Science and practice of balanced scorecard in a hospital in Pakistan : Feasibility, context, design and implementation

Background: Millennium Goals emphasize good governance and health systems research. In Pakistan, hospitals provide the major bulk of both basic and advanced care. Challenges faced by the hospitals in Pakistan include: poor quality of care, weak management structures, inappropriate resource allocation and a lack of timely information system for decision making. Balanced Scorecard (BSC) is a strategic performance management tool that could offer an opportunity to improve performance measurement and management. Main aim: To aim was to determine whether BSC application is feasible in the context of a lowincome hospital setting, to identify organizational culture, as well as design the scorecard and describe the contextual barriers and strategic processes that hinder or facilitate its implementation. Methods: The study setting for three sub-studies (II, III,IV) is a private university hospital in Karachi Pakistan. In Study I, a systematic review of electronic databases explored the experience of BSC in highincome countries (HICs), and its feasibility in the context of lowincome countries (LICs). A crosssectional cultural assessment survey in a clinical department with eight subspecialty units was conducted prior to designing the BSC (study II). Validated questionnaires were used. The first contained twenty items addressing perceptions of cultural typology (64 respondents). The second assessed staff views on quality improvement implementation (48 faculty members). Applying the modified Delphi technique, an expert panel of clinicians and hospital managers reduced a long list of indicators to a manageable size (Study III). Study IV was a multimethod case study of contextual implementation of BSC in four clinical units of this hospital. Pettigrew’s framework of strategic change was used to guide data collection and analysis. Results: It was concluded that despite contextual challenges, BSC application can be undertaken in selected LICs. Committed leadership, conducive culture, quality information systems, viable strategic plans, and optimum resources are required (I). Organizational culture was assessed prior to designing and implementing the BSC. A mixed culture was observed (II). The mean cultural scores were group (participatory) = 17.5, developmental (open))=13.7, rational (efficiency driven)= 31.2 and hierarchical (bureaucratic) =37.2. The latter was the dominant cultural type. Group (participatory) and developmental (open) culture types had significant positive correlation with optimistic perceptions about leadership (r = 0.48 and 0.55 respectively, p<0.00). Using modified Delphi, an expert panel of clinicians and hospital managers selected 20 indicators for the four BSC quadrants with consensus (III). Indicators were rated on a scale of 1–9 using a predefined criteria and median scores assigned. Five interrelated themes were identified through data triangulation (IV). Making the culture more participatory, presenting clear direction integrating support for BSC in policies and resources emerged as desirable attributes in all four units. The two units that lagged behind were more involved in direct inpatient care with considerable clinical workload. Conclusion: Feasibility of BSC in LICs is dependent on certain criteria being fulfilled. The study hospital which has predominant characteristics of a hierarchical culture needs to enhance participatory leadership approaches. The role of the multidisciplinary teams is important in selecting indicators for BSC with consensus. Existing hospital data in LICs can be used to choose indicators for the BSC despite issues with data quality. Leadership could consider role clarification for BSC with adequate rewards and recognition system. A starting point could be outpatient clinical services with gradual scorecard scalability. Findings have implications for hospital management in both HIC and LIC settings.