the organisation under study. The use of the BSC was studied with respect to the management levels in each branch organisation, which can be viewed as the embedded cases within the case.

Collection of data Case North was conducted in Spring 2002, Case Central in Autumn 2003, and Case South in Spring 2004. The same investigator looked at Cases North and South, while two other researchers dealt with Case Central. However, the fact that the cases were conducted over different periods in time and partly by the same investigator may affect the conrmability of the research (Bryman, 2001). However, we tried to put aside our personal values during the investigation and to focus primarily on the interviewees perceptions regarding the phenomena. In addition, we sought comment from other researchers outside the research group to give an outsiders perspective on the ndings. Interviews and documents were the major sources for data collection. A total of 34 1-1.5 hour interviews were conducted, with a tape recorder used in most of them; the investigator also took notes. The interview guide included several themes: . the interviewees professional background; . the design of the scorecard; . the implementation of the scorecard; and . the practical use of the scorecard. The interviewees were free to describe the BSC with respect to the themes during the interview. To ensure the interviewee focused on the subject, key questions were stressed within each theme. A model of the BSC used in the organisation was used during the interviews. The interviewees were selected on the basis of their position in the organisation and whether they had been working in the organisation since the introduction of the BSC. Table II shows the number of interviews and the positions of the interviewees. The most important documents in the analysis have been the representations of the BSC used as artefacts during the interviews to focus the discussion and clarify any obscurities. Other documents used were the annual reports of the county councils, a measurement document, budget plans, and the Swedish Quality Awards assessment report. Analysis of data In order to make the material accessible to others, the interviews were reprinted in full. The material from the interviews was coded by dividing it into different units that

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Case North Interviews Position 14 interviews 1 1 2 1 1 7 head of production unit head of department quality coordinators county director of nance head of care section employees

Case Central 12 interviews 1 1 1 1 2 2 3 head of department county director of nance head of hospital hospital controller administrators heads of care sections employees

Case South 8 interviews 1 2 1 1 3 head of centre coordinators head of department head of unit employees

Table II. Number of interviews and the interviewees positions in each case

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were denoted with codes derived from the core of the unit. The units were categorised in each interview into the themes that were used in the interview guide. Thereafter the units were categorised into sub-themes. Documents were reviewed and analysed as the interviews commenced. Visions, strategic goals, critical success factors, goals, measures, targets, and action plans were identied as design elements included in the BSC literature, and were taken into account when reviewing the documents. Since these documents were then used during the interviews, we complemented our own review with the interviewees stories in order to conduct further analysis. We could then critically review the material by emphasising differences between our own presentation based on literature, and the comments from the interviewees. The cases were analysed separately and lengthy descriptions of each case were written (Elg and Persson, 2003; Kollberg, 2003, 2004). The cross case analysis aimed to compare the results by identifying common patterns in the three cases. Five factors were analysed: the purpose of the BSC, the measures, the implementation process, actions taken upon the BSC information and experienced contribution. Results The following section presents the ndings from the case study. Case North The following case concerns a hierarchical organisation at a university and research hospital in Sweden (also presented in Kollberg, 2003). The organisation belongs to a county council serving a population of about 420,000 people with health care. The use of the BSC is studied on three management levels: (1) production unit management level; (2) department management level; and (3) section level. The production unit is one of ten units in the hospital and employed, at the time of this study, 702 people. The main focus is on the diagnostics and treatment of tumour diseases according to approved rules and regulations. In total, 11 clinical departments belong to the production unit. The department represented in this research employs 75 people organised into ve outpatient sections and one inpatient section. The interviews show that the BSC is mainly used to plan future events, in discussions in management groups and to disseminate information both within and without the organisation. At the production unit, planning occurs once a year in the quality steering group. The BSC is then approved and discussed in the management group. At the department level, the content of the BSC is discussed frequently during management meetings and the discussions mainly revolve around the construction of measurements, their validity and reliability. At the beginning of each year, the management team in the department reviews the measures and action plans from the different sections in relation to the goals set in the BSC. The BSC at the department level is also used during department meetings to present the departments result and future direction. The departments scorecard is also used during forums and seminars aimed at presenting the departments status to external stakeholders.

The BSC at the production unit and department level is divided into ve perspectives: (1) patient/customer perspective; (2) process perspective; (3) development/future perspective; (4) employee perspective; and (5) production/economic perspective. Within each perspective key performance measures are specied, for example the number of employees participating in development work (employee perspective), the number of patients that start treatment within one week (process perspective), the number of patients receiving care within three months (customer perspective), the number of main processes specied (development/future perspective), and medication costs in institutional care (production/economic perspective). The departments BSC is passed onto eight sections, each of which is expected to develop its own scorecard, which includes a yearly action plan, measures and goals. In addition, employees are obliged to ll out project plans for each action in the scorecard. All sections report their results from three perspectives: (1) the customer perspective; (2) the process perspective; and (3) the employee perspective. The sections report most key measures in the customer perspective, indicating an emphasis on this perspective on the section level. The measures in the economic perspective dominate the discussions on the production unit and department level. Employee measures are also discussed to a large extent on the department management level. Case Central This case (also presented in Elg and Persson, 2003) takes as its starting point a hierarchical organisation that for the time of this study had practised the BSC for six years. The use of the BSC is studied on four management levels: (1) county council level; (2) hospital management level; (3) department management level; and (4) section level. The county council provides about 330,000 people with health care services and has three hospitals. The hospital in focus of this research employs about 1,500 people in 20 departments and units. About 240 employees work at the department of interest, which is divided into six sections. The scorecards link various management levels in several ways, including meetings in the hierarchy in which common performance measures are discussed. A top-down approach with goal deployment, emphasised by proponents of BSC, is found in some of the perspectives and related to some performance measures, but all in all, the BSC is viewed more as a communication tool rather than one for goal deployment.

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The purpose of using the BSC, as described by the interviewees, is not clear and unambiguous. Rather, many different aspects are discussed and elaborated on by the respondents. The BSC seems to shift focus from economic values to other important areas to manage and develop. Other aspects presented include feedback on performance, a wider view of what it means to manage a health care organisation, personal development and career (people working with BSC can go to conferences, participate in activities outside the own unit), and better coordination of organisational units. Four perspectives nance, process/productivity, customer/patient and learning are represented in the scorecard. In each perspective several performance measures are presented, such as number of patients expected to wait more than one month for treatment (process/productivity perspective), patient satisfaction (customer/patient perspective), number of training days for professionals (learning/innovation perspective) and lab costs (nance perspective). All perspectives are equally evaluated in discussions on the different management levels. Before the introduction of the BSC the nancial measures were emphasised in the discussions. The BSC provides the managers with a spectrum of different measures that increase their understanding of the processes. Elg and Persson (2003) conclude that the structure of the visual display of the BSC has an important impact on how discussions, analyses and decision making actually take place. For example, the BSC not only functions as a tool for assessments of organisational functioning, but also as a tool for structuring meetings: the agenda is in the diagram. The BSC also serves as a reporting instrument in which comments regarding various measurements are written directly on the measures. In general, respondents at all levels of the organisation trust in such a method for reporting information. Case South This case study was conducted in a health care organisation belonging to a university hospital in Sweden providing about 1.7 million people with specialised health care services (also presented in Kollberg, 2004). The hospital comprises eight centres and the BSC is studied on three management levels: (1) centre management level; (2) department management level; and (3) unit level. At the time of this study, the centre employed about 700 people and was organised into ve departments identied on the basis of different groups of diseases. Four care units, two intensive care units, one surgery unit, one health unit and four outpatient units comprised the centre. The centre had practised the BSC for four years at the time of the study. The interviews show that the BSC is used for different purposes in the organisation. Management uses the system to receive information about the organisations activities and to spread information among the employees. The BSC is also used as a source of information in discussions between people, i.e. during staff meetings and introductions for new employees. Managers at the three organisational levels do not review the BSC on a regular basis, but whenever they experience a need to increase their knowledge.

For instance, the head of unit uses the BSC to receive concrete measures on what employees feel and experience. The BSC at the top management level includes ve perspectives: (1) nancial; (2) process; (3) employees; (4) innovation and development; and (5) customer. Within each perspective the management has developed strategic objectives taking the vision as a starting point. The overall scorecard for the centre is based around the departments and units. The BSC on the centre level includes about 25 measures, such as customer satisfaction (customer perspective), medication costs (nancial costs), the number of management decisions implemented (process perspective), the personnel turnover (employee perspective), and the number of people in continuous improvement training (renewal and innovation). The measures in the process perspective seem to receive great attention from the management teams. However, the head of the centre has seen an increased interest in employee measures in the organisation, while measures capturing the innovation capability and customer perspective are more difcult to identify. The departments management focuses primarily on input measures and waiting times in the process perspective, since these indicate how the production varies over time. Financial measures are also of great interest. The main focus at the unit level is on process and employee measures. Table III depicts a summary of the case ndings. Discussion Above we have presented how three health care organisations make use of the BSC in practice in different ways. As Table III shows, there are several similarities between the organisations. The following discussion focuses on these similarities by taking ve aspects as a starting point: (1) purpose; (2) measures; (3) implementation; (4) actions taken; and (5) contribution experienced. The cases show that the BSC is used for different purposes. In all three cases the use of the BSC aims to create a structure for different occasions. Case North uses the structure to make the strategic direction clearer, Case Central to structure management meetings, and Case South uses the structure to make the strategies of the new organisation more comprehensive. These ndings indicate that the BSC functions as a system to spread and communicate the vision, strategies and values of the organisation. Other studies have also shown that a BSC may function as a value system when applied to a health care context (Aidemark, 2001; Hallin and Kastberg, 2002; Rahm et al., 2002; Atkinson, 2006). In addition, we found that the BSC aims to follow-up and report results to

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Aspect To improve communication within the organisational hierarchy To enable organisational improvement and development To create a structure of management meetings Measures in four perspectives 21 measures for the department level Relations with different levels in the organisation and with actors outside the organisation Perseverance Change agents support employees Prior knowledge from quality management Managers use the BSC: To report results to superiors For discussions of improvement efforts To disseminate information Employees use the BSC: In discussions between professionals and in teams For yearly planning Increased coordination between units Wider view of what it means to lead an organisation Personal development

Purpose

Measures

Implementation

Actions

Contribution

Table III. Summary of case study Case Central Case South To create a clear structure and direction for a new organisation To consider the values of the employees and their working situation Measures in ve perspectives 25 measures for the centre level Identication of a need to change Change agents involve and support employees in using the BSC High involvement of employees IT support providing people with reliable and fast data Managers use the BSC: To receive information about the organisation when needed To disseminate information In discussions with employees Employees use the BSC: To receive information and knowledge about the organisation Increased interest in employees working situations Increased employee participation in development activities Improved structure in managerial work

Case North

To enable follow-up and reporting of results To create a clear structure for the strategic direction

Measures in ve and three perspectives 15 measures for the department level

High involvement of employees in an early stage Change agents involve and support employees in using the BSC Adaptation of terminology in the BSC Prior experience from quality management

Managers use the BSC: To report results to superiors To follow-up yearly results For yearly planning To disseminate information Employees use the BSC: In discussions between professionals and in teams For yearly planning

Improved orderliness and structure in managerial work Increased understanding of the work among employees Increased participation

superiors in order to improve performance in accordance to a standard or target. Case North uses the BSC regularly to report outcomes to management and Case Central uses the BSC to enable improvement and development of the organisation. Thus, the purpose of the BSC in these cases seems to be to improve and follow-up performance towards a specic target. This resembles the ndings from other studies (see, for example, Zelman et al., 2003, Funck, 2009). Finally, ndings in Case South show that the BSC also serves as an interactive system by which the management can increase their understanding of the employees situation and their values. The scorecards include a wide range of measurements structured in three to ve perspectives. Measures focusing the performance of medical treatment and health care, such as number of patients with correct diagnosis and number of care occasions, seem to dominate the process perspective. Cycle times and waiting time for treatment are also found as a measure in all the cases. However, there are also measures missing in the scorecards that have gained great national attention last years and are critical in the management of health care. For example, measures regarding patient safety, such as number of care related infections, hygiene routines and prevention programs, are not part of the BSC systems indicating that the validity of the picture presented by the BSC may be questioned. The ndings indicate that the BSC may be of interest for different stakeholders in the health care organisation. Physicians may focus the medical performance in the process perspective in order to improve health care quality; administrators, such as clinic management, may focus their attention on economic measures and customer satisfaction indexes in order to control the clinic in the most efcient way. The present case study shows that the management uses the BSC to increase their understanding of the organisation by not merely focusing on the nancial measures. Even though the nancial perspective still dominates the discussions in various management teams the ndings show that the BSC has provided a more balanced picture of performance in the cases. Hence, in common with prior studies (see, for example, Andersson et al., 2000) it seems as the BSC as a multi-dimensional measurement tool serves the medical and administrative staff with useful information from different perspectives. Focusing on the implementation of the BSC the results elucidate several important factors. One prominent factor in all cases is the importance of change agents in involving and engaging people in the BSC initiative. The change agents identied in these cases have a management position and a professional background in the clinical activity. They also have a genuine interest and knowledge in the techniques of the BSC, which is either received through education, self-studies or relations with other clinical organisations. Another important factor prominent in Cases North and South is the high involvement of employees in the implementation. Case North informed employees during an early stage of the implementation and let all sections design their own scorecards. In Case South the top management arranged seminars with all employees and the department management ensured people came up with improvement suggestions and encouraged feedback loops. This level of high involvement may be an explanation why the adaptation and adjustment of the BSC to the current conditions have been so common among the studied organisations. When people become involved in changes and see that they can inuence process and outcome, they also attach meaning to implemented concepts (Weick et al., 2005, Funck, 2009). In Case North the adaptation of terminology to the concepts used in the organisation helped people more

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easily accept the BSC. The adaptation in Case Central saw managements perseverance in the implementation and let the acceptance take time. The BSC in Case South was introduced after having identied a need to change which also can be viewed as a way of adaptation since the management takes the current situation and its needs as a starting point. Another major factor identied in the material is the organisations prior experience from quality management. Two of the three cases have experience of using the Swedish Quality Award, and this use has enabled the adaptation and acceptance of the BSC terminology, the thinking in terms of goals and measurements. However, the fact that the organisation in Case South lacks quality management experience indicates this experience is not a pre-requisite for using the BSC. The next aspect deals with the actions taken based on the information in the BSC. The most prominent application of the BSC for managers is to disseminate information to people both within and outside the organisation. This may be an additional indication of the scorecards importance in understanding the organisation. The structure divided into perspectives is easy to understand and recognise, and provides people with a unied picture of the organisation. The BSC is also used as a foundation in discussions between management and employees, between professions and within teams in the organisations. It provides the foundation for a dialogue about improvement efforts, a nding that is supported in the BSC literature (Kaplan and Norton, 1996; Olve et al., 2003). The main difference in the use of the BSC in the three cases concerns the use of the BSC as a follow-up and reporting system. Whereas in Cases North and Central the BSC supports reporting results to superiors and following up the activities on a regular basis, Case South uses the BSC to receive knowledge and information when it is needed for internal affairs. An explanation for this difference may be found in the implementation of the BSC. In both Case North and Case Central the BSC has been implemented as a reporting tool for the entire hospital and the organisations frequently followed up and reported their results to the hospital management. In Case South on the other hand, the BSC was introduced as a way of improving internal effectiveness and enabling the organisational change. This shows that how people make use of the BSC largely depends on the initial purpose of its introduction. Finally, the ndings indicate that the BSC mainly contributes to improved structure in managerial work. In Cases North and South people experience an enhanced structure when managing the organisation and in Case Central the BSC has led to an increased understanding of what is meant by managing and leading an organisation. In addition, the interviews show that people experience a contribution to the employees working conditions and engagement in improvements. People experienced an increased understanding and engagement into improvement work as the BSC was being implemented. Thus the BSC may be viewed as a way of moving the power of knowledge about improvement initiatives from top management down to the employees, which may increase employees inuence on management decisions. Conclusions The purpose of this paper was to identify the main characteristics of the BSC practice in health care services. Three health care organisations that have come far in the implementation and are using the BSC in their daily management were investigated.

We aimed to explore one central research question: how are public health care organisations using the BSC in their work practice? Research-based knowledge about BSC is in itself an important and well-established area of research. Much research in this area has been devoted to the meaning of the concept Balanced Scorecard in itself (Aidemark, 2001), but also to how the relationships between the concept and practice can be understood and managed (e.g. Funck, 2009). On the basis of our ndings in the three cases it is possible to distinguish some key features in the practice of Balanced Scorecard in Swedish healthcare organisations. The notion of balanced has several meanings in this respect. Balancing perspectives In what ways does the BSC balance the differing perspectives in the health care organisations studied here? There are two mechanisms that are of interest here. First, the goal of public-nanced Swedish health care is good health care given to citizens on equal terms. This goal is unbalanced with the underlying assumptions in the original use of BSC, which emphasise that the ultimate goal is to provide value for shareholders. Thus, for practitioners within Swedish health care organisations, nancial aspects are just one out of several perspectives that contribute to an overall aim to provide good health care. Also, in this respect the decentralisation of health care and the autonomy of the various county councils may further support the introduction of a common information system, such as BSC, in order to highlight different perspectives. This further enables comparisons between counties and contributes to make health care more transparent to citizens. Thus, the balance of perspectives does not only concern the various clinics in a hospital, but is also interesting on an over-all national level. Balancing organisational roles The structure of the health care organisation as a professional organisation with various stakeholders with different roles and views on health care indicates a need to nd an instrument that reects and communicates the performance in all these domains. In this sense, the practice of BSC seems to open up avenues for traditionally weak voices to be heard. The views and opinions of nurses and medical secretaries become more visible in the organisations as the BSC is practised. In addition, the BSC is, in the cases studied, not only a tool limited to the management group, which is often emphasised by its advocates, but is also a tool for improvements and knowledge creation on an operational level. This leads to increased openness, since knowledge of the activities is disseminated inside and outside the organisation. Consequently, this openness implies increased demands on the management to make good, viable and well-established decisions based on measurable facts. Thus, instead of using the BSC as a tool to implement and communicate strategy formulated by management, as suggested by Kaplan and Norton, in health care it is used as a tool for opening up the organisation and providing a foundation for an improvement dialogue, which consequently increases the demands on management. Consequently, the practice of BSC seems to balance different organisational roles when applied in a health care context.

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Balancing improvement activities In line with the previous mechanism, we conclude that the BSC is used as a tool for improving internal capabilities and supporting organisational development. More specically, the BSC is used as a tool by management and employees in discussions, information dissemination, knowledge creation, follow-up and reporting processes. It provides the organisation with a structure that increases the understanding and meaning of improvements in the organisation and emphasises the need of different improvement initiatives. Due to the fact that the BSC helps to focus the organisation on performance improvements, we suggest that the BSC can be viewed as a quality management tool when used in public health care. The historical background and experience of the organisations have also an impact on the use of the BSC. Two of the cases have had prior experiences from quality management through, for example, the Swedish Quality Award, which means that they had identied areas of improvements and established measurement and follow-up processes with goals and targets before the BSC was introduced. This may have affected the adaptation of the BSC to become a supportive information framework rather than a tool for strategy implementation. Managerial implications Regarding what is needed to make use of the BSC in a health care context, we would like to emphasise the importance of having committed people involved in the BSC implementation full-time. Change agents have been shown to play a signicant role in other kinds of change initiatives as well, and their trust, motivation and knowledge of the BSC and the clinical activities are valuable features in making people accept the new concept. In addition, we suggest that there should be a high level of employee involvement in the early stages of BSC implementation, since without this engagement the quality of the measures reported can be questioned as people do not know why the system has been implemented. If the measurements are not correctly registered and performed the main point of the BSC is lost, whether the aim is to implement strategy or to improve quality. This view somewhat contradicts that advocated by Kaplan and Norton, who argue that the BSC should be implemented top-down by management. Limitations of the study The discussion above brings out some specic contextual features that may explain the practice of the BSC in public health care. Since qualitative case studies focus on the uniqueness in a specic context and the meaning of a specic aspect of social reality (Denzin and Lincoln, 2001), the primary aim of this study is not to draw generalising conclusions that are valid in all contexts and organisations. However, in order to increase the transferability of the results to other context, we have tried to specify how the cases are typical and unique and thereby selected for this study. In addition, detailed descriptions of each case are also provided in order to help the reader to translate the results to his or her own context. Finally, the investigation of several cases makes the study more robust than just studying a single case, which further increases the chance to generalise the results to other cases. Based on this discussion, the results are primarily valid for public health care organisations in Sweden with focus on elective care. However, public health care organisations in other countries with similar structures as the one investigated may also gain valuable knowledge from the ndings.

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