International Journal for Quality in Health Care 2009; Volume 21, Number 4: pp. 259 –271 10.

1093/intqhc/mzp024
Advance Access Publication: 19 June 2009

The Balanced Scorecard of acute settings:

development process, definition of 20
strategic objectives and implementation
OLIVER GROENE 1, ELIMER BRANDT2, WERNER SCHMIDT2 AND JOHANNES MOELLER3
1
Avedis Donabedian University Institute, Autonomous University of Barcelona, CIBER Epidemiology and Public Health, Barcelona, Spain,
2
Immanuel Diakonie Group, Berlin, Germany, and 3Dean Health and Nursing Care, Hamburg University of Applied Sciences, Hamburg,
Germany

Abstract
Context. Strategy development and implementation in acute care settings is often restricted by competing challenges, the
pace of policy reform and the existence of parallel hierarchies.
Objective. To describe a generic approach to strategy development, illustrate the use of the Balanced Scorecard as a tool to
facilitate strategy implementation and demonstrate how to break down strategic goals into measurable elements.
Design. Multi-method approach using three different conceptual models: Health Promoting Hospitals Standards and
Strategies, the European Foundation for Quality Management (EFQM) Model and the Balanced Scorecard. A bundle of
qualitative and quantitative methods were used including in-depth interviews, standardized organization-wide surveys on
organizational values, staff satisfaction and patient experience.
Setting. Three acute care hospitals in four different locations belonging to a German holding group.
Participants. Chief executive officer, senior medical officers, working group leaders and hospital staff.
Intervention(s). Development and implementation of the Balanced Scorecard.
Main outcome measure(s). Twenty strategic objectives with corresponding Balanced Scorecard measures.
Results. A stepped approach from strategy development to implementation is presented to identify key themes for strategy
development, drafting a strategy map and developing strategic objectives and measures.
Conclusions. The Balanced Scorecard, in combination with the EFQM model, is a useful tool to guide strategy development
and implementation in health care organizations. As for other quality improvement and management tools not specifically
developed for health care organizations, some adaptations are required to improve acceptability among professionals. The
step-wise approach of strategy development and implementation presented here may support similar processes in comparable
organizations.
Keywords: quality management, patient-centred care, hospital care

Background through new hospital reporting and payment systems,

requirements to improve quality and safety and contractual
Hospitals in health care systems throughout Europe and arrangements to facilitate integrated care provision [1 – 3].
worldwide are subject to a wide range of external pressures. Yet, for hospital management it becomes increasingly diffi-
These include macro-level societal changes such as demo- cult to adapt to the pace of policy reform while balancing
graphic and epidemiological transformations, increasing economical considerations, social responsibility to provide
expectations of citizens and patients, mobility of pro- high-quality health care to the community served and, finally,
fessionals and difficulties with recruitment and retention of ecological concerns [4 – 6].
staff, increasing cultural diversity and the constantly rising There are several reasons why it might be difficult for hos-
financial concerns. These pressures result in a long list of pitals to adapt to new strategic objectives. First, a common
policy reforms to which hospitals have to adapt, for example pitfall of strategy implementation is to assume that strategy,

Address reprint requests to: Oliver Groene, Avedis Donabedian Research Institute, Autonomous University of Barcelona,
C/ Provenza, 293, pral. 08037 Barcelona, Spain. Tel: þ34 932 076 608; Fax: þ34 934 593 864; E-mail: ogroene@fadq.org

International Journal for Quality in Health Care vol. 21 no. 4

# The Author 2009. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 259
Groene et al.

once drafted and approved, unfolds independently to organ- macro-level societal changes, as described in the Ottawa
izational units. This failure to integrate strategy into organiz- Charter for Health Promotion [14]. Due to its broad vision
ations’ policies can, for example, be observed evaluating the and in the absence of clear tools to facilitate and gauge
effect of hospitals’ mission statements [7 – 10]. Secondly, implementation, the impact of this project has been ques-
management may take strategic decisions solely on the basis tioned [15 – 17]. In order to encounter the along going reluc-
of routine performance and financial data. This is an issue tance, two international working groups were established by
that has been observed for private sector-oriented organiz- WHO in 2001 to (i) develop standards for health promotion
ations such as Health Maintenance Organizations operating and (ii) identify main strategies for health promotion in hospi-
in the US health care industry, but has also been raised in tals. The output of these groups (five standards with 40 mea-
European countries, for example, with the introduction of surable elements and 18 strategic directions) was used to align
Diagnosis-related Groups in Germany [11]. For mid- and the progression of the strategy with overall holding develop-
long-term planning of hospital services; however, additional ment presented in this paper [18, 19].
information about patients, clients, staff, core processes and The EFQM model is a well-known and established quality
innovation potentials gain increasingly in importance [2]. management system which has been widely applied to health
Thirdly, new strategic themes developed by management are care [20 – 22]. It is based on nine criteria (leadership, people,
frequently not shared, understood and equally supported by policy and strategy, partnership and resources, processes,
all members of staff [12]. As a result of these limitations, people results, customer results, society results and key per-
existing planning, practice and reporting systems and pro- formance results) which in turn embrace 32 sub-criteria. The
fessional practice are not sufficiently transformed by execu- models’ basis is that excellent results relating to performance,
tive management’s strategic positioning. customers, employees and society will be achieved by man-
Considering the difficulties associated with strategy agement that places a high value on policy and strategy,
implementation, hospitals depend on a sound approach to employees, partnerships, resources and processes. Despite
develop and implement a clear strategy that leads them the widespread application in health care, the model has also
through the above-named points of departure. been criticized for not being specific enough to address the
In this paper, we present the steps and lessons learned core business for hospitals and that it requires adjustment to
during a 5-year project that aimed at the organization-wide account for the main results of hospital services [23]. In this
implementation of the Health Promoting Hospital strategy study, the EFQM model was used as a basis for the compre-
using the Balanced Scorecard. We will draw on a framework hensive and organization-wide identification of quality
in order to allow a more general learning experience with improvement potentials.
regard to the implementation of quality goals in hospitals. The Balanced Scorecard is a management technique
Detailed empirical results of the implementation process will designed to solve problems along with strategy transform-
be described in subsequent research articles. The specific ation widely applied both in industry and in health care [24,
objectives of this paper are to describe a generic approach to 25]. Its goal is to co-ordinate and to adjust an organization’s
strategy development, illustrate the use of the Balanced strategy with operational business. The Balanced Scorecard
Scorecard as a tool to facilitate strategy implementation in a breaks down the strategy into four basic business perspec-
acute care setting and demonstrate how to break down stra- tives: finance, customer, internal processes and innovation.
tegic goals into measureable elements, which are then As part of the implementation process, every perspective is
assessed towards their strategy contribution using the allocated a number of objectives, measurement strategies,
example of one of the core health promotion strategy: target values and improvement initiatives. The resulting
improving patient involvement. archive of measurements paired with strategy-borne cause
and effect relationships builds up to a powerful toolkit to
facilitate the implementation of health promotion strategies
in hospital settings [26, 27].
Methods
Concepts and models used in the project Methodology applied in the implementation
process
The project uses the following models: Health Promoting
Hospitals Strategies and Standards, European Foundation for A bundle of methods and instruments were adopted to
Quality Management (EFQM) Excellence Model and the gather the necessary data for strategy development and
Balanced Scorecard, which are briefly described below. implementation: first, an in-depth review of constitutional
The WHO Health Promoting Hospitals project brings documents was carried out to guide value and strategy devel-
together more than 700 hospitals throughout the world. Its opment. Secondly, in-depth interviews were carried out with
mission is to ‘work towards incorporating the concepts, 20 senior doctors and the chief executive to assess current
values, strategies and standards or indicators of health pro- and future quality issues. Thirdly, the values of the organiz-
motion into the organizational structure and culture of the ation were assessed in a standardized, representative,
hospital/health services’ [13]. The project aims at re-orienting organization-wide survey in 2002 and 2007. The 2002 survey
health services to better serving the needs of patients, staff focused on staff agreement with the values of the organiz-
and the community and to adapt hospital services to the ation; the 2007 survey assessed whether staff agrees with the

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values, and whether they experience them. Fourthly, standar- to assess individual perceptions of the broader concepts
dized representative, organization-wide surveys were con- entailed in the mission and vision. A survey of draft values
ducted on staff satisfaction in 2002, 2005 and 2008. Fifthly, was distributed among all staff in 2002 in order to gather
patient experiences were assessed using standardized, repre- feedback. Based on the responses, the values were updated
sentative, organization-wide surveys in 2006 and 2008 (using and published in May 2003 as the common basis for future
the PICKER questionnaire). Last but not the least, two self- action in the holding. In a fourth step, the core project team
assessments according to the EFQM model were carried out and additional members of management discussed key stra-
with the help of independent evaluators in 2003 and 2008. tegic themes in a number of workshops which led to a con-
All methods described were embedded in the EFQM self- centration on four key themes: health gain through
assessments which in turn relate to various strategic objec- comprehensive patient orientation, process optimization and
tives in the Balanced Scorecard. quality management, partnerships and development of health
centre and developing a health promoting culture. Fifthly
and finally, the four key themes are incorporated into the
Setting and context
Balanced Scorecard; all strategic objectives subsequently
The project started as a WHO pilot project initiated by the developed are thus related to the four Balanced Scorecard
German-holding Immanuel Diakonie Group in 2002 [28]. perspectives (finances, consumers, processes and innovation)
The holding embraces a broad range of medical and social and the organizational key themes described above. The
services. This includes on the one hand services such as overall process of preparing the basis for strategy develop-
gynecology and obstetrics, pediatrics and surgery, internal ment can be illustrated as follows (Fig. 2).
medicine including rheumatic care and comprehensive cardi-
ology and heart surgery treatment and rehabilitation. On the
other hand, the holding provides social care including psy- Developing the strategy map
chiatry, drug abuse services, elderly care and family and life
planning services, social consulting and assisted living Based on the preceding steps, the so-called strategy map was
(Table 1). Including 50 different institutions and more than developed displaying the four key directions for strategy
2000 staff, the holding represents an important network of implementation (header), the four business perspectives of
social and health care in the Region of Berlin-Brandenburg the Balanced Scorecard (left column) as well as the cause –
and Thüringen in Germany and Steiermark, Austria. The effect relationship between individual strategic objectives
timing of the project is illustrated in Fig. 1. (inward-positioned arrows). The latter emerged from a sys-
tematic discussion internal to the holding’s executive and
senior management team. Both, the strategic objectives as
Results well as the cause – effect relationships between these objec-
tives fed into the construction of the final Balanced
The multiple methods described in the previous section were Scorecard strategy map (Fig. 3).
applied to inform strategy development and assess its
implementation. The process followed and results achieved Preparing the Balanced Scorecard
are described in the following steps: building the basis for
strategy development, developing the strategy map, preparing Subsequently, the Balanced Scorecard as the definitive man-
the Balanced Scorecard and breaking down strategic objec- agement tool was developed. It integrates an overall of 20
tives into actions. strategic objectives, accompanied by measurements and stra-
tegic initiatives. For each strategic objective, it includes
detailed definitions, references to quality models and relevant
Building the basis for strategy development standards, identification of responsibilities, frequency of data
At first we reviewed and defined the mission of the partici- collection, data on past performance as well as data on per-
pating hospitals. Since this is based primarily on the care pro- formance targets. Moreover, planned activities necessary to
vision contract and the legal status of the participating reach the target value are detailed with time indications and
institutions, it was not necessary to develop new orientations, overall action plan. Along with 20 strategic objectives and
but to clearly define the mission on the basis of existing inherent cause-and-effect relationships, these components
documentation. In a second step, we determined the strategic constitute the strategy implementation instrument. In
vision of the holding based on a strategy interview with the Table 2, an overview on the Balanced Scorecard for the
chief executive office and interviews with 20 senior doctors holding is presented (Table 2).
and managers, considering both the vision of the overall
holding as well as for the specialized departments they were
Breaking down strategy into action: Objective P1:
responsible for. In doing so, both the vision of the overall
‘improving patient involvement’
holding as well as the specific care providing contract of the
respective departments were accounted for. In order to back To illustrate the implementation activities fostered by the
up the holding’s strategic vision, in a third step organization- Balanced Scorecard, we describe one objective in more
wide values were drafted to provide additional guidance and detail. Table 3 illustrates definitions, remarks, relations,

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Groene et al.
Table 1 Characteristics of participating institutions

Organization name Immanuel hospital, Berlin Wannsee/Berlin-Buch Evangelian-freechurch Evangelian-freechurch hospital and
hospital, Rüdersdorf heart centre, Brandenburg, Bernau
............................................................................................................................................................................................................................................

Departments and services Anestesiology Emergency medicine Emergency medicine

Ellbow, hand and microsurgery Anestesiology Anesthesiology
Orthopedics with rheumasurgery Intesive care Intensive care and pan therapy
Pain therapy
Internal medicine Surgery Surgery
Rheumatology and clinical immunology Obstetrics and Obstetrics and gynecology
gynecology
Internal medicine Heart surgery
Metabolical disorders and osteology Pediatrics Cardiology
Neurology Internal medicine pediatrics
Psychiatry
psychosomatic medicine
Psychotherapy
Personnel
Medical doctors 45 68 105
Nurses 157 213 171
Allied health professions 96 173 191
Administration 21 30 31
Number of patients
Inpatients 6.756 10.714 10.702
Outpatients 6.785 10.735 10.835
Number of beds 280 376 253
Financial volume (MioE) 24.0 31.9 50.9
 The Balanced Scorecard

Figure 1 Timeline of the project.

measurements, frequency of data collection, responsibilities,

targets, strategic actions and additional remarks for objective
‘Involving the patient as co-producers in his health’. This
table serves as the strategy implementation and monitoring
instrument for the objective and is revised periodically to
include new data and activities, or adjust to new strategic
challenges. For example, at the beginning of the implemen-
tation, it was noticed that existing patient surveys were not
sufficient to inform strategic actions on patient involvement.
Therefore, in order to obtain a more specific picture of the
situation and justify additional workload to improve patient
involvement, additional patient surveys using a standardized
methods in the whole holding were launched (in this case
using the PICKER method). The first survey in 2006
allowed a comparative analysis of patient experiences among
the holdings’ hospitals and led to the identification of a dif-
ferentiated set of actions. A repeat survey was carried out in
2008 to assess the impact of the implementation and target
further improvement actions.
The complete Balanced Scorecard integrates similar
detailed descriptions of rationale, planned activities, mile-
stones, targets and responsibilities, as exemplified in Table 3,
for all strategic objectives.

Discussion
We described the use of the Balanced Scorecard as a tool to
facilitate strategy implementation in health care organizations
using the example of the health promoting hospitals strat-
egies. In our experience, the use of the Balanced Scorecard
and contentious implementation efforts helps avoiding the
three pitfalls of strategy implementation as described in the
introductory section, such as assuming that strategy unfolds
independently to organizational units, developing strategy
Figure 2 Five-step approach to strategy development. based on limited data and ignoring that strategic themes are

263
Groene et al.

Figure 3 Strategy map of the holding.

not shared or understood by staff. These pitfalls, as well as adapted to reflect the objectives and strategic orientations of
general limitations, are presented in the following sections. the Balanced Scorecard.

Pitfall 1: assuming that strategy unfolds Pitfall 2: developing strategy based on limited data
independently to organizational units A contentious decision was made at the beginning of the
The very reason for the use of the Balanced Scorecard and project to base strategy development on the comprehensive
EFQM model was the recognition that strategy implemen- vision as pursued by the WHO Health Promoting Hospitals
tation tools are necessary. This is of particular relevance in project, rather than limited financial or marketing data that
the context of the Health Promoting Hospitals Strategy might have been available at the start of the project. The
which, in many cases, suffered from mission statements and importance of this vision was also confirmed by a recent edi-
declarations that never resulted in concrete actions at ward torial as guiding principle for strategic development of health
level [16, 17]. To this end, the Balanced Scorecard as strategy services, making the case of the need to further reorient health
implementation tool and the EFQM model as quality assess- services towards the promotion of health [29]. The original
ment framework were adopted. Furthermore, recognizing the health promoting hospitals concept as defined in the Ottawa
parallel hierarchies (managerial and professional) which are Charter for Health Promotion is widely represented by the 18
characteristic for health care organizations, all senior doctors health promoting hospitals values, the holding’s four key direc-
were involved in the process of strategy formulation. In tions and the resulting Balanced Scorecard-borne measure-
order to ensure the involvement of all staff, value surveys ments and their associated cause-and-effect relationships.
were conducted assessing whether the values identified by
the senior management team were also shared by staff.
Pitfall 3: strategic themes are not shared or
Considerable resources were dedicated to appoint not less
understood by staff
than 60 executive and senior doctors accountable for stra-
tegic objectives and actions within the four hospitals of the Various measures were taken from the beginning of the
holding. Finally, the internal SAP# Information Technology project to ensure that all staff share and understand the strat-
system (the instrumental backbone for reporting and evalu- egy. This included one-way communication (information circu-
ation of administrative and patient-related processes) was lars), eliciting feedback (value survey) and active participation.

264
 Table 2 The Balanced Scorecard of the holding

Strategic objective Measurements Strategic initiative

............................................................................................................................................................................................................................................

Finance (F) F1 Plan for case cost Proportion of departments that inform on Prepare reports based on the data provided
a monthly basis on costs, services provided for periodic business meetings.
and results
Prepare overall report for health
conferences that allows interpretation of
data
F2 Make positive operating results Proportion of overall financial turnover Report on monthly status and prepare
(goals range between 5 and 9% depending quarterly report
on type of institution)
F3 Open additional business Proportion of revenue from additional Annual analysis and business report on
segments and financial resources business segments new business segments established in the
previous 3 years
F4 Improve public relations Degree of implementation of the public Establish criteria list for public relations.
relations concept
Realize transparency of costs.
Set up public relations department
Customer (C) C1 Increase satisfaction of patients, Satisfaction index from patient surveys Set up working group on patient surveys.
occupants and their relatives
Improve existing patient survey, carry out
surveys and analyze results (internally)
C2 Increase staff satisfaction Satisfaction from staff survey Set up working group on staff survey.
Improve existing staff survey. Survey will
be carried out and analyzed by an external
institute
C3 Promoting health in the region Degree of implementation of the action Carry out assessment of needs and
plan possibilities for health promotion actions
in the corresponding region. Prepare action
plan.

The Balanced Scorecard

Standardized reporting on activities and
participation in health promotion activities
(continued )
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Groene et al.
Table 2 Continued

Strategic objective Measurements Strategic initiative

............................................................................................................................................................................................................................................

Processes (P) P1 Involve patients as co-producer Patient involvement index based on Establish standards of care (Clinical
of their health questionnaire Pathways#) including criteria for patient
assessment and discharge preparation.
Develop information material.
Develop checklist for emergency patients
P2 Create transparent structures of Degree of implementation Set up working group on structures of
responsibilities and information responsibilities and information
P3 Develop and transmit corporate Degree of implementation Prepare action plan (including relations to
identity according to the values of patient and staff surveys according to C1
the holding and C2
P4 Organize delivery networks and Degree of implementation, including: Prepare action plan.
co-operation with other providers - number of co-operation contracts Assessment of current co-operations.
with providers (pre/post admission) Establish new contracts for co-operations.
- proportion of cases with co-operation Regular control and analysis of
contract co-operations. coop
- assessment of co-operations regarding
(a) benefits for patients, (b) work-flow,
(c) business results
P5 Consider and document patients Realization of needs assessments (goal Approve patients’ rights (including patients’
and occupants needs attained/not attained). complaints procedures).
Index on needs assessment based on Quality circle on patients’ needs to prepare
patient survey form to assess patients needs in hospitals,
nursing homes and for outpatient care
P6 Identify and reduce depreciative % change of processes Improvement management
processes
P7 Introduce a comprehensive Goal attainment Establish system for human resource
human resource development management for the holding
 Innovation (I) I1 Promote communication culture Proportion of realized feedback rounds Prepare list of feedback rounds
(participants, co-ordinator and frequency).
Training of co-ordinators on feedback
culture.
I2 Holistic view of patients, Satisfaction index from survey on holistic Quality circles on competence training to
occupants and their relatives health perception based on C1. prepare standards according to 1 – 4 of the
target definition.
Punctuation for training of competence in Offer competence training for staff
holistic assessment (for every member of
staff)
I3 Distinguish performance Realization of targets (yes, no) Targets for market analysis.
spectrum
Commission internal and external market
analysis.
Realize profiling dialogue with executive
managers.
Create concept for further profiling
I4 Lead staff to success Proportion of staff for each institution with Training of managers in carrying out
annual performance review. performance reviews with staff.
Proportion of staff in each institution with Establish procedures for reports on
agreed performance targets. performance appraisal and performance
targets
I5 Establish regularly Carry out EFQM assessment according to 2005: Assessment and EFQM training
self-assessments RADAR logic (punctuation) 2006: Second self-assessment
Proportion of hospital staff responsible for 2007: Assessment and EFQM training
EFQM criteria with specific training 2008: Third self-assessment according the
EFQM and RADAR logic
I6 Strengthen staffs health Degree of implementation Offer holding-wide and hospital-specific
competence services

The Balanced Scorecard

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Groene et al.

Table 3 Strategic objective patient involvement (P1)

Objective: Involving patient as co-producer of his health P1

Definition: To involve patients as co-producers includes comprehensive information of patients and occupants, their active
involvement in the decision-making and treatment process and integrate necessary health promotion activities/interventions
in the clinical pathways. Participation and co-production of patients and occupants is closely related to improving patients’
rights.
Remarks: the systematic involvement of patients and occupants Relation: EFQM Part-criteria 6a; Health promoting
aims at achieving a high possible health gain. This requires a hospitals strategies [PAT2 þ PAT4] and standards
high level of patient-centred communication. [S2 þ S3]
Measurement: Patient involvement index Frequency of data collection: bi-annually
Responsibility: Defined responsibility in each institution (for strategic actions the holding will be responsible)
Targets:
2005: Baseline assessment (internal tool)
2006: First Picker survey (implementation)
2007: Identification of improvement actions based on survey results and identification of targets for 2008
2008: Second Picker survey
Strategic actions:
Create Patient involvement index
Establish standards of care (Clinical Pathways#) including criteria for patient involvement and discharge preparation.
Develop information material.
Develop checklist for emergency patients.
Additional remarks: The Picker survey feeds into the Balanced Scorecard objectives C1 and P1. The survey first carried out in
2006 provides a comprehensive picture of patient experience for each participating institutions with comparative data for all
Picker surveys carried out in the same year in Germany. Thus it establishes a benchmark for priority setting and action
planning. In general, the Picker-generated problem scores for the holding’s hospitals are similar to the German average
although for particular items substantial variation can be observed within the holding’s hospitals. Based on these data,
institution-specific improvement actions were launched and target values to diminish problem scores were formulated for
2010 and 2012. The repeat survey carried out in November/December 2008 will allow evaluating the effect of the Balanced
Scorecard implementation on patient experience as pre– post test design

For the actual preparation of the Balanced Scorecard, an inter- reflect the organizations’ core processes and key businesses?
disciplinary project team of leaders of the three participating There is an undeniable limitation as these measurement
institutions was set up. The chief executive officer of the instruments cannot be assumed to capture all relevant pro-
holding participated in these working meetings. A number of cesses and outcomes. However, this is true also for other
educational workshops were carried out to train staff on the performance assessment [30]. Secondly and highly relevant
objectives of the project and the tools used. After all leaders within the context of a project that aims at facilitating health
were informed by the chief executive officer of the intention to promotion, a dispute is the assessment of health gain [31].
implement the Balanced Scorecard within the framework of a Ongoing health promotion-related measurements in the
kick-off meeting for the pilot project, all employees received Balanced Scorecard are mostly oriented towards enabling
an information circular on the project. All staff were continu- standards and processes and do not allow assessing com-
ously informed about the developments with regard to the mensurable results of health gain. While some selected indi-
strategy implementation through the newsletter, staff journal cators have been applied, for example the Picker surveys that
and staff assemblies. Management staff, in particular the hospi- address patient perceptions of involvement and quality of
tal executives, were involved by the chief executive officer in care, ongoing research is required to provide hospital execu-
board meetings, team meetings, executive management training tives with management-friendly measurement tools that
and the weekly information circular and encouraged to con- reflect health gain components. It should be noted that as
tribute to the process. Finally, all members of staff have access other hospitals in Germany the holding routinely collects
to the Balanced Scorecard and a postcard version of the strat- data on clinical performance indicators in the framework of
egy map was produced for easy reference. the contract with the Federal Office for Quality Assurance
[32]. While these indicators are monitored separately they
were not included in the Balanced Scorecard since they
Monitoring strategy implementation address only about 20% of the volume of services provided
Key to the Balanced Scorecard reflection is the question of and they do not reflect the strategic orientations for the hold-
whether the complexity of hospital operation can be benefi- ing’s future development. The integration of staff and patient
cially ‘reduced’ to 20 strategic objectives: Do these objectives survey results into the Balanced Scorecard, too, proved

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difficult. As these bi-annual surveys produce new results management was necessary, reflecting the challenge of health
every other year, the implementation cycle for measurable care organizations to address both management and pro-
improvements is necessarily restricted. Narrow but feasible fessional objectives at the same time [6, 34]. A conceptual
deadlines for improvement activities accompanied the limitation of the project is that it does not draw explicitly on
Balanced Scorecard process in order to ensure that previous the experience of other models or authors on strategy devel-
quality improvements be implemented before engaging and opment, such as Mintzberg and Porter, although some of
committing the holding in new projects. their assumptions are implicit to the Balanced Scorecard
design. This includes, for example, Mintzberg’s Five P’s
( plan, ploy, pattern, position and perspective) or his notion
Combining quality management tools: EFQM and
to avoid detachment of strategic management from oper-
the Balanced Scorecard
ational practice and using both hard and soft data in strategy
The combination of different tools (EFQM and BSC) to development, which are well embedded in our project [35].
implement the broad Health Promoting Hospitals vision Likewise, many of the ideas exposed by Porter and Teisberg
leads to a certain complexity of the project and implemen- on the way health care organizations shift costs and restrict
tation strategy. There are similarities in the models such as services rather than create value for patients are reflected
the aim to promote dialogue for improved organizational upon in the Balanced Scorecard and in the Health Promoting
performance, the dependence on feedback and continuous Hospitals Standards and Strategies as the guiding framework
learning and the substantial organizational efforts required to [36]. On the other hand, some of Porter’s thinking on strategy
being effective. However, there are a number of differences in terms of demand side (strategic scope) and supply side
between these models which make them complementary (strategic strength) factors in order to identify the main stra-
rather than competing with each other. First, the self- tegic competencies, or his five forces analysis, is less relevant
assessments carried out within the context of the EFQM to our project, given the limited competition in the German
model tend to identify locally relevant quality improvement health care market as compared to the US health care industry
activities, but they are not a strategy development tool. In [37]. From a methodological viewpoint, the most important
contrast, the Balanced Scorecard starts with strategy develop- limitation is that the impact of strategy deployment on
ment and adapts it throughout the organization. It does not patient- or staff-level outcomes is not presented in this paper.
include a specific methodology for the identification of For example, if an objective aims at better patient involve-
quality improvement potentials. Secondly, both models estab- ment, such objective should be evaluated using patient survey
lish links between the criteria used. While this is done data on perceived patient involvement. Similarly, strategic
implicitly in the EFMQ model (RADAR logic), the Balanced objectives related to increase staff satisfaction should be evalu-
Scorecard is based on a strategy map and explicit causal ated using staff surveys. This survey data have been gathered
pathways. Thirdly, the EFQM model is based on improving and will be used in future research papers discussing the
processes and comparing processes with best practices, while impact of the strategy implementation. However, since these
the Balanced Scorecard is based on the definition of strategic surveys are embedded as pre–post evaluations in the overall
objectives that lead to the identification of new processes. project, it is difficult to isolate the effects of strategy
EFQM does not support the strategic decision-making implementation from other possible confounders that may
process. Instead, it focuses on improving processes without have caused changes in patient and staff satisfaction.
questioning the strategic objectives and without assessing the Moreover, it needs to be considered that the findings pre-
relative contribution of individual processes towards each sented here do not result from a project with a primary scien-
strategic theme. Both models can thus be considered comp- tific purpose, but rather that scientific methods were used for
lementary quality management tools in the same way as it managerial purposes. As such this study puts itself in the line
was also recently proposed as an integrated management of pragmatic sciences as suggested by Berwick [38].
approach for Spanish hospitals [33].

Conclusion
General limitations
This study has a number of limitations that merit discussion. The Balanced Scorecard, in combination with the EFQM
From a project management perspective, despite the efforts Excellence Model, is a useful tool to guide strategy develop-
to avoid the pitfalls of strategy implementation, a number of ment and implementation in health care organizations. Its
difficulties persisted. In the case of personnel from middle strength is the combination of generic business perspectives
management and administration, time restrictions were with internally identified key themes for strategic develop-
expressed as an important barrier to Balanced Scorecard ment, which are illustrated in a strategy map and summarized
implementation and its impact on daily operations. In the in the scorecard. As for other quality improvement and man-
case of clinical staff, substantial efforts were required to con- agement tools not specifically developed for health care
vince of the benefits of the Balanced Scorecard implemen- organizations, some adaptations are required to improve
tation in view of the use of abstract concepts, unclear impact acceptability among professionals. The step-wise approach of
on clinical results and remoteness from the priorities of daily strategy development and implementation presented here
work. For this group, substantial mediation by executive may support similar processes in comparable organizations.

269
Groene et al.

Acknowledgements 12. Horváth, Partner. Balanced Scorecard umsetzen. Zweite,

überarbeitete Auflage, Stuttgart: Schäffer-Poeschel, 2001.
We would like to thank the following persons for their col- 13. WHO. The International Health Promoting Hospitals Network:
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Funding 17. Whitehead D. The European Health Promoting Hospitals

(HPH) project: how far on? Health Promot Int 2004;19:259– 67.
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