See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/235253278

The practice of the Balanced Scorecard in health care services

Article  in  International Journal of Productivity and Performance Management · June 2011

DOI: 10.1108/17410401111140374

CITATIONS READS

40 1,470

2 authors, including:

Mattias Hans Elg

Linköping University
55 PUBLICATIONS   690 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Healthcare Service Research View project

Competence in Quality Management View project

All content following this page was uploaded by Mattias Hans Elg on 29 April 2016.

The user has requested enhancement of the downloaded file.

International Journal of Productivity and Performance Management
Emerald Article: The practice of the Balanced Scorecard in health care
services
Beata Kollberg, Mattias Elg

Article information:
To cite this document:
Beata Kollberg, Mattias Elg, (2011),"The practice of the Balanced Scorecard in health care services", International Journal of
Productivity and Performance Management, Vol. 60 Iss: 5 pp. 427 - 445
Permanent link to this document:
http://dx.doi.org/10.1108/17410401111140374
Downloaded on: 28-06-2012
References: This document contains references to 54 other documents
To copy this document: permissions@emeraldinsight.com
This document has been downloaded 2255 times since 2011. *

Users who downloaded this Article also downloaded: *

Changiz Valmohammadi, Azadeh Servati, (2011),"Performance measurement system implementation using Balanced Scorecard and
statistical methods", International Journal of Productivity and Performance Management, Vol. 60 Iss: 5 pp. 493 - 511
http://dx.doi.org/10.1108/17410401111140400

D.R. Towill, P. Childerhouse, (2011),"Industrial engineering priorities for improved demand chain performance", International
Journal of Productivity and Performance Management, Vol. 60 Iss: 3 pp. 202 - 221
http://dx.doi.org/10.1108/17410401111111961

Marvin Soderberg, Suresh Kalagnanam, Norman T. Sheehan, Ganesh Vaidyanathan, (2011),"When is a balanced scorecard a balanced
scorecard?", International Journal of Productivity and Performance Management, Vol. 60 Iss: 7 pp. 688 - 708
http://dx.doi.org/10.1108/17410401111167780

Access to this document was granted through an Emerald subscription provided by

For Authors:
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service.
Information about how to choose which publication to write for and submission guidelines are available for all. Please visit
www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
With over forty years' experience, Emerald Group Publishing is a leading independent publisher of global research with impact in
business, society, public policy and education. In total, Emerald publishes over 275 journals and more than 130 book series, as
well as an extensive range of online products and services. Emerald is both COUNTER 3 and TRANSFER compliant. The organization is
a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive
preservation.
*Related content and download information correct at time of download.
 The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1741-0401.htm

BSC in health
The practice of the care services
Balanced Scorecard in health care
services
427
Beata Kollberg
Industrial Marketing, Department of Management and Engineering, Received March 2010
Linköping University, Linköping, Sweden, and Revised September 2010
Accepted October 2010
Mattias Elg
Quality Technology and Management,
Department of Management and Engineering, Linköping University,
Linköping, 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 specifically, 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., International Journal of Productivity
2006) and the number of case studies reported in the context of health care has and Performance Management
Vol. 60 No. 5, 2011
pp. 427-445
q Emerald Group Publishing Limited
The authors gratefully acknowledge help and insightful comments from Assistant Professor 1741-0401
Johan Holtström, Linköping University. DOI 10.1108/17410401111140374
IJPPM increased (Kollberg and Elg, 2006; Schmidt et al., 2006; Kocakülâh and Austill, 2007;
Chan, 2009, Aidemark and Funck, 2009) practitioners have nevertheless started
60,5 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 field seem to be technically focused –
428 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
specific 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 briefly 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 influence 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, BSC in health
structural arrangements, and work modes, and they can be seen as conflicting with care services
each other. Östergren 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
429
(3) the political.
Furthermore, Wikström (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 conflict 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 financed 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 financial and provider
responsibilities to the county councils and the municipalities, resulting in greater
decentralisation. The Ädel 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-financed, 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 unified compared to other countries, with county councils and municipalities
serving as financiers and dominant providers.

Theoretical framework
The following sections discuss how BSC is defined in the literature and looks at recent
studies in the field 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 financial
measurements with non-financial measurements (Kaplan and Norton, 1992). In
addition, the BSC is intended to provide executives with a comprehensive framework
that translates the company’s vision and strategy into a coherent set of performance
measurements (Kaplan and Norton, 1993, 1996). Accordingly, the objectives and
IJPPM measures on a BSC should be derived from the organisation’s vision and strategy so as
60,5 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
430 require specific 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
reflect 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 identified 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 define, 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 patient’s
physical status) as well as administrative activities (e.g. efficiency, rationality,
productivity, conformity, waiting times and care times, economic measures).
 The implementation process of the BSC is another important aspect in this study. In BSC in health
particular we are interested in identifying the central factors that have made people use care services
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 431
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 flexibility 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 fit the
organisation’s 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) find that the BSC is the dominant performance
measurement system in industry, but that implementations often fail due to difficulties
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 identified 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
specific questions for the analysis.
IJPPM
Aspect Analysis question
60,5
Purpose Is the purpose of the BSC:
– To define, communicate, and reinforce basic values, purpose, and direction
for the organisation?
– To monitor organisational outcomes and correct faults from standards of
432 performance?
Measures Do the measures in the BSC emphasise patients, health care processes and/or
professional staff? Do the measures reflect the whole organisation, both
administrative and medical activities?
Implementation Which factors are important to consider in the implementation of the BSC?
Table I. Actions What actions are taken in the organisation based on the information from the
Important aspects in the BSC? Which people in the organisation are taking action?
analysis of the BSC Contribution What contributions do people gain from using the BSC in their work practice?

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 financial and non-financial 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 organisation’s
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 identified 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 BSC in health
Case North was conducted in Spring 2002, Case Central in Autumn 2003, and Case care services
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 confirmability of the research (Bryman, 2001). However, we tried to put aside our
personal values during the investigation and to focus primarily on the interviewees’ 433
perceptions regarding the phenomena. In addition, we sought comment from other
researchers outside the research group to give an outsider’s perspective on the
findings.
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 interviewee’s 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 Award’s 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

Case North Case Central Case South

Interviews 14 interviews 12 interviews 8 interviews

Position 1 head of production unit
1 head of department
2 quality coordinators
1 county director of finance
1 head of care section
7 employees
1 head of department
1 county director of finance
1 head of hospital
1 hospital controller
2 administrators
2 heads of care sections
3 employees
1 head of centre
2 coordinators
1 head of department
1 head of unit Table II.
3 employees Number of interviews
and the interviewees’
positions in each case
IJPPM were denoted with codes derived from the core of the unit. The units were categorised
60,5 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
identified as design elements included in the BSC literature, and were taken into
434 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 findings 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 five 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
department’s result and future direction. The department’s scorecard is also used
during forums and seminars aimed at presenting the department’s status to external
stakeholders.
 The BSC at the production unit and department level is divided into five perspectives: BSC in health
(1) patient/customer perspective; care services
(2) process perspective;
(3) development/future perspective;
(4) employee perspective; and
(5) production/economic perspective. 435
Within each perspective key performance measures are specified, 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 specified (development/future perspective), and
medication costs in institutional care (production/economic perspective). The
department’s 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 fill 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.
IJPPM The purpose of using the BSC, as described by the interviewees, is not clear and
60,5 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,
436 participate in activities outside the own unit), and better coordination of organisational
units.
Four perspectives – finance, 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 (finance perspective). All perspectives are equally
evaluated in discussions on the different management levels. Before the introduction
of the BSC the financial 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
five departments identified 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 organisation’s 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 BSC in health
employees feel and experience. care services
The BSC at the top management level includes five perspectives:
(1) financial;
(2) process;
(3) employees; 437
(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 (financial 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
difficult to identify. The department’s 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 findings.

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 five
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 findings 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

Table III.
Summary of case study
Aspect Case North
Purpose To enable follow-up and reporting of
results
To create a clear structure for the
strategic direction
Measures Measures in five and three perspectives
15 measures for the department level
Implementation 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
Actions 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
Contribution Improved orderliness and structure in
managerial work
Increased understanding of the work
among employees
Increased participation
Case Central
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
60,5
438
IJPPM
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 five perspectives
25 measures for the centre level
Identification 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
superiors in order to improve performance in accordance to a standard or target. Case BSC in health
North uses the BSC regularly to report outcomes to management and Case Central uses care services
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 specific target. This resembles the findings from other studies (see, for
example, Zelman et al., 2003, Funck, 2009). Finally, findings in Case South show that
the BSC also serves as an interactive system by which the management can increase 439
their understanding of the employees’ situation and their values.
The scorecards include a wide range of measurements structured in three to five
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 findings 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 efficient 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 financial measures. Even though the
financial perspective still dominates the discussions in various management teams the
findings 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 identified 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 influence 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
IJPPM easily accept the BSC. The adaptation in Case Central saw management’s perseverance
60,5 in the implementation and let the acceptance take time. The BSC in Case South was
introduced after having identified 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 identified in the material is the organisations’ prior
experience from quality management. Two of the three cases have experience of using
440 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 scorecard’s importance in understanding the organisation. The
structure divided into perspectives is easy to understand and recognise, and provides
people with a unified 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 finding 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 findings 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’ influence 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 BSC in health
organisations using the BSC in their work practice? care services
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 findings in the three cases it is possible to distinguish 441
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-financed 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,
financial 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
find an instrument that reflects 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.
IJPPM Balancing improvement activities
60,5 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
specifically, 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
442 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 identified 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 significant 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 specific contextual features that may explain the
practice of the BSC in public health care. Since qualitative case studies focus on the
uniqueness in a specific context and the meaning of a specific 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 findings.
References BSC in health
Aidemark, L.G. (2001), “The meaning of Balanced Scorecards in the health care organisation”, care services
Financial Accountability and Management, Vol. 17, pp. 23-40.
Aidemark, L.G. and Funck, E.K. (2009), “Measurement and health care management”, Financial
Accountability & Management, Vol. 25, pp. 253-76.
Andersson, P.M., Persson, J.E. and Ramberg, U. (2000), “Balanced Scorecard i landsting:
erfarenheter från tolv projekt i region Skåne”, Institutet för ekonomisk forskning vid 443
Lunds universitet, Lund.
Anthony, R.N. and Govindarajan, V. (2001), Management Control Systems, McGraw-Hill, Boston,
MA.
Atkinson, H. (2006), “Strategy implementation: a role for the balanced scorecard?”, Management
Decision, Vol. 44, pp. 1441-60.
Bhagyashree, P., Margaret, R. and Victor, P. (2006), “Performance measurement systems:
successes, failures and future? A review”, Measuring Business Excellence, Vol. 10, pp. 4-14.
Bititci, U.S., Carrie, A.S. and McDevitt, L. (1997), “Integrated performance measurement systems:
a development guide”, International Journal of Operations & Production Management,
Vol. 17, pp. 522-34.
Bititci, U.S., Nudurupati, S.S., Turner, T.J. and Creighton, S. (2002), “Web enabled performance
measurement systems”, International Journal of Operations & Production Management,
Vol. 22, pp. 1273-87.
Bourne, M., Mills, J., Wilcox, M., Neely, A. and Platts, K. (2000), “Designing, implementing and
updating performance measurement systems”, International Journal of Operations &
Production Management, Vol. 20, pp. 754-71.
Bryman, A. (2001), Social Research Methods, Oxford University Press, New York, NY.
Chan, Y.-C.L. (2009), “How strategy map works for Ontario’s health system”, International
Journal of Public Sector Management, Vol. 22, pp. 349-63.
Chavan, M. (2009), “The Balanced Scorecard: a new challenge”, Journal of Management
Development, Vol. 28, pp. 393-406.
Courty, P., Heinrich, C. and Marschke, G. (2006), “Setting the standard in performance
measurement systems”, Public Management Review, Vol. 8, pp. 321-47.
Denzin, N.K. and Lincoln, Y.S. (2001), “Introduction – the discipline and practice of qualitative
research”, in Denzin, N.K. and Lincoln, Y.S. (Eds), Handbook of Qualitative Research, Sage
Publications, New York, NY, pp. 1-28.
Elg, M. (2001), Performance Measures and Managerial Work, Division of Quality Technology
and Management, Linköpings universitet, Linköping.
Elg, M. and Persson, B. (2003), “Svarta lådor”, organisatorisk utveckling och visualisering,
Division of Quality Technology and Management, Linköping University, Linköping.
Epstein, M.J. and Manzoni, J.F. (1997), “The Balanced Scorecard and tableau de bord: translating
strategy into action”, Management Accounting, Vol. 79, pp. 28-36.
Etzioni, A. (1966), Moderna organisationer, Aldusböcker, Stockholm.
Fitzgerald, L. and Moon, P. (1996), Performance Measurement in Service Industries: Making It
Work, The Chartered Institute of Management Accountants, London.
Funck, E.K. (2009), Ordination Balanced Scorecard – översättning av ett styrinstrument inom
hälso- och sjukvården, (Prescription Balanced Scorecard – Translation of a Management
Control Instrument in Health Care), Ekonomihögskolan, Växjö universitet, Växjö.
IJPPM Gustafsson, R.Å. (1987), Traditionernas ok – Den svenska hälso- och sjukvårdens organisering i
historie-sociologiskt perspektiv, Esselte Studium, Falköping.
60,5
Hallin, B. and Kastberg, G. (2002), Balanced Scorecard i teori och praktik. En flerdimensionell
styrmodell i hälso- och sjukvården, Göteborgs universitet, Göteborg.
Henriksen, E. (2002), Understanding in Healthcare Organisations – A Prerequisite for
Development, Faculty of Medicine, Uppsala Universitet, Uppsala.
444 Kaplan, R.S. and Norton, D.P. (1992), “The Balanced Scorecard – measures that drive
performance”, Harvard Business Review, Vol. 70 No. 1, pp. 71-9.
Kaplan, R.S. and Norton, D.P. (1993), “Putting the Balanced Scorecard to work”, Harvard
Business Review, Vol. 71 No. 5, pp. 134-42.
Kaplan, R.S. and Norton, D.P. (1996), “Using the Balanced Scorecard as a strategic management
system”, Harvard Business Review, Vol. 74 No. 1, pp. 75-85.
Kaplan, R.S. and Norton, D.P. (2001), The Strategy-focused Organization, Harvard Business
School Press, Boston, MA.
Keegan, D.P., Eiler, R.G. and Jones, C.R. (1989), “Are your performance measures obsolete?”,
Management Accounting, June.
Kennerley, M. and Neely, A. (2002), “A framework of the factors affecting the evolution of
performance measurement systems”, International Journal of Operations & Production
Management, Vol. 22, pp. 1222-45.
Kocakülâh, M.C. and Austill, A.D. (2007), “Balanced Scorecard application in the health care
industry: a case study”, Journal of Health Care Finance, Vol. 34, pp. 72-99.
Kollberg, B. (2003), “Exploring the use of Balanced Scorecards in a Swedish health care
organization”, Kvalitetsteknik, IKP, Linköpings universitet, Linköping.
Kollberg, B. (2004), Organisatorisk utveckling, implementeringsproblematik och IT-stöd, Division
of Quality Technology and Management, Linköping University, Linköping.
Kollberg, B. (2007), Performance Measurement Systems in Swedish Health Care Services,
Division of Quality Technology and Management, Linköping University, Linköping.
Kollberg, B. and Elg, M. (2006), “Exploring the use of Balanced Scorecards in Swedish health care
organizations”, Asian Journal on Quality, Vol. 7, pp. 1-18.
Kouzes, J.M. and Mico, P.R. (1979), “Domain theory: an introduction to organizational behavior in
human service organizations”, Journal of Applied Behavioral Science, Vol. 15, pp. 449-69.
Mintzberg, H. (1993), Structure in Fives: Designing Effective Organizations, Prentice-Hall
International, Englewood Cliffs, NJ.
Neely, A., Adams, C. and Kennerley, M. (2002), The Performance Prism, Prentice-Hall, London.
Neely, A., Gregory, M. and Platts, K. (1995), “Performance measurement system design: a literature
review and research agenda”, International Journal of Operations & Production
Management, Vol. 15, pp. 80-116.
Neely, A., Richards, H., Mills, J., Platts, K. and Bourne, M. (1997), “Designing performance
measures: a structured approach”, International Journal of Operations & Production
Management, Vol. 17, pp. 1131-52.
Olve, N.G., Petri, C.J., Roy, J. and Roy, S. (2003), Making Scorecards Actionable, Wiley, Stockholm.
Olve, N.G., Roy, J. and Wetter, M. (1997), Balanced scorecard i svensk praktik, Liber, Malmö.
Östergren, K. and Sahlin-Andersson, K. (1998), Att hantera skilda världar, Landstingsförbundet,
Stockholm.
Othman, R. (2006), “Balanced Scorecard and causal model development: preliminary findings”, BSC in health
Management Decision, Vol. 44, pp. 690-702.
Ouchi, W.G. (1979), “A conceptual framework for the design of organizational control
care services
mechanisms”, Management Science, Vol. 25, pp. 833-48.
Radnor, Z. and Lovell, B. (2003), “Success factors for implementation of the balanced scorecard in
a NHS multi-agency setting”, International Journal of Health Care Quality Assurance,
Vol. 16/2, pp. 99-108. 445
Rahm, C., Henriks, G. and Skreding, M. (2002), Insiktsboken – en skrift om ett nätverk som arbetar
med Balanced Scorecard, Landstingsförbundet, Stockholm.
Schmidt, S., Bateman, I., Breinlinger-O’Reilly, J. and Smith, P. (2006), “A management approach
that drives actions strategically: Balanced Scorecard in a mental health trust case study”,
International Journal of Health Care Quality Assurance, Vol. 19, pp. 119-35.
Stake, R.E. (1994), “Case studies”, in Denzin, N.K. and Lincoln, Y.S. (Eds), Handbook of
Qualitative Research, Sage Publications, New York, NY, pp. 435-54.
Tangen, S. (2004), “Performance measurement: from philosophy to practice”, International
Journal of Productivity and Performance Management, Vol. 53, pp. 726-37.
Toni, A.D. and Tonchia, S. (2001), “Performance measurement systems – models, characteristics
and measures”, International Journal of Operations & Production Management, Vol. 21,
pp. 46-71.
Weick, K.E., Sutcliffe, K.M. and Obstfeld, D. (2005), “Organizing and the process of
sensemaking”, Organization Science, Vol. 16, pp. 409-21.
Wikström, E. (2006), “Ledarskap i vårdpraktiken – hierarki och dialog”, in Brorström, B. and
Larkö, O. (Eds), HEL – Hälso- och sjukvårdens ekonomi och logistik, Göteborgs universitet,
Göteborg.
Yin, R.K. (1994), Case Study Research: Design and Methods, Sage Publications, London.
Zelman, W.N., Pink, G.H. and Matthias, C.B. (2003), “Use of the Balanced Scorecard in health
care”, Journal of Health Care Finance, Vol. 29, p. 1.

About the authors

Beata Kollberg is a Research Fellow at Linköping University, where she obtained her PhD in
Quality Management. Her research interests are in the areas of performance measurement and
strategic management.
Mattias Elg is an Associate Professor at Linköping University and Head of the Division of
Quality Technology and Management. His research interests are in quality management and
performance measurement in health care. Mattias Elg is the corresponding author and can be
contacted at: mattias.elg@liu.se

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints

View publication stats