Faculty of Commerce
Department of Accounting and Finance
Analysis of the applicability of the Balanced Scorecard concept to faith-based
health institutions in Zimbabwe: The case of Adventist Dental Practice
A dissertation by:
Dumisani S. Dlodlo
L018 0446K
Supervised by:
Dr. S. Makurumidze
Submitted In Partial Fulfilment of the Requirements of the Master of Science
Degree in Accounting and Finance
© June 2020
Lupane, Zimbabwe
Release Form
Student Name:
Dumisani Sipho Dlodlo
Student Number:
L0180446K
Title of Dissertation: Analysis of the applicability of the Balanced Scorecard concept to faithbased health institutions in Zimbabwe: The case of Adventist Dental Practice
Program: Master of Science Degree in Accounting and Finance
Year of Award: 2020
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and/or otherwise without the prior written permission of the publisher. Permission is hereby
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Permanent Address:
1895 Mahatshula North, Bulawayo
Date:
26/06/2020
2
Approved Form
The undersigned certify that they have supervised the student Dumisani Sipho Dlodlo.
Dissertation entitled ‘Analysis of the applicability of the Balanced Scorecard concept to faithbased health institutions in Zimbabwe: The case of Adventist Dental Practice’ submitted in
partial fulfillment of the requirements for the MSc. Accounting and Finance with the Lupane
State University
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SUPERVISOR
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CHAIRPERSON
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Declaration
I, Dumisani Sipho Dlodlo do hereby declare that this dissertation is the result of my own
investigation and research, except to the extent indicated in the Acknowledgements and
References and by acknowledged sources in the body of the report, and that it has not been
submitted in part or full for any other degree to any other University or College.
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Student signature
Date
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Acknowledgments
I would like to thank my supervisor Dr. S. Makurumidze for his guidance and direction during the
carrying out of this research. Secondly I would like to thank the staff and administrators of
Adventist Dental Practice for their cooperation and support. Thirdly I would like to acknowledge
the support and care of my wife, Precious. Through thick and thin, through the sunshine and the
rain, you have stood by me and supported me. Dear mother, MaMkwananzi, thank you for the
encouragement, prayers and financial support.
Lastly and most importantly, I would like to acknowledge my forever-friend, Lord and Saviour,
Jesus Christ, who enables us to do all things.
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Dedication
Dedicated to my daughter Gabriella Iminathi Dlodlo.
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Abstract
Dental service provision in Zimbabwe and Africa is relatively scarce when compared with the
extent of provision in Europe and America. Faith based institutions are also playing their part,
together with the government and the private sector to cater for society’s health and dental needs.
The purpose of this study is to carry out an analysis in order to provide the necessary information
to ascertain whether and how a model Balance Scorecard can be developed for Adventist Dental
Practice in Suburbs, Bulawayo in Zimbabwe, as well as design such a Balanced Scorecard. The
study setting is a faith-based dental practice in Bulawayo, Zimbabwe. A systematic review of
electronic databases explored the experience of BSC in high- income countries (HICs), and its
feasibility in the context of low- income countries (LICs). observation, content analysis and indepth interviews where used to gather information, using the modified Delphi technique, an
expert panel of clinicians and clinic managers reduced a long list of indicators to a manageable
size. 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 Using modified Delphi, an expert panel of
clinicians and clinic managers selected 20 indicators for the four BSC quadrants with consensus.
Indicators were rated on a scale of 1–9 using a predefined criteria and median scores assigned.
Feasibility of BSC in LICs is dependent on certain criteria being fulfilled. 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.
Findings have implications for hospital management in both HIC and LIC settings.
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Key Words
Balanced Scorecard, Low-Income countries, Hospital, Systematic Review, Organizational
Culture, Leadership, Modified Delphi, Indicators, Context, Pettigrew’s Framework, Case Study,
Implementation, Barriers, Strategic Processes.
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Contents
List of Figures ................................................................................... 13
List of Tables .................................................................................... 14
List of Abbreviations and Acronyms ................................................. 15
Chapter 1: Introduction.................................................................... 16
1.1 Introduction ............................................................................................................................ 16
1.2 Background of the study ........................................................................................................ 16
1.3 Statement of the problem ....................................................................................................... 19
1.4 Purpose of the study ............................................................................................................... 20
1.5 Objective of the study ............................................................................................................ 20
1.6 Research Questions ................................................................................................................ 21
1.7 Definition of Terms................................................................................................................ 22
1.8 Scope of the Study ................................................................................................................. 23
1.9 Limitations and Delimitations................................................................................................ 23
1.10 Assumptions of the study ..................................................................................................... 24
1.11 Organization of the study ..................................................................................................... 24
1.12 Chapter Summary ................................................................................................................ 24
Chapter 2: Literature Review ........................................................... 25
2.1 Introduction ............................................................................................................................ 25
2.2 Performance Evaluation ......................................................................................................... 25
2.2.1 The concept of performance evaluation ................................................................................ 26
2.2.2 Comparison of the principles of traditional and modern performance evaluation methods . 27
2.2.3 Comparison of modern company performance evaluation methods ..................................... 28
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2.3 Theoretical Framework .......................................................................................................... 32
2.4 The Balanced Scorecard Concept .......................................................................................... 34
2.4.1 Customer Perspective .............................................................................................................. 37
2.4.2 Financial perspective ............................................................................................................... 39
2.4.3 Internal processes.................................................................................................................... 42
2.4.4 Learning and Innovation Perspective ...................................................................................... 44
2.4.5 Performance ............................................................................................................................ 47
2.5 The Balanced Scorecard in Health Care ................................................................................ 47
2.6 The Five Perspectives of the BSC ......................................................................................... 49
2.7 Problems with the Balanced Scorecard.................................................................................. 49
2.8 The generations of BSC ......................................................................................................... 50
2.9 The Conceptual Framework ................................................................................................... 52
2.10 Empirical Literature Review ................................................................................................ 55
2.10.1 Zambian Case Study............................................................................................................... 55
2.10.2 Ethiopian Case Study ............................................................................................................. 56
2.10.3 Swedish Case Study ............................................................................................................... 57
2.10.4 Hawaiian Case Study.............................................................................................................. 58
2.11 Chapter Summary ................................................................................................................ 59
Chapter 3: Methodology .................................................................. 60
3.1 Introduction ............................................................................................................................ 60
3.2 Research Philosophy .............................................................................................................. 61
3.3 Research Design..................................................................................................................... 62
3.3.1 Research Approach and Strategy............................................................................................. 62
3.4 Study Population and Sample ................................................................................................ 64
3.4.1 Study population ..................................................................................................................... 64
3.4.2 Study sample ........................................................................................................................... 64
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3.4.3 Sampling Techniques ............................................................................................................... 67
3.5 Data Collection Techniques ................................................................................................... 68
3.5.1 Semi-structured interviews ..................................................................................................... 68
3.5.2 Content Analysis ...................................................................................................................... 69
3.5.3 Observation ............................................................................................................................. 69
3.6 Data reliability and validity ................................................................................................... 70
3.6.1 Reliabilty .................................................................................................................................. 70
3.6.2 Validity ..................................................................................................................................... 70
3.6.3 Generalizability ........................................................................................................................ 72
3.7 Data analysis techniques and presentation ............................................................................. 73
3.8 Ethical considerations ............................................................................................................ 74
3.9 Chapter summary ................................................................................................................... 75
Chapter 4: Data Presentation and Analysis ....................................... 76
4.1 Introduction ............................................................................................................................ 76
4.2 Feasibility of BSC Implementation In LICs ........................................................................... 76
4.3 Use of existing data in designing BSC ................................................................................... 79
4.4 Depth Interview Feedback ..................................................................................................... 80
4.5 Designing the BSC Using Formal Consensus Technique ....................................................... 82
4.6 Summary of Results ............................................................................................................... 84
Chapter 5: Conclusion and Recommendations ................................. 85
5.1 Introduction ............................................................................................................................ 85
5.2 Summary of Findings............................................................................................................. 85
5.2.1 Feasibility of BSC in the HICs .................................................................................................... 85
5.2.2 Feasibility of BSC in LIC settings................................................................................................ 85
5.2.3 Paucity of Analytical Studies On BSC in Health Care................................................................... 87
5.2.4 Indicator Selection and Measurement Issues ............................................................................ 88
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5.3 Conclusions ............................................................................................................................ 90
5.4 Recommendations of the Study ............................................................................................. 91
5.5 Limitations of the study ......................................................................................................... 91
5.5.1 Challenges of doing research in one’s own organization ........................................................... 91
5.5.2 Limitation of Study Questionnaire ............................................................................................. 93
5.5.3 Generalizability ......................................................................................................................... 93
5.6 Recommendation for further studies ......................................................................................... 94
References ....................................................................................... 95
Appendices .................................................................................... 103
APPENDIX 1: DATA EXTRACTION FORM FOR SYSTEMATIC REVIEW .................................................. 104
APPENDIX 2: KEY INFORMANT GUIDE .............................................................................................. 106
APPENDIX 3: AUTHORIZATION TO CARRY OUT THE RESEARCH............................................................ 108
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List of Figures
Figure 2.1: Comparison of modern and traditional company evaluation methods…..……..30
Figure 2.2: The Conceptual Framework…………………………………………..………..54
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List of Tables
Table 2.1: Comparison of Modern and Traditional Company Evaluation Methods………..31
Table 3.1: Target Sample Statistics ………………………………………………………...65
Table 4.1: Analytical Framework for translating BSc experience from HI to LI settings….78
Table 4.2: Demographic Analysis of Respondents…………………………………………80
Table 4.3: Analysis of interview feedback………………………………………………….80
Table 4.4: Shortlisted List of Indicators for the ADP Balanced Scorecard…………………83
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List of Abbreviations and Acronyms
BSC: The Balanced Scorecard is a strategic planning and management tool that was designed by
Kaplan & Norton. Its intent is to tie all aspects of an organisation together using
details other than traditional financial measures (Kaplan & Norton, 1996).
ADP: Adventist Dental Practice is a dental clinic located in Suburbs, Bulawayo. It is run and
owned by the Seventh Day Adventist Church and had 8 employees at the time of carrying out this
research.
PM: Performance Management is an on-going communication process of creating relationships
that is taken on by the employee and the supervisor. It is structured ways of letting your employees
know what is expected of them, with the goal of achieving a more successful operating
organization (Bacal, 2004).
15
Chapter 1: Introduction
1.1 Introduction
The success of any business enterprise, whether large or small, depends, to a great degree, on the
manner in which it is managed. Organisational management is concerned with planning,
organising, leading and controlling, and in order for executives to effectively carry out their
mandate, they need to carry out regular and systematic performance evaluations. This research,
in the area of Strategic Management Accounting and Performance Evaluation, seeks to develop a
view on the performance of Zimbabwean health institutions, and how such performance can be
improved. Such an analysis would also have a telling effect on the quality of health services
provided, highlight possible areas of improvement and give indications on the sustainability of
the operations of these health facilities, which are critical to the health and well-being of the
citizens of any nation.
This chapter will focus on the background of the study, statement and purpose of the study,
objectives of the study, research questions, significance of the study, limitations and delimitations
as well as assumptions of the study, as well as describing how the study is going to be organised.
1.2 Background of the study
Health-care is a multifaceted, multi-trillion dollar business. According to Deloitte (2019),
combined health spending worldwide is projected to increase at an annual rate of 5.4 percent in
2017–2022, from USD $7.724 trillion to USD $10.059 trillion. This increase is likely to be driven
by aging and growing populations, developing market expansion, clinical and technology
advances, and rising labor costs. Healthcare is broad and covers many disciplines like nutrition
and dietetics, physiology and dentistry.
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According the World Health Organisation (2020), the dentist to population ratio in Africa is
approximately 1:150000 against about 1:2000 in most industrialized countries.
According to the Medical and Dental Practitioner’s Council of Zimbabwe (2020), Zimbabwe
currently has the following numbers of registered personnel; 214 dental practitioners, 25 Dental
technicians and 159 dental therapists. Dental institutions provide much needed dental health
services, provide employment, and contribute to the fiscus directly and indirectly. As such, they
are a necessary cog in the wheel of the Zimbabwean economy. Faith based institutions also play
a key role in providing health care to the Zimbabwean population. The Zimbabwe Association of
Church-related Hospitals (2020), currently has a membership of 130 hospitals and clinics.
Adventist Dental Practice is a Seventh-day Adventist owned dental practice in Bulawayo. It had
8 employees at the time this study was carried out; that is 3 dentists, an accountant, a receptionist,
2 dental assistants, and a janitor. Adventist Dental Practice is run by a Board, which is under the
auspices of the Zimbabwe West Union Conference of the Seventh Day Adventist Church, one of
the three equal administrative units covering the nation.
According to Siddiqui et al (2017), patients expect appropriate quality treatment including, but
not limited to, being served by a presentable dentist, who will welcome them, listen patiently to
their problem, explain treatment options and the treatment procedure.
Evaluation is an important component of strategic management accounting, and in order for
institutions to discern their performance, administrators need to continuously assess if they are
proceeding as planned. This needs to be buttressed by clearly communicating the entity’s strategy,
goals and objectives to all employees. Such activities will allow continual evaluation of corporate
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alignment with strategic goals, as well as increase the probability and pace at which progressive
change occurs in the organisation (Kim et. al., 2003)
20th Century organizational performance has been mainly anchored on the short term objective of
maximizing and generating value for the shareholder as the principal stakeholder (Zingales,
2000). As a result, managers and executives have often maximized short and medium term profits
at the expense of long-term sustainability (Kotler & Caslione, 2009), while relying predominantly
on financial indicators (Kaplan, 2010). This approach often led to resource misallocation and was
one of the factors that led to the world financial crisis at the turn of the last decade (Bair, 2011).
According to Wongrassamee et. al. (2003), other limitations of traditional performance measures
include exclusion of performance from strategy, measures being inflexible and fragmented, and
measures hindering progressive innovation and thinking.
Consequently, a more balanced approach is needed in order to effectively assess organizational
performance while seeking to achieve all of the afore-mentioned goals. A number of performance
management tools are available for the purpose of this study, including the Total Quality
Management (Feigenbaum, 1991; Juran, 2004), Performance Pyramid (Mcnair, Lynch and Cross,
1990), the Balanced Scorecard (Kaplan & Norton 1992, 1996, 1996a) and Integrated Thinking
(Topazio, 2014). The Balanced Scorecard has been selected for the purpose of this dissertation,
because of its balanced focus on financial and non-financial measures.
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1.3 Statement of the problem
The Balanced Scorecard is a strategic management tool that aims to solve the inefficiencies of
traditional performance evaluation based on lagging financial indicators like return on equity or
earnings per share. This inefficient form of evaluation fails to capture the value of operational
measures that include dealer relationships, customer loyalty and employee skills, resulting in a
lack of customer orientation, as well as a neglect of product innovation, employee improvement
and process engineering. These often overlooked factors are essential components for the success
any business enterprise. The Balanced Scorecard was developed in a bid to make up for these
inefficiencies, and provide a more comprehensive framework to the measurement of the goals and
successes of any business entity. According to Gustafsson, Schold, Sihvo and Summitt (2009),
employing these methods enables business enterprises to move away from dependence on
historical information and focus on future performance.
As a former employee of Adventist Dental Practice, I am aware of a number of strategic and
performance evaluation deficiencies within the entity. Being a faith-based institution with a few
employees may have resulted in a detachment from corporate best practice, and an inclination to
traditional performance evaluation based on historical financial indicators, as a way of minimising
the workload on the burdened employees. I envisage a situation where Adventist Dental Practice
is using the Balanced Scorecard and other strategic management best practice concepts, to
maximise value to all stakeholders, and achieve all organisational goals and objectives. This is
the ideal, and this study is a means to that end.
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1.4 Purpose of the study
The purpose of this study is to carry out an analysis in order to provide the necessary information
to ascertain how a model Balance Scorecard can be developed from continuous improvement and
performance measurement monitoring at Adventist Dental Practice in Suburbs, Bulawayo in
Zimbabwe. Such a model can be used as a basis for strategic management tools to be developed
for other dental practices and health institutions at large, whether faith-based or not. It is desired
that this study will also benefit the administrators of Adventist Dental Practice to look at their
operations and make improvements from a strategic-management accounting and evaluation
perspective.
1.5 Objective of the study
The objectives of this dissertation are to:
•
analyse performance measures at Adventist Dental Practice and
•
evaluate if they fit into the Balanced Scorecard Model.
This will be done in order to ascertain how the Balanced Scorecard Model can be implemented at
Adventist Dental Practice, and provide management with information and advice on how they can
improve their strategic management accounting and evaluation framework.
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1.6 Research Questions
The primary research question is “How can the Balanced Scorecard be implemented at Adventist
Dental Practice?” Supportive research questions will be:
1. What would you describe as the critical success factors for ADP?
2. In what way is performance measurement carried out at ADP?
3. How is the BSC different from what performance measurement systems already existed
in your clinical clinic?
4. What resources if any, can be allocated for BSC implementation
5. How do you expect the implementation of the BSC to affect the clinic’s staff and
operations?
6. What might helped or hinder the BSC implementation activities in your clinic?
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1.7 Definition of Terms
Below the reader can find definitions of the terminology that we have used in this study.
BSC: The Balanced Scorecard is a strategic planning and management tool that was designed by
Kaplan & Norton. Its intent is to tie all aspects of an organisation together using
details other than traditional financial measures (Kaplan & Norton, 1996).
ADP: Adventist Dental Practice is a dental clinic located in Suburbs, Bulawayo. It is run and
owned by the Seventh Day Adventist Church and had 8 employees at the time of carrying out this
research.
PM: Performance Management is an on-going communication process of creating relationships
that is taken on by the employee and the supervisor. It is structured ways of letting your employees
know what is expected of them, with the goal of achieving a more successful operating
organization (Bacal, 2004).
22
1.8 Scope of the Study
This dissertation contains a complete review of measures of performance and business processes
in place at Adventist Dental Practice. This study is also intended to familiarise the reader with the
basic components of the Balanced Scorecard Concept, as well as provide the management with
recommendations to improve performance evaluation and strategic management through the
Balanced Scorecard.
It is assumed that the reader has a basic knowledge of the general organizational structure of a
commercial enterprise as a well as a good knowledge of business, management and accounting
terminology. The study seeks to assess the applicability of the balanced scorecard to Adventist
Dental Practice in the period June 2019 – June 2020, considering that organisations are very
dynamic and susceptible to change.
1.9 Limitations and Delimitations
The main limitations in carrying out this research are the time and financial resource constraints.
However, these are not expected to affect the outcome of the study. Further to this, the researcher
does not have any control over the degree of honesty of the respondents. Due to the large number
of potential participants, this study will focus on a sample of Adventist Dental Practice
administrators, employees and patients.
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1.10 Assumptions of the study
It is assumed that:
1.
Respondents’ feedback will not be affected by gender, denomination or other
demographic characteristics.
2. The researcher will be granted permission by Adventist Dental Practice administrators to
carry out the research and collect data.
1.11 Organization of the study
The study will move from the current Chapter One (Introduction) to Chapter Two, the Literature
Review, then on to the Methodology (Chapter Three), Findings and Discussions (Chapter Four)
and will end with the Recommendations (Chapter Six).
1.12 Chapter Summary
Having looked at the preliminary and background issues of the study, statement and purpose of
the study, objectives of the study, research questions, significance of the study, limitations and
delimitations as well as assumptions of the study, as well as describing how the study is going to
be organised, I will now go on to review the literature on the subject matter under consideration.
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Chapter 2: Literature Review
2.1 Introduction
In order to improve the author’s and reader’s knowledge, as well as to improve insight into issues
of the Balanced Scorecard, a literature search was carried out. In this section of the dissertation,
this study will give a comprehensive review of the literature related to the problem under
investigation. The chapter will be divided into sections, including performance evaluation, the
concept of the Balanced Scorecard and its applicability to dental clinics, the four aspects of the
Balanced Scorecard, performance aspects and concludes with the conceptual framework.
2.2 Performance Evaluation
Performance evaluation is defined ambiguously in the research literature, with a number of
authors giving various definitions for the concept. Some of these definitions are similar, while
other are quite different. Neely, Gregory, Platts (1995) say performance evaluation is the process
of quantifying the effectiveness and the efficiency of actions with a set of metrics. Marshall, Wray,
Epstein, Grifel (1999) define it as the development of indicators and collection of data to describe,
report on and analyse performance. Najmi, Kehoe (2001) posit that performance evaluation is
Monitoring, management and improvement of measurable criteria that tell how the tasks were
fulfilled and motivate to perform in order to achieve the goals of the company. On the other hand,
Choong (2013) says performance evaluation is concerned with improvement in which its
implementation requires targets or goals, so that measurement and evaluation can be made against
appropriate benchmarks, while Peleckis (2013) defines it as a clock showing the current business
situation and trends in its development, helping the company to decide where to go.
By way of summary and analysis, some authors (Neely, Gregory, Platts (1995), Marshall, Wray,
Epstein, Grifel (1999), Najmi, Kehoe (2001)) perceive performance evaluation as a process,
25
where company’s results are evaluated quantitatively by analysing certain indicators. On the other
hand, the authors of the latter decade (Moullin (2007), Klovienė (2012), Choong (2013), Peleckis
(2013)) note that performance evaluation should not necessary be quantitative. Managing quality
evaluation, defining customer value and value created for other interested parties, disclosure of
common business situation, and raising further goals for improvement are significant. Out of a
list of definitions in research literature, the most plausible and exact perception of performance
evaluation is provided by Klovienė (2012): it is a broad and multifunctional process that combines
the key performance indicators which help evaluating performance, guarantees company
management process, value creation, adjustment, speedy reaction, and enables improvement and
growth of a company.
2.2.1 The concept of performance evaluation
Under dynamic business environment, performance control plays an especially significant role,
thanks to which one can observe ongoing changes and timely react to them. For a long time,
performance evaluation has been conducted based on financial activity information by analysing
indicators of profitability, liquidity, solvency and other financial ones. Such an evaluation has
formed a traditional view that is as well followed by businesses nowadays. On the other hand,
under modern economic environment, it is more and more often that the traditional performance
evaluation methods receive criticism. Christauskas and Kazlauskienė (2009) state that the
traditional performance evaluation systems do not help solving managerial problems that arise
under the context of dynamic business conditions; these systems are not capable to evaluate real
factors that create a value. For this reason, the modern performance evaluation methods have a
higher and higher demand in business performance evaluation.
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2.2.2 Comparison of the principles of traditional and modern performance evaluation
methods
Like many other business concepts, performance evaluation has evolved over time, from the
traditional view and methods, to more modern and comprehensive ones. De Toni and Toncia
(2001) distinguished the essential differences between traditional and modern performance
evaluation systems. According to these authors, the traditional performance evaluation systems
are oriented to profit and based on performance cost and efficiency analysis. With these systems,
one strives to evaluate the results of the period in the past by calculating individual financial
indicators and comparing them to the defined standard values. Differently from the traditional
systems, the modern performance evaluation systems are oriented to consumers and satisfaction
of their needs and are based on company’s created value. With these systems, one has an intention
not only to evaluate results of the period in the past, but also to define reasons that led to these
results and to foresee steps to improve the future results. For this purpose, not individual
indicators, but sets of key indicators that include various crosscuts of performance are evaluated.
According to De Toni and Toncia (2001), traditional performance measures are based on
cost/efficiency, evaluate the results are profit and short term oriented, predominantly use
individual and functional measures, compare with a standard and aim at evaluating. On the other
hand, modern performance evaluation is value-based, evaluates results and causes, is customer
and long term oriented, uses a prevalence of transversal and team measures, focuses on
improvement monitoring and aims at evaluating and involving.
According to Wongrassamee et. al. (2003), other limitations of traditional performance measures
include exclusion of performance from strategy, measures being inflexible and fragmented, and
measures hindering progressive innovation and thinking. Hence modern evaluation methods are
to be preferred.
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2.2.3 Comparison of modern company performance evaluation methods
Narkunienė and Ulbinaitė (2018) after conducting research literature analysis on the topic of
business evaluation systems suggest the classification scheme of performance evaluation methods
(see Figure 1), where the methods are classified into smaller groups according to method contents
and performance evaluation purpose. According to this scheme, performance evaluation methods
are first of all classified into traditional and modern ones. Traditional performance evaluation
methods, as it was mentioned earlier, include analysis of financial performance results and their
relative values. Narkunienė and Ulbinaitė (2018) go on to split modern evaluation methods into 6
categories that is;
Performance record (accounting) methods - that is accounting data-based performance evaluation
methods that calculate the financial value created by performance. Quality management concept
methods - that is performance evaluation methods that are based on the conception of total quality
management. The purpose of these methods is to evaluate how the companies keep up with the
requirements, what progress they do when improving their performance, and similar. Causal
relationship theory models - that is performance evaluation models that distinguish the main
factors which affect the successful performance. Business process evaluation models - that is
models that emphasize processes during performance evaluation. The purpose of these models is
to evaluate economy of performance and efficacy during the separate steps of the process.
Balanced system models are overall models of performance evaluation that are closely related to
company’s vision and strategy. They involve both financial and non-financial performance
evaluation indicators and reflect the results in different performance perspectives. And finally,
Multi-criteria methods which are complex performance evaluation methods that join many
relevant performance indicators into a single summarising performance estimator.
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Narkunienė and Ulbinaitė (2018), observed that out of all performance evaluation methods that
are distinguished in the classification scheme, the most popular and most widely employed are
the following ones: economic value added (EVA), balanced scorecard (BSC), performance prism,
performance pyramid, six sigma, and multi-criteria performance measurement. They provided the
following diagrammatic analysis.
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Comparison of modern company performance evaluation methods
Fig 2.1: Comparison of Modern and Traditional Company Evaluation Methods
30
Comparison of modern company performance evaluation methods
Table 2.1: Comparison of Modern and Traditional Company Evaluation Methods
On the basis of the above strength and weaknesses, the Balanced Scorecard was chosen as the
basis for this study, seeing as it has the highest rates of criteria satisfaction, together with the
Performance Pyramid, and the Performance Prism. The balanced scorecard (BSC) is one of the
most influential theoretical frameworks in the fields of management accounting and strategic
management (Modell, 2012). In addition, BSC has been successfully implemented by numerous
organizations and has been regularly listed among the top ten management tools used throughout
the world (Rigby and Bilodeau, 2011). According to Kryslov (2016) the BSC is considered to be
one of the essential instruments of the organization management system (enterprise, firm,
company, and business-unit) and hence it has been chosen above the other performance evaluation
concepts that ranked at the same level.
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2.3 Theoretical Framework
During the past two decades of its existence, BSC has evolved, from a high profile performance
measurement system (Kaplan and Norton, 1992), to a strategic management system (Kaplan and
Norton, 1996a, 1996b), a tool for comprehensive strategy maps (Kaplan and Norton, 2000, 2001a,
2004a) and a vehicle of corporate-wide strategic alignment (Kaplan and Norton, 2006a). By
noticing this evolution, Modell (2012, p. 476) argues that BSC has evolved “in tandem with
increasing concerns with the need to render management accounting practices strategically
relevant”. As a result, much of what scholars in management accounting, regarding its early
performance management manifestations, and in strategic management, relating to its
contemporary strategic implications, study, write about and teach has been greatly influenced by
the fundamental arguments of the balanced scorecard theoretical framework. Therefore, BSC has
become a dominant interdisciplinary theory in management accounting and strategic
management.
Given that all theories must survive repeated attempts at empirical falsification before they can
be accepted as ‘true’ (Godfrey and Hill, 1995), one might assume that the BSC owes its influence
to well-documented assessments of the empirical support for its theoretical underpinnings.
Surprisingly, this is not the case. The theoretical underpinnings of BSC emanate from the central
tenet of the balanced scorecard theoretical framework relating to the four distinct perspectives,
i.e. financial, customer, internal-business-processes and learning and growth (Kaplan and Norton,
1992). In summary, the balanced scorecard theoretical framework hypothesizes that the four
aforementioned perspectives are the cornerstones of a multidimensional performance
measurement system that balances financial and non-financial performance indicators (Kaplan
and Norton, 1996a). Thus, all performance indicators measuring the same perspectives are
theoretically grouped into four categories, equal in number to BSC’s four distinct perspectives.
32
For that reason, all performance indicators should converge with the performance indicators
measuring the same perspective and should discriminate from generic performance indicators
measuring the other perspectives. According to Sagalis (2015), the above proposition can be
articulated as the theoretical underpinnings of BSC.
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2.4 The Balanced Scorecard Concept
The BSC was first developed by Robert Kaplan, and Professor David Norton in 1992. BSC was
first mentioned by Johnson and Kaplan (1987) in their book “Relevance Loss”. The roots of BSC
were further documented in 1990, when the Nolan Norton Institute, the research arm of KPMG
auditing company, sponsored a one-year, multi-company study, called “Measuring Performance
in the Organisations of the Future” (Kaplan and Norton, 1996). The study, according to Kaplan
and Norton (1996), was motivated by a belief that existing performance measurement tools,
mainly focusing on financial accounting measures, were becoming out-dated.
The term “balanced” means that each indicator or measure has its own weight that shows its
relative importance. These weights help companies know which goals, indicators, and tasks are
most important to their strategy. In addition, the term also leads firms to have a balanced view of
business activities as whole. This includes internal processes, customer relationships, learning and
growth, as well as finance. In this view and according to Kaplan and Norton (1996), companies
should balance financial and non-financial perspectives. Consequently, this balanced view
provides an objective benchmarking indicator for evaluating the progress in achieving an
organisation’s strategic objectives. The balanced also means that companies should balance their
objectives. Furthermore, BSC enables companies to develop a more comprehensive view of their
strategic and operations management.
Kaplan and Norton (1992) proposed a new concept to overcome the limitations of traditional
performance measures, which over-emphasised the financial perspective of an enterprise. The
Balanced Scorecard Concept as proposed by Kaplan and Norton (1992) is hinged on the idea that
management should not be limited, in their view, to the financial aspects of a business, but should
also focus on the customer, internal, learning and innovation aspects. In their view, this would
34
encourage management to have a comprehensive and holistic view of the organisation. The
Balanced Scorecard concept also allows administrators and those charged with governance to
focus on the critical aspects of the dental practice in order to drive strategy forward. The Balanced
Scorecard helps to communicate and implement an organisation’s strategy.
The Balanced Scorecard is an essential technique for assessing performance of a business
enterprise. It builds on the Critical Success Factor (CSF) concept of a few performance measures,
and reports four different aspects with equal weights. These four perspectives are the: customer,
financial, internal and learning perspectives. The financial perspective measures the enterprises’
ability to meet the shareholders expectations (Samir, 2006). The customer perspective deals with
the firm’s ability to meet customer demands (Kaplan & Norton, 1996). The internal perspective
seeks to assess the appropriateness of the businesses selected policies and processes in meeting
customer and shareholders’ expectations (Samir, 2006). Finally, the learning perspective
measures if the institution is dynamic enough to sustain its ability to change (Kaplan & Norton,
2005). The aim of the Balanced Scorecard is to add leading measures that represent indicators of
future financial performance, to traditional, historical financial measures. The Balanced Scorecard
emphasizes the need for an evaluation model that covers all relevant areas of relevant corporate
performance management systems. Asiedu (2015) posits that the model encompasses a balance
of all four perspectives necessary to ensure that improvements are not made in one area, at the
detriment of another facet.
Therefore, the Balanced Scorecard is a very efficient tool for developing and communicating
strategy by enabling the organisational model to be portrayed as a strategy map, forcing those
charged with governance to think from cause-to-effect (Kaplan & Norton, 2005). Organizational
performance is the sustained strategic and integrated success of an organization that is attained by
35
improving the contribution of the people who work in it and developing the capabilities of teams
and individuals (Nordberg, 2008).
The Balanced Scorecard helps organisations in the management process, by helping entities to
translate their mission and strategy into concrete goals and measures. The Balanced Scorecard
also balances the external and internal aspects by considering the financial (for shareholders and
customers) and non-financial (internal processes, innovation and learning) measures respectively
(Kim et. al., 2003). In addition, the Balanced Scorecard balances results measures (financial
outcome) and driver measures (for future improvements i.e. customer, internal processes, learning
and innovation) (Wongrassamee et. al., 2003).
The Balanced Scorecard is ranked as an excellent evaluation tool because it ties the performance
matrix very closely to an enterprise’s strategy and long term vision. If properly implemented and
driven internally, the Balanced Scorecard can aid in the creation of a new corporate culture which
is strategically aligned (Gibbons and Kaplan, 2015). The main disadvantage of the Balanced
Scorecard concept is that it may not bring about the intended results if not modified in accordance
with the mission, strategy, culture and technology of the enterprise in which it is to be used (Kim
et. al., 2003, Khamba et. al., 2012). Not-withstanding these drawbacks, the Balanced Scorecard
has been adapted to suit and cater for a number of different scenarios, including sustainability
(ethics, social issues and the environment) where it is known as Sustainability Balanced Scorecard
(SBSC)(Hansen and Schalleger, 2012). These researchers posit that the SBSC can be a promising
framework for integrating strategy and sustainability in business.
36
2.4.1 Customer Perspective
In the customer perspective of the BSC, companies identify the customer and market segments in
which they have chosen to compete. This perspective enables the firm to position their key
customer measurements with the market segments with which they have chosen to compete. The
organization of the decisive customer satisfaction indicators lets management form a more
coherent strategy concerning the goals of the customer perspective. The key customer outcome
measurements are: satisfaction, loyalty, retention, acquisition, and profitability (Kaplan & Norton,
1996). Of these measurements only satisfaction is applicable to ADP. Retention and acquisition
of patients would conflict with their goals of minimizing patient appointments and treatment
duration. If private companies fail to recognize their customer’s needs they inevitably lose their
customers to competitors who offer higher quality goods and better customer service.
Kaplan and Norton (1996) state that when implementing the BSC managers must translate their
mission and strategy statements into specific market and customer based objectives. When
formatting their organizational goals to that of the BSC, the firm will apply the five core measures
of; market share, customer acquisition, customer retention, customer satisfaction, and customer
profitability. These outcome measures represent the targets for companies’ marketing,
operational, logistics, and product and service development processes. Once an organization has
completed the initial step of identifying their market segment, they can address the issue of
objectives and measures to deliver satisfaction to their customers, which in the future will create
retention, acquisition and market share (Kaplan & Norton, 1996).
The above measures do have their disadvantages. “These outcome measures are lagging
indicators, meaning that employees will not know how well they are doing with customer
satisfaction or customer retention until it is too late to affect the outcome” (Kaplan & Norton,
1996, pg. 85). Kaplan and Norton (1996) also state that the measures do not communicate what
37
the employees should be doing in their day-to-day activities, and that managers must also identify
what their targeted customer’s value and deliver to these customers. Contrary to these limitations
the BSC gives managers the ability to concentrate on delivering superior quality goods to their
targeted customer segments.
Ruekert (1992) defined customer orientation that Lee (2006) quotes as the degree to which an
entity obtains and uses information from customers, develops a strategy that will meet customer
needs and implement that strategy in response to customers desires. Adventist Dental Practice
customers include all its stakeholders including patients, patients family members, medical aid
societies, suppliers, employees, board members and the sponsoring organisation.
Customer orientation would positively contribute to the performance of any enterprise in the sense
that customers will continue to be satisfied as their needs and wants continue to be met. This
would positively impact the institution as resultant higher treatments would result in higher
revenue and higher profits that could be used to improve the internal processes of the institutions
as well as improve its learning and innovation processes (Lee, 2006). This view is supported by
Pelham and Wilson (1996). On the other hand, failure to meet customer needs and wants would
result in the dental practice’s patient base becoming eroded, as patients would end up patronizing
other dental clinics. A significant reduction in the production and sales revenue of an institution
would result in a depletion funds to improve the other key aspects of internal processes, innovation
and learning.
Researchers have opted to assess customer orientation from different perspectives. For example,
Chen et al. (2006) evaluate customer orientation in two dimensions: namely customer satisfaction
38
and institutional promotion. They measure satisfaction by looking at treatment finality and the
number of patient complaints. They suggest that the dental clinic’s image can be measured by
looking at the number of applicants seeking treatment, institutional reputation and the institution’s
participation in charity activities.
Whilst some measures like reputation can be difficult to measure objectively, they describe the
type of relationship that exists between the entity and its stakeholders. Consequently, this research
will employ them as a of Adventist Dental Practice’s customer orientation.
2.4.2 Financial perspective
Financial measures historically have been the only tool, which a manager of a company could use
to navigate themselves through the unclear waters of performance measures. Financial measures,
though a good provider of information concerning quarterly and financial reports is mired in an
accounting model that was developed centuries ago. This antiquated model is still being used by
informational age companies, and is failing to account for vast sums of intangible assets (Kaplan
& Norton, 1996). “During the industrial age financial measures were an adequate tool for
valuing the success of a firm, which was not reliant on customer loyalty and motivated employees
as critical for success” (Kaplan & Norton, 1996, pg.7).
In today’s dynamic and new age marketplace it is necessary to account for a company’s intangible
and intellectual assets, such as the quality of products and services, skilled and motivated team
members, a satisfied and loyal customer base as well as brand name value and intellectual patents
(Kaplan & Norton, 1996). Although Adventist Dental Practice does not have shareholders they
do have financial concerns and goals that must be accounted for, and that require delineation. Cost
effectiveness and the quality of patient care are both concerns for the organization.
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During the initial phase of the scorecard design and construction an organization should ask
themselves what their goals are and how they plan on measuring them. The following is a list of
some of the goals (and measurements) the management of ADP use when the investigating into
their organization’s goals and strategies; maximizing value at least cost (cost-to-spend ratio); LOF
minimization (number of claims to the LOF); lowest cost per capita (average of all medical costs
divided by the number of inhabitants) and lowest cost per patient (cost per patient relative to the
number of patiens). Identifying the goals and the ways in which they should be measured are the
foundational stages of building a successful BSC (Kaplan & Norton, 1996).
According to Kaplan and Norton (1996), when an organization are building their BSC they should
promote all of its business units to link their financial objectives to the corporate strategy and in
doing this use their financial goals as the pinnacle for development of the other areas of their
scorecard. A mistake commonly made by management is applying the same financial standards
and measurement to all of their business units. This unilateral approach fails to recognize that
individual business units may use completely different strategies and approaches in achieving
goals and it may not be appropriate to apply a single financial metric to all of the companies units.
Thus, in the early stages of a company’s BSC development it is crucial that the business unit
executives determine the strategy and financial goals for each individual unit and establish the
relevant method of application while maintaining a prevalent and clear picture of the entire
company’s goals (Kaplan & Norton, 1996).
According to Kaplan and Norton (1996), financial objectives represent the long-term goal
of the organization: to provide superior returns based on the capital invested in the unit.
The BSC does not conflict with this vital goal. They also stated that the implementation of
the BSC could make the financial objectives explicit while customizing financial objectives
40
to business units in different stages of their growth and life cycle. The drivers of the financial
measurements should be modified for each business unit’s competitive environment
and strategic goals. Ultimately, all of the objectives within the BSC should be linked with
the financial objectives to recognize the long-run goals of the business (Kaplan & Norton,
1996).
Amaratunga et al. (2001) posit that the financial perspective shows the results of strategic choices
made in the other three perspectives; that is, internal processes, the customer perspective, and
innovation and learning. The financial perspective also indicates whether the organisations
strategy, implementation and execution have contributed to the bottom line. In other words, it is
used as a barometer to measure how well the enterprise has performed (Wongrassamee et al.,
2003). Lee (2006) alleges that prudent financial management helps to achieve better results,
economically, that is at minimum cost. The financial perspective is important because it gives the
results of all the other perspectives of the Balanced Scorecard. In addition, the other perspectives
may not be realised, without the resources and funding provided by the financial perspective
(Niven, 2002).
However, the traditional approach of using the financial perspective as the only performance
management tool has been criticised by many researchers. Amaratunga et al. (2001) claim that
this arrangement encourages short-termism, furnishes misleading information for decision
making, fails to consider requirements of today’s organisation and strategy, provides misleading
information for cost allocation and control of investments, and furnishes abstract information to
employees. Love and Holt (2000) maintain that over reliance on financial measures is
retrogressive and out of date. In their analysis, Kaplan and Norton (1992) concluded that assessing
41
companies based on financial aspects only do not accurately reflect the interest of the
shareholders.
The measures that can be used to measure financial performance of a dental institution include
good financial management, fund raising capabilities and external relationships (Dorweiler and
Yakhou, 2005), dental income, reduced human resource cost and increased asset usage (Chen et
al., 2006).
2.4.3 Internal processes
After the objectives of the customer perspective and financial perspective have been put into
effect, the organization will then begin to address the other two perspectives, the internal business
perspective and the learning and growth perspective (Kaplan & Norton, 2004).
“The Internal Perspectives accomplish two vital components of an organization’s strategy: (1)
they produce and deliver the value proposition for customers, and (2) they improve processes and
reduce costs for the productivity component in the financial perspective” (Kaplan & Norton,
2004, pg. 98). “The internal measures for the BSC should stem from the business processes that
have the greatest impact are; cycle time, quality, employee skills, and productivity” (Kaplan &
Norton 1992, pg. 132). “It is also necessary that companies try to identify their core competencies
as well as the critical technologies that are required to safeguard their market share” (Kaplan &
Norton 1992, pg. 132).
For the BSC, Kaplan and Norton (1996) recommend that the managers define a complete internal
process value chain that starts with the innovation process. The innovation process begins with
42
identifying current and future customers’ needs and creating and forming new resolutions, and
applying new formulas to solve these needs. According to Baker et. al.(2008), Satisfaction of such
customer needs include the focus on timelines (length of waiting for appointments); quality
(quality of patient care – defined by the patient) and service (responsiveness – as defined by the
patient).
Customers’ needs, in the context of ADP, pertain to the needs of patients within the healthcare
system. The final process in the value chain could be the post-sale service that offers services
after the sale, follow-up, letters and thank you notes. This final process would help strengthen
customer loyalty, and perhaps achieve a higher rate of customer retention and acquisition if the
customers’ needs were meet. When a high level of customer satisfaction is achieved the
organization will be rewarded with references and recommendations (Kaplan & Norton, 1996).
“The process of deriving objectives and measures for the internal-business process perspective
represents one of the sharpest distinctions between the BSC and traditional performance
measurement systems” (Kaplan & Norton, 1996, pg. 92). The more traditional measures of
performance relied heavily on controlling and relied almost exclusively on the financial aspect.
These more complex, flexible and complete methods of performance measurement appear to be
an improvement over the old reliance on financial reports (Kaplan & Norton, 1996). This may be
especially true for a healthcare organization such as ADP, which is attempting to remain within
budget while providing superior medical care to its residents. Financial measures alone would be
an insufficient evaluation of failure or success when accounting for the quality of an individual’s
life.
43
Papenhausen and Einstein (2006) define internal processes as critical internal functions that drive
the customers (stakeholders) satisfaction, and consequently, the financial outcome of the business
enterprise. Amaratunga et al. (2001) share the same perspective; they view internal processes as
mechanisms through which performance expectations are achieved. Following an assessment of
its customers’ requirements (needs and wants), an entity needs to implement processes that will
convert customer wishes and desires into realities (Lee, 2006).
This would require dental practices workers at all levels to have the necessary technical skills and
knowledge to be able to deliver the desired customer outcomes. These skills and knowledge would
need to be complimented by modern facilities and technology, as well as appropriate procedures
and regulations (Punniyamoorthy and Murali, 2008).
Internal processes play a big role in organisational performance. Dorweiler and Yakhou (2005)
claimed that good internal processes in an institution lead to, among other things, quality of
services and efficiency. Chen et al. (2006) measured internal processes from two perspectives,
namely quality service process and complete facilities. On quality service process they look at
administration efficiency and patient-to-staff ratio.
2.4.4 Learning and Innovation Perspective
Innovation and learning can be defined as the identification of the sets of skills, and processes that
drive the dental practice to continuously improve its critical internal processes (Papenhausen and
Einstein, 2006). According to Edwards (2006), learning and innovation encompass steps and
activities that focus on an enterprise’s development and learning ability. These may include the
number of qualified employees or the total number of hours spent on staff training. This
perspective includes staff training and attitudes to organisational culture related to the selfimprovement of individual employees and the institution as a whole. This aspect recognises that
in a knowledge-worker organisation, like a dental clinic, human capital is the greatest resource.
44
Kaplan and Norton emphasise the fact that 'learning' denotes more than ‘training', in the sense that
one may carry out a training exercise that does not better the trainees in any way.
The final perspective develops the objectives and measures necessary to motivate learning and
growth with the organization. The objectives established in the financial, customer, and internal
business process perspectives identify the key areas that are indispensable when it comes to
accomplishing superior quality products and performance. The goals of the learning and growth
method perspective are to create successful strategies that serve as a road map for achieving the
targets of the first three perspectives. For an organization to maintain competitiveness and growth,
it is essential that they make continual investments back into their firm. The BSC stresses the
importance of investing in not only traditional areas of investment, such as, equipment and
research & development but also advocates investment in their infrastructure (Kaplan & Norton,
1996). Through Kaplan and Norton’s (1996) experience building BSCs they have been able to
identify three principal categories for the learning and growth perspective; employee capabilities,
information systems capabilities and motivation, empowerment, and alignment. These three
principal categories help to clarify the objectives and stress the importance of the learning and
growth perspective.
Innovation processes can be the most important processes performed by a company to increase
productivity, sustain a competitive advantage and promote growth from within. Often
management overlooks the importance of learning and innovation (Kaplan & Norton,
2004). Within an organization, like ADP, it is imperative that a strong emphasis be put
on the learning and continual growth perspective. If there is no decoupling between the strategy
and the ability to promote and teach this strategy, then there is a much greater chance for success.
45
“The learning and growth perspective identifies the intangible assets that are most important to
the strategy, and the objectives within this perspective identify which jobs (the human capital),
which systems (the information capital), and what kind of climate (the organizational capital) are
required to support the value creating internal process” (Kaplan & Norton, 2004, pg. 32).
The four perspectives link to create a chain of relationships that strengthen and unite the
intangible assets and the tangible assets within an organization. This unification leads to improved
process performance, customer satisfaction and financial performance (Kaplan & Norton, 2004).
Businesses entities need to identify customer needs, and once these have been identified,
institutions need to convert these requirements into activities that can process them into tangible
output that customers can use. At times, it is found that there is a gap between the internal
processes requirements in terms of skills, information systems and the organisation climate, and
that which is available, (Lee 2006). For instance, the institution might be lacking some skills that
are necessary for the provision of a need to the customer. It is the duty of the innovation and
learning to consider what it must do to maintain and/or develop the know-how required for
understanding and satisfying customer needs (Amaratunga et al., 2001). In addition to meeting
the gaps that might be there, Amaratunga et al. (2001) also emphasise that the purpose of this
perspective is to consider how it can sustain the necessary efficiency and productivity of processes
which are presently created for customers.
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2.4.5 Performance
Performance is a multifaceted concept, and in analysing it, Kaplan and Norton (1996) considered
time, quality, flexibility, financial efficiency, customer satisfaction and human resource as some
of its key tenets. However, Lee (2006) viewed these dimensions into common factors of
efficiency, quality, responsiveness, cost and overall effectiveness. In the commercial world,
customers use their knowledge and expectations to measure the quality of the services being
offered (Parasuraman et al., 1986). However, unlike products that are manufactured, it is not easy
to measure the quality and effectiveness of services in service industry like dental services because
of the intangibility of the outcome. Despite this challenge, Soutar and McNeil (1996) recommend
the use of a service-marketing instrument called SERVQUAL (Service quality) to measure
intangibles. This instruments prescribe that service be viewed from five dimensions. The
dimensions include: tangibles, reliability, responsiveness; assurance and empathy.
2.5 The Balanced Scorecard in Health Care
According to Schaeffers (2007), the medical fraternity is undergoing a paradigm shift, where
patients are now being called customers and medical institutions are now regarded as ‘industries’
charged with producing more and better goods (health care) within available budgets. Innovative
management methods and regular collection and reporting of financial information (linking
clinical, volume and financial data by product line) are being advocated in health care settings
(Travis, Bennet, Heinnes, Pang, Bhutta, Hyder, Pielemeier, Mills, Evans, 2004). The emphasis on
performance measurement in the 1990s led to the development of dashboard metrics and report
cards emerged as viable options for evaluation of health-care programmes and management
practices (Woodward, Manuel, Goel, 2004). The first refereed article on BSC in healthcare
appeared in 1994 and discussed the need for ‘continuous quality improvements’ in the healthcare
setting (Griffith, 1994).
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About a decade after Kaplan and Norton developed the Balanced Scorecard, a number of healthcare institutions in high-income countries began to adapt and implement the BSC framework for
their organisations. Examples of BSC use in healthcare are scarce. However, performance
measurement strategies similar to the BSC have been studied in Ethiopia (Hartwig et. al, 2008)
and Sri Lanka (Ministry of Health Sri Lanka and Japanese International Cooperation Agency,
2003). Recently BSC was used in Afghanistan at a national level to show how provinces and the
nation are doing in the delivery of the basic package of health services in Afghanistan (Peters et.
al. 2007). It is therefore evident that healthcare systems are looking for empirical evidence to
demonstrate excellence in performance (Axelsson, 2000) and with these recent examples of the
use of PM systems in lower income countries there is increasing scope of applying BSC in the
lower income country context.
Applicability of the Balanced Score Card to Health Delivery Systems, developing country
While Kaplan & Norton (1996) state that the Balanced Score Card has been used mainly by large
and complex business organisations, Ten Asbroek ,Arah ,Geelhoed, Custers, Delnoij & Klazinga
(2004) developed a national performance indicator framework for the Netherland’s health system
based on the Balanced Score Card. Further to this, Peters, Noor, Singh, Kakar, Hansen & Burnham
(2007) also developed a BSC framework to monitor the progress of the Afghani public health
system, which they state as the first study of this kind for a developing nation. This BSC was
designed to assist the Afghani government to monitor their health facilities and partnerships with
NGOs providing health services after their public health system had been decimated by decades
of war and conflict under the Taliban. The researchers in the Afghani study faced obstacles in
developing a BSC based on surveys, including the lack of a sampling frame, insecurity, bad roads
and poor communications.
48
At the design workshops for the Afghani study by Ten Asbroek et. al (2004) , six domains were
identified for incorporation into the BSC: patient perspectives, staff perspectives capacity for
service provision (structural inputs), service provision (technical quality) financial systems as well
as overall vision for the health sector.
2.6 The Five Perspectives of the BSC
One key tenets of successful BSC implementation is adapting the framework to the context in
which it is to be applied. In a study of the BSC implementation at King Faisal Specialist Hospital
and Research Centre (KFSH-RC),Thunaian (2013) posits that the BSC has been amended to
include five main perspectives: quality of care; medical care; employee; financial; and the
education and research perspective (learning and growth). In the study, the researcher outlines
that the medical care perspective focuses on medical and clinical services. The quality care
perspective concentrates on increasing service capacity, through effective facility planning, and
expansion of projects. The employees’ perspectives include strengthening staff selection,
recruitment and retention strategies, incorporating human resources (HR) and recruitment
programs, and the provision of an employee friendly environment and education programs. These
are achievable through the approach of change management, skill projection and effective
organizational roles. The financial perspective focuses on improving the efficiency and
effectiveness of financial decision making processes. In addition, it focuses on cost and billing
actions with operational linkages. The educational and research perspective provides
improvement in systems, advanced IT training, data reporting skills, employee educational
programs, skill development programs, role playing programs and research integration initiatives.
2.7 Problems with the Balanced Scorecard
Schneiderman (1999), the former Vice President of Quality and Productivity at Analog Inc.
(USA), after observing the use and misuse of the Balanced Scorecard over many years, offered
49
the following six reasons as to why it may fail as a strategic management tool. Non-financial
measures are incorrectly identified as the primary drivers of future stakeholder satisfaction, the
metrics are poorly designed, improvement goals are negotiated rather than based on objective
analysis, lack of simplification of high level goals to the process level where actual improvement
resides, absence of state of the art improvement systems as well as absence of a quantitative
linkage between non-financial measures and expected financial results. Other pitfalls of the BSC
are described in the table below.
2.8 The generations of BSC
Kaplan and Norton upgrade BSC through three generations. Speckbacher et al. (2003) present
these three generations in detail. In the first generation, companies use specific multi-dimensional
perspectives for strategic performance measurement that combines financial and non-financial
strategic measures. The second generation is similar to the first generation and additionally applies
50
the strategy by using cause-and-effect relationships. The third generation implements a strategy
by defining objectives, action plans, outcomes and linking incentives with BSC. Molleman (2006)
asserts that 50%, 21%, and 29% of companies applied the first, the second and the third
generation, respectively. Molleman (2006) reported that companies using the third generation
benefit more from the full services of BSC.
The third generation fills the gap between theoretical strategic plans and real business activities.
However, Kaplan and Norton (1996) suggest that when applying the third generation, companies
should be careful to link the reward system to BSC. There is a risk in applying the reward system
due to the unreliability of the selected measures, lack of knowledge in linking the four
perspectives; and firms’ satisfaction with their BSC compared to firms with less developed BSC.
Malina and Selto (2001) suggest that BSC can be worked if organisations reward managers on
the basis of the achievements of BSC measures. Speckbacher et al. (2003) found that companies
implementing higher generations, such as the third, are less subject to strategic difficulties. The
study also showed that the majority of companies associated with less developed BSC suffered
from difficulties in implementing BSC. In addition, half of the companies failed to obtain causeand-effect relationships as they had only recently started the implementation process.
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2.9 The Conceptual Framework
The understanding of BSC perspectives is determined by several factors, including the
version/generation applied, the level of communication, the weighting, the management
information system, the organisational culture and the linkage between perspectives and the
business strategy. The conceptual framework considers that efficient application of these factors
may improve business performance, and in turn, the business strategy is achieved. Kaplan and
Norton (2001a) explain that for organisations to achieve their business strategy, whether they are
a manufacturer or providing service, private or public, for profit or not-for-profit, all
organisational participants need to be aligned to the strategy. The challenge for organisations is
how to enlist the hearts and minds of their employees. According to Huang (2009) the BSC model
depends on activities that develop by learning and growth perspective. This perspective captures
the ability of employees, information systems, and organisational alignment to manage a business
and adapt to change. Process success depends on skilled and motivated employees, as well as
accurate and timely information.
The BSC literature suggests that the implementation process should start with education by
creating strategy awareness. Then, the understanding of employees should be tested to ensure that
they have received the right message. This should involve the use of tools to check that
employees’ understanding and day-to-day behaviour is conducive to achieving the organisation
strategy. Organisations should always know how many of the employees understand the process
and how many do not. A precise budget should be set for the employee communication and
education process.
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Kaplan and Norton (2001b) have reported that the more employees understand the strategy, the
higher their individual performance is. In their study, they discovered that 67% of the employees
deliver high performance when they know and understand the entities strategic direction, whereas
26% deliver higher performance with senior managers using more efective communication. These
statistics above show that when employees understand the strategy of their organisation, their
performance becomes higher.
In formulating the conceptual framework, the researcher builds on the work of Thunaian (2013)
who developed a BSC conceptual framework for a hospital. Thunaian’s (2013) framework
summarises the determinants of BSC understanding. Basing on the reviewed literature in his
study, he said the understanding of the five perspectives of BSC in the hospitals are determined
by many factors including the level of communication; the generation of BSC applied; weighting;
management information systems; the culture; and the linkage of perspectives. Efficient and
effective implementation of these perspectives may improve the business performance, and meet
the business strategy as a result.
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The Conceptual Framework
BSC Perspective
BSC Determinant
Medical Care
Communication
Quality Care
Generation
Employees
Finance
Education and
Research
Weighting
Management
Information
System
Performance
Strategy
Vision
Performance
Management
Mission
Objectives
Culture
Linkage
BSC Improves Performance
BSC is linked with Business Strategy
Figure 2.2: The Conceptual Framework
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2.10 Empirical Literature Review
2.10.1 Zambian Case Study
Mutale, Stringer, Chintu, Chilengi, Mwanamwenge (2014) proffer that in many low income
countries, the delivery of quality health services is hampered by health system-wide barriers
which are often interlinked, however empirical evidence on how to assess the level and scope of
these barriers is scarce. A balanced scorecard is a tool that allows for wider analysis of domains
that are deemed important in achieving the overall vision of the health system. In the study, the
researchers present the quantitative results of the 12 months follow-up study applying the
balanced scorecard approach in the Better Health Outcomes through Mentorship and Assessments
intervention (BHOMA) with the aim of demonstrating the utility of the balanced scorecard in
evaluating multiple building blocks in a trial setting.
The BHOMA is a cluster randomised trial that aims to strengthen the health system in three rural
districts in Zambia. The intervention aims to improve clinical care quality by implementing
practical tools that establish clear clinical care standards through intensive clinic implementations.
This paper reports the findings of the follow-up health facility survey that was conducted after 12
months of intervention implementation. Comparisons were made between those facilities in the
intervention and control sites. STATA version 12 was used for analysis.
The study found significant mean differences between intervention(I) and control (C) sites in the
following domains: Training domain (Mean I:C; 87.5.vs 61.1, mean difference 23.3, p = 0.031),
adult clinical observation domain (mean I:C; 73.3 vs.58.0, mean difference 10.9, p = 0.02 ) and
health information domain (mean I:C; 63.6 vs.56.1, mean difference 6.8, p = 0.01. There was no
gender differences in adult service satisfaction. Governance and motivation scores did not differ
between control and intervention sites. The study demonstrates the utility of the balanced
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scorecard in assessing multiple elements of the health system. Using system wide approaches and
triangulating data collection methods seems to be key to successful evaluation of such complex
health intervention.
2.10.2 Ethiopian Case Study
According to Teklehaimanot, Teklehaimanot, Tedella, and Abdella (2016), in 2004, Ethiopia
introduced a community-based Health Extension Program to deliver basic and essential health
services. The researchers developed a comprehensive performance scoring methodology to assess
the performance of the program. A balanced scorecard with six domains and 32 indicators was
developed. Data collected from 1,014 service providers, 433 health facilities, and 10,068
community members sampled from 298 villages were used to generate weighted national,
regional, and agro-ecological zone scores for each indicator. The national median indicator scores
ranged from 37% to 98% with poor performance in commodity availability, workforce
motivation, referral linkage, infection prevention, and quality of care. Indicator scores showed
significant difference by region (P < 0.001). Regional performance varied across indicators
suggesting that each region had specific areas of strength and deficiency, with Tigray and the
Southern Nations, Nationalities and Peoples Region being the best performers while the mainly
pastoral regions of Gambela, Afar, and Benishangul-Gumuz were the worst. The findings of the
study suggest the need for strategies aimed at improving specific elements of the program and its
performance in specific regions to achieve quality and equitable health services.
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2.10.3 Swedish Case Study
According to Gustaffson et. al. (2009) the BSC framework gives management the opportunity to
better understand how the organization is functioning. They emphasize communication as the
vital factor for success with the Balanced Scorecard and the organization. Nowadays, in a world
of rapid change and competition the organizations face an untold quantity of leadership
challenges, and by applying the Balanced Scorecard the management will get the chance to
achieve results by putting their strategies into action. The Jonkoping County Council is
responsible for the healthcare within its area, and is one of numerous organizations that have
implemented the Balanced Scorecard.
The purpose of the study was to investigate the reasons the healthcare department within
Jonkoping County Council applied the Balanced Scorecard, how they use it, and to
understand from their perspective how it benefits them. In addition to this, the researchers
presented advice from employees to the management that is considering implementing the tool.
The study was qualitative with an abductive approach, where both primary and secondary data
were used in the research paper. The primary data was gathered through interviews with different
departments at Jonkoping County Council, which contributed to different views on the use of the
Balanced Scorecard. Theories about the Balanced Scorecard were gathered through secondary
data.
The results of the study showed that generally, the management at Jonkoping County Council
were pleased and satisfied with the Balanced Scorecard. In addition to this they are all motivated
and engaged in using the framework. However, they believe that the main drawbacks with the
Balanced Scorecard are to make employees understand and connect the daily work to the
framework, as well as finding the “correct” numerical values that reflects the organization.
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The benefits according to the management are the multidimensional view of the organization
through the four perspectives in the Balanced Scorecard, and also the fact that they now have a
framework which encourage the staff to strive to achieve a unison vision through action plans.
The nursing-staff were not aware of the term ‘Balanced Scorecard’ or the four perspectives, and
therefore wanted to get more information about it from their executives, since they are expected
to work in accordance with the framework. Through interviews with the upper- and middle
management and the nursing staff the researchers drew the conclusion that the Jonkoping County
Council implemented the Balanced Scorecard since they wanted to have a system that could be
used at all levels within the organization, this to get an overview and a better control of what is
happening within the business.
2.10.4 Hawaiian Case Study
Fryzlewicz (2000) carried out a research whose objective was to examine the applicability of the
Balanced Scorecard concept to governmental organisations as a potential strategic management
tool. The chosen institution as a basis for this study was the Naval Dental Centre in Pearl Harbour
(NDCPH) because it had recently been recognised in 1998 for its organizational excellence by
receiving the Hawaii State Award of Excellence.
The study centred on analysing NDCPH’s mission, vision, key-success factors (KSFs) and
performance metrics, for use in developing a proposed Balanced Scorecard framework. This was
done by equating the KSFs with Kaplan and Norton’s perspectives and then matching appropriate
performance metrics to the KSFs. A Balanced Scorecard framework that followed Kaplan and
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Norton’s concept was recommended. The potential for adapting this framework to other Naval
Dental Centres was also demonstrated.
2.11 Chapter Summary
Having reviewed past writings and publications related to the core concepts, applicability and
different perspectives of the Balanced Scorecard, as well as literature related tp performance and
the conceptual framework, the researcher will now move on to the Methodology.
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Chapter 3: Methodology
3.1 Introduction
This chapter discusses the research methodology and design used to carry out and complete the
study. Fisher (2010) defines research methodology as the studying of methods which involves
numerous questions, philosophical in nature, concerning possibilities to the researchers in an
attempt to ascertain how valid curtained hypothesis are in the process adding to the body of
knowledge. The methodology covers the conceptual framework of the research, the research
design and techniques used in the analysis of the applicability of the Balanced Scorecard concept
to ADP as well as to meet the research objectives.
The chapter goes on to define the population and sampling method used; the research methods
used to collect, present and analyse data are also discussed together with the motivations and
justifications for adopting such methods. The research limitations encountered are also explained.
The minimal time available for the research (6 months) and the associated limitation of the
researcher not being a full time researcher led to the choice of a case study. There are no known
studies on the analysis of the applicability of the Balanced Scorecard concept to any health
institutions in Zimbabwe. This led the researcher to adopt an exploratory research purpose. The
research adopted a survey strategy and employed an inductive approach. Interviews eliciting work
and service related factors were conducted on a sample of the dental practice’s stakeholders.
Participants were selected using a non-random purposive technique.
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3.2 Research Philosophy
The researcher used the interpretivist or phenomonological philosophy, which is based on the
belief that reality is socially constructed and that the goal of social science is to understand what
meaning people give to that reality (Edwards and Skinner, 2009). This qualitative research
paradigm attempts to probe lived experiences of individuals who are being investigated
(Saunders, 1982). Saunders et al.(2008) argue that an interpretivist perspective is highly
appropriate in the case of business and management research ,particularly in such fields as
organizational behavior, marketing and human resources management .
Saunders et al. (2008) further argue that the phenomenological research philosophy is useable
where the subject is new and when previous studies in the area are limited, as is the case with the
current study. The study was carried out from a subjectivist point of view, as the researcher holds
the view that management perceptions and decisions will affect strategy and performance.
According to Saunders et. al (2009) the subjectivist aspect of ontology
“holds that social phenomena are created from the perceptions and consequent actions
of those social actors concerned with their existence.”
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3.3 Research Design
The research design provides the glue that holds the research processes together and enables the
researcher to address the research questions in ways that are appropriate, efficient and effective,
(MANCOSA, 2014). Saunders, Lewis and Thornhill (2009) proffer that research design is the
general plan of how the researcher will go about answering the research questions. The researcher
used exploratory research in this study. Saunders, et al., (2009) define exploratory study as a
valuable means of finding out “what is happening; to seek new insights; to ask questions and
assess phenomena in a new light”. The researcher utilised the exploratory research technique as
there is no documented research on the analysis of the applicability of the Balanced Scorecard to
health institutions in Zimbabwe.
3.3.1 Research Approach and Strategy
Owing to the exploratory nature of this research (Robson 2002), the data collection, organisation
and analysis will be guided primarily by an inductive approach. The collection, examination and
process of continual re-examination of data will determine the research findings. The researcher
sought to draw generalizations from data collected. Gray (2009) proffers that the inductive
approach starts with the collection of data; the collected data are then analysed to see if any
patterns emerge that suggest relationships between variables. The results are then used to
formulate generalizations, relationships and even theories.
The research was carried out based on a holistic single case study strategy. Robson (2002) defines
case study as ‘a strategy for doing research which involves an empirical investigation of a
particular contemporary phenomenon within its real life context using multiple sources of
evidence’. Yin (2003) also highlights the importance of context, adding that, within a case study,
the boundaries between the phenomenon being studied and the context within which it is being
studied are not clearly evident.
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Saunders et. al. (2009) argue that the case study strategy will be of particular interest to the
researcher who wishes. to gain a rich understanding of the context of the research and the
processes being enacted (Morris and Wood 1991). The case study strategy also has considerable
ability to generate answers to the question ‘why?’ as well as the ‘what?’ and ‘how?’ questions.
This makes the case study strategy suitable for this exploratory type of study.
Cresswell (2014) proffers that case study research is defined as a qualitative approach in which the
researcher investigates and explores a real-life, contemporary bounded system (a case) or multiple
bound systems (cases) over time, through detailed, in-depth data collection involving multiple sources
of information, and reports on it. The unit of analysis in the case study might be multiple cases (a
multisite study) or a single case (a within-site case study). It involves extensive research, including
documented evidence of a particular issue or situation - symptoms, reactions, effects of certain stimuli,
and the conclusion reached following the study. A case study focuses on a particular group of people
having something in common. In the case of this research, the people in question all work for the same
institution of higher learning.
Strengths of the case study strategy
• Case study is detailed and richer in bringing out information; and
• Involvement of the researcher is intensive.
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3.4 Study Population and Sample
3.4.1 Study population
According to Kothari (2004) all items in any field of inquiry constitute a ‘Universe’ or
‘Population.’ A complete enumeration of all items in the ‘population’ is known as a census
inquiry. It can be presumed that in such an inquiry, when all items are covered, no element of
chance is left and highest accuracy is obtained. But in practice this may not be true. Even the
slightest element of bias in such an inquiry will get larger and larger as the number of observation
increases. This type of inquiry involves a great deal of time, money and energy. Therefore, when
the field of inquiry is large, this method becomes difficult to adopt because of the resources
involved. In this study, the population is all the faith-based health institutions in Zimbabwe, which
according to the Zimbabwe Association of Church-related Hospitals (2020), currently stands at
130 hospitals and clinics.
3.4.2 Study sample
Many a time it is not possible to examine every item in the population due to constraints of time,
money and access (Saunders, 2009). Kothari (2014) proffers that it is usually possible to obtain
sufficiently accurate results by studying only a part of the total population. In such cases there
would be no utility of census surveys. However, it needs to be emphasised that there is no use in
resorting to a sample survey when the universe is a small.
In practical life, considerations of time, cost and access when conducting field studies almost
invariably lead to a selection of a sub-set of respondents. The respondents selected should be as
representative of the total population as possible in order to produce a miniature cross-section
(Kothari, 2004).
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Henry (1990) argues that using sampling makes possible a higher overall accuracy than carrying
out a census. This is according to him is because the smaller number of cases for which one would
need to collect data would allow more time for other critical activities such as designing and
piloting the means of data collection, checking and testing data for accuracy prior to analysis, as
well as more resources to higher for example higher qualified research staff or assistants.
ADP currently has the following employees and patients listed below. For the purposes of this
case study, the researcher opted to approach more than 50% of the possible respondents, to
economize on limited time whilst getting an accurate cross-sectional view of ADP. The target
sample is also enumerated below.
Demographic Classification
Current
Study sample
Percentage
Statistics
Dentists
3
2
67%
Dental Support Staff
2
1
50%
Ancillary Support Staff
3
2
67%
Non-Employee
2
2
100%
634
159
25%
Administrators
Patient and patient records
Average
62%
Table 3.1: Target Sample Statistics
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The dentists and dental assistants are the frontline, revenue generating workers. The support staff
members are the accountant, receptionist and janitor, while the Administrators’ have been
classified as non-employee members of the Administrative Committee, the body charged with the
oversight and day to day running of the institution. The Administrative committee comprises the
senior dentist, the accountant, the receptionist and the two non-employee administrators from the
head-office, housed at the same complex as ADP.
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3.4.3 Sampling Techniques
A combination of sampling techniques was employed in the study, as a result of the different
groups involved. According to Saunders et. al. (2009) with probability sampling the chance, or
probability, of each case being selected from the population is known and is usually equal for all
cases. This means that it is possible to answer research questions and to achieve objectives that
require you to estimate statistically the characteristics of the population from the sample. For nonprobability samples, the probability of each case being selected from the total population is not
known and it is impossible to answer research questions or to address objectives that require you
to make statistical inferences about the characteristics of the population.
Convenience sampling was used in conjunction with quota sampling to select interviewees from
the staff members. Two of the three dentists were interviewed, and care was to be taken to ensure
gender balance. Both administrators were interviewed. Of the three support staff members, one
manager and one non-manager where selected.
According to Saunders et. al.(2009), probability sampling (or representative sampling) is most
commonly associated with survey-based research strategies where you need to make inferences
from your sample about a population to answer your research question(s) or to meet your
objectives. The researcher opted to follow the process recommended by these authors for carrying
acquiring a probability sample for the purposes of analysing patient records. The sampling process
is divided into four stages: 1) Identify a suitable sampling frame based on your research
question(s) or objectives.2) Decide on a suitable sample size. 3) Select the most appropriate
sampling technique and select the sample. 4) Check that the sample is representative of the
population.
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The random sampling method chosen for analysing patient cards is the systematic random
sampling method. The researcher had to select one out of four records (159 out of 634 patient
records). A sampling frame which was a list of all patients was extracted from the AccountingOne
Software System, and the patients’ names numbered chronologically from number 1 to number
634. An online random number generator (www.random.org) was used to determine the starting
point (Patient 187), and that patient, as well as every fourth patient thereafter was included in the
sample, reverting back to the start of the list when I reached the end. The list of 159 patients was
then followed, analysing each patients record for key success factors to be considered in the
construction of the balanced scorecard.
3.5 Data Collection Techniques
According to Saunders et. al (2009), various data collection techniques may be employed and are
likely to be used in combination. They may include, for example, interviews, observation,
documentary analysis and questionnaires. Consequently, if one is to use a case study strategy one
is likely to need to use and triangulate multiple sources of data. This research made use of
interviews, document analysis and observation. Saunders et. al. (2009) define triangulation as the
use of different data collection techniques within one study in order to ensure that the data are
telling you what you think they are telling you. The guides for documentation analysis and the
interviews are included in the appendices.
3.5.1 Semi-structured interviews
An interview is a purposeful discussion between two or more people (Kahn and Cannell 1957).
The use of interviews can help the researcher to gather valid and reliable data that are relevant to
the research question(s) and objectives. Interviews can be classified as structured, semi-structured
and in-depth (unstructured) interviews. Semi-structured and in-depth interviews are often referred
68
to as ‘qualitative research interviews’ (King 2004). Saunders et. al. (2009) posit that in semistructured interviews the researcher will have a list of themes and questions to be covered,
although these may vary from interview to interview. This means that one may omit some
questions in particular interviews, given a specific organisational context that is encountered in
relation to the research topic. The order of questions may also be varied depending on the flow of
the conversation. On the other hand, additional questions may be required to explore the research
question and objectives given the nature of events within particular organisations. The nature of
the questions and the ensuing discussion mean that data will be recorded by audio-recording the
conversation or perhaps note taking. The researcher employed the use of semi-structured
interviews in this study.
3.5.2 Content Analysis
According to Kothari (2004) content-analysis consists of analysing the contents of documentary
materials such as books, magazines, newspapers and the contents of all other verbal materials
which can be either spoken or printed. Content-analysis prior to 1940’s was mostly quantitative
analysis of documentary materials concerning certain characteristics that can be identified and
counted. However, since 1950’s content-analysis is mostly qualitative analysis concerning the
general import or message of the existing documents. The researcher employed content analysis
to analyse the financial reports, patient cards and other business documents relevant to the study.
3.5.3 Observation
Kothari (2004) defines observation as the collection of information by way of investigator’s own
observation, without interviewing the respondents. The information obtained relates to what is
currently happening and is not complicated by either the past behaviour or future intentions or
attitudes of respondents. This method is no doubt an expensive method and the information
69
provided by this method is also very limited, but it may provide insights that may not be
discovered by other methods. The researcher will set aside one day to visit ADP and observe
operations so as to gain a comprehensive understanding of their operations and this will be
combined with the knowledge I gained while working at ADP.
3.6 Data reliability and validity
3.6.1 Reliabilty
According to Saunders et. al. (2009), reducing the possibility of getting the answer wrong in
research means that attention has to be paid to two particular emphases on research design:
reliability and validity. According to Saunders et. al. (2009), reliability refers to the extent to
which your data collection techniques or analysis procedures will yield consistent findings. It can
be assessed by posing the following three questions (Easterby-Smith et al. 2008:109): 1) Will the
measures yield the same results on other occasions? 2) Will similar observations be reached by
other observers? 3) Is there transparency in how sense was made from the raw data?
3.6.2 Validity
Kothari (2004) posits that validity is the most critical criterion and indicates the degree to which
an instrument measures what it is supposed to measure. Validity can also be thought of as utility.
In other words, validity is the extent to which differences found with a measuring instrument
reflect true differences among those being tested.
Robson (2002) proffers four threats to reliability; subject or participant error, subject or participant
bias, observer error, and observer bias. The researcher considered the fact that the interviewees
might give different answers depending on their mood the day the interview took place. This is
referred to as subject or participant error. The researcher does not think this would result in any
misleading information for the study since it is based on a number of interviews and buttressed
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by triangulation. Participant relates to whether the interviewees were sharing their real point of
view or will they provide information they are expected to by their immediate supervisors (Lewis
et al., 2003). This issue has been solved by guaranteeing anonymity and confidentiality of
information submitted. The main purpose of the anonymity is to protect the dental staff and
patients or clients.
Two other threats to reliability are regarding the observers of the interview. Observer error is the
problem that occurs when more than one person performs the interview; different people might
elicit different opinions from the interviewees. In addition to this is the observer bias, which is if
two or more conduct the interview, there are different ways to interpret the answers (Lewis et al.,
2003). This will not affect the current study, as the research is being carried out by an individual
researcher. Further to this, the intention is to give feedback to the respondent documenting their
input so as to verify intent, content as well as eliminate any misunderstandings.
Validity is present when the findings actually support the point or claim. There are some different
threats also to validity, one is that the researchers should consider if there has been any special
event or changes that have taken place at the research organization that might influence or affect
the results (Lewis et al., 2003). There has been an administrative change at Adventist Dental
Practice, since the 1st of June 2020, with the appointment of a new director and a new accountant,
however this has not borne any operational changes to date, and is therefore not expected to affect
the research.
The research concerns the functioning of the BSC and its application and therefore includes
information covering or affecting several years. When conducting interviews one can increase
both the validity and reliability by provide interviewees with information about the interview
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beforehand (Lewis et al., 2003). Before the interviews with the respondents we sent our questions
beforehand to them, to make sure that they had the information that we needed and also to make
sure that the interviewees were prepared to answer the questions.
3.6.3 Generalizability
Generalizability is an issue that is difficult when it comes to semi-structured interviews (Lewis et
al., 2003). The chosen ADP case study cannot be generalized to other settings since this thesis is
only based upon this one organization. Thus any generalizations made in this study can only refer
to ADP and will need further research to be applicable to other dental clinics and health
institutions..
Other issues to be considered are whether the correct information has been obtained as opposed
to just the positive aspects of the BSC. Has the appropriate theory been used in the study, and
finally, do the conclusions stand-up to the closest scrutiny (Lewis et al., 2003).The few
respondents that we interviewed may only give a general reflection of the communication and
information paths that are being created with individual employees, and therefore provide an
overall impression.
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3.7 Data analysis techniques and presentation
In order to select indicators for BSC, the modified Delphi consensus process was applied using
the standard criteria developed by RAND (Marshall et al., 2006). This includes; (i) importance,
(ii) scientific soundness (credibility), (iii) appropriateness to clinics’ strategic plan, (iv) feasibility
(i.e. whether the measure was available easily as part of management information system, could
be collected accurately, reliably, and at a reasonable cost); and (v) modifiability of the clinical
outcome measures. Each indicator was rated on a scale of 1-9 for the above criteria. Median scores
and measures of disagreement for the whole panel and individual ratings were discussed, in
subsequent meetings.
Panel members were given an opportunity to change their ratings after the discussions. Indicators
receiving final scores of 7-9 were regarded as robust, 4-6 as equivocal, and 1-3 as weak. All
indicators receiving scores of 7 or more (face validity) were included in the final set. In addition,
a small number of indicators which received scores of 4-6 were retained if the panelists considered
the indicators essential to contribute to the overall balance and comprehensiveness of the final set.
The indicators (receiving a median score of 7 or more) were finally selected and organized into
the four BSC quadrants.
Qualitative ’content analysis’ was done. It is a well-developed and widely used method in social
sciences with an established pedigree (Dixon-Woods et al., 2005). Data abstraction, emphasizing
actual communications (manifest content), descriptions and interpretations on a higher logical
level (latent content) with the creation of codes, categories and themes was done. For the key
informant interviews the unit of analysis was the interview text and for participant observation
the meeting diary.
As a next step descriptive codes were abbreviated on the left-hand margin of the interview text.
A short sheet was then prepared that listed page numbers devoted to particular items, which later
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became subheadings in the text. Once the interviews and observation diary were coded, a simple
storage and retrieval system was designed in QSR Nvivo software 2.0 so that researchers could
easily locate relevant items of information, each in a separate folder.
Triangulation of methods gives multiple perceptions which can clarify meaning and verifies the
repeatability of observations (Stake, 2005). Reflections and reporting based on both field notes
from participant observation studies and other empirical data such as interviews is emphasized in
ethnographic studies (Palsson, 2007). All sources of evidence (content analysis, participant
observation and key informant interviews) were reviewed by the researcher. Data was analyzed
together, so that the case study findings were based on convergence of information from these
three sources. Unclear responses and contradictory reports obtained during key informant
interviews were checked with participant observation text and by sharing draft notes with key
informants. Moving between these two venues (interviews and observations) allowed for frequent
independent reflection and then discussions with other involved project members.
The evolution of discrete themes could therefore be explored and either confirmed or refuted.
Themes were only retained when more than 50% of respondents described the same items in key
informant interviews and then the same was confirmed by analysis of participant observation
texts. Findings from quantitative surveys were also consulted to highlight the cultural context of
BSC implementation.
3.8 Ethical considerations
The study was submitted and approved by the medical director. Institutional consent and
support was a part of this project throughout the execution of the study. The study subjects
were institutional employees (administrators and staff) as well as patients.
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Participation in survey and interviews was purely voluntary and without any monetary
compensation. There were several queries on the purpose and institutional utility of this project
however no refusals to consent to the key informant interviews were or to be observed were
noted.
Interviewees had the right to skip any question they did not wish to answer or to withdraw from
the interview at any point. Interview transcripts were shared with interviewees before coding
for the purpose of qualitative analysis.
Some individual participants were reluctant to contribute occasionally. Reassurance was
therefore required from time to time to clarify that survey and interview data will only report
analysis and their personal identity or clinical unit affiliation will not be revealed. This shows
the importance of periodic sensitization to the objectives of the study and highlights challenges
of conducting research in one’s own organization or former organization of employment.
3.9 Chapter summary
Having looked at the research plan and analysis procedure covering content analysis, interviews
and observation, together with issues pertaining to reliability and validity, the researcher will now
go on to document the actual research findings.
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Chapter 4: Data Presentation and Analysis
4.1 Introduction
This chapter focuses on presentation techniques, interpretation and discussion of research
findings.
4.2 Feasibility of BSC Implementation In LICs
Using the specified search terms and review methodology, 32 articles were found to be of direct
relevance. Of these 26 were actual descriptions (case studies) of BSC implementation in various
health care settings, one was a review (Zelman et al., 2003) and 5 were related to BSC design and
principles.
There were 174 articles which do not report using a formal BSC but use tools, performance
measurement techniques and indicators quite similar to the BSC framework. Most common
themes were centered on quality of care initiatives and organizational management. The majority
(135) of these articles were from HICs while the remaining 39 were based on experience and
context of LICs. The latter provided information for commentary while comparing experience of
BSC in HIC against contextual realities of LIC.
It was found that use of BSC is spread over a broad range of health care settings with great
diversity and concentrated in the HICs (United States mainly). Besides its application for strategic
management it appears that these health care organizations have used BSC for public information,
clinical pathways, hospital department performance, women’s quality of care, outcome
measurement, managed care evaluation and performance measurement of a consortia of hospitals
(Inamdar et al., 2000; Jones and Filip, 2000; Zelman et al., 2003). The traditional four perspectives
of BSC were thus quite amenable to modification. Most of the organizations that used BSC report
an improvement in all four traditional quadrants of BSC. Two large scale health sector
applications of the BSC were found for acute care hospitals in Ontario Canada and critical access
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hospitals in the US (Zelman et al., 2003). A third dimension of NHS Trust hospitals UK was
added to this in order to enhance the body of evidence. Although all three applications are based
on theory and concepts of BSC, they are different in their approaches and thus make an interesting
comparison and contrast.
Using the criteria developed by the National Committee for Quality Assurance (NCQA) for
improving quality of services in low and middle-income countries (NCQA, 2006), the researcher
contextualized application of BSC in LICs (Table 5).
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Analytical framework for translating BSC experience from high to low income settings
PARAMETERS
Benefits
COMMENTARY
BSC has resulted in improved and effective health care in HIC.
Interest, ability to report, respond and compliance to performance
measurement is however questionable in LIC.
Feasibility
In HIC basic requirement for BSC implementation turned out to be
infrastructure for valid, comprehensive and timely information
system. This is currently lacking /of low quality in LIC
Objectivity
BSC was designed in HIC using established guidelines and strategic
plans. This shows that BSC has a basis in science not in individual
judgement. However most LIC do not have operational strategic
planning in place
Cost-effectiveness
BSC has been applied in HIC at a single health outlet or a larger
health system with minimal training and input. Even then the
issue of costs is a major constraint in under-resourced systems.
Sustainability
BSC was designed by program staff themselves in HIC based on
needs. However accountability systems are weak in LIC and
sustainability may be an issue
Table 4.1: Analytical Framework for translating BSc experience from HI to LI settings
Adapted from: NCQA recognition model on quality assessment and improvement in low and middleincome countries
Source: Hibbard et al., 2005; Langenbrunner and Liu, 2005; McIntyre et al., 2001; McNamara, 2006;
Mehrotra et al., 2003; Siddiqi et al., 2005; Smits et al., 2002; Unger et al., 2003; Bhat, 1996; Bourne
2000; Grol, 2001; Brown et al., 2001; Nandraj et al., 2001
Any direct evidence describing BSC use in a low-income health care setting or why such an
implementation is hindered or how it could be facilitated was not available at the time of this
systematic review. The articles that described BSC use in HICs were all individual case studies
and not designed to evaluate BSC outcomes. Regarding experience of using BSC in HICs, it was
observed that theory and concepts of BSC have been applied among all types of health care
organizations and on a large scale. Committed leadership, quality information systems, viable
strategic plans, and optimum resources emerged as required prerequisites for BSC
78
implementation. It is however to be noted that even within LICs there are pockets of relatively
less deprivation where the required BSC prerequisites may be fulfilled. Cautious implications
for BSC adaptability in LICs however need to be drawn. An organizational cultural assessment
must precede BSC implementation
4.3 Use of existing data in designing BSC
In the initiative towards BSC design, data which are routinely collected by ADP were used in to
develop an integrated core of 20 indicators. Despite few measurement issues related to
comparability across various settings, many indicators in were similar to the ones shortlisted in
HICs (Baker and Pink, 1995). Other studies have also used existing documents to create effective
Balanced Scorecards by using similar criteria (Idänpään-Heikkilä etal., 2006; Marshall et al.,
2006; McLoughlin et al., 2006). The Afghanistan study (Peters et al., 2007) shortlisted 29
indicators for the BSC including domains of patient and community, staff, capacity for service,
service provision, financial system and overall vision. Despite contextual differences similarity
can be drawn among indicators shortlisted those that were identified in Canadian dental clinics
(Schalm, 2008).
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4.4 Depth Interview Feedback
The researcher will now proceed to document the feedback from the depth interviews, by
beginning with a tabular summary. Of the planned 9 interviews, the researcher was only able to
carry out 7 face to face interviews due to the unavailability of prospective interview respondents
within the limited time (3 administrators and 4 staff members).
Demographics
Factor
A
B
C
D
Gender
Male: 3
Female: 4
Age
Below 40 yrs: 3
Above 40 yrs: 4
Qualification
None: 1
Diploma: 2
Degree/s: 4
Position
Dentist: 2
Dental Assistant: 1
Support staff: 2
Administrator: 2
Tenure at ADP
Less than 1 yr: 2
1-3yrs: 2
3-5yrs: 1
More than 5 yrs:
2
Table 4.2: Demographic Analysis of Respondents
Interview Feedback
Interview Question/Area
Constructive
What would you describe as the critical success factors for
ADP?
7
In what way is performance measurement carried out at ADP?
5
2
4
3
What resources if any, can be allocated for BSC
implementation
5
2
How do you expect the implementation of the BSC to affect
the clinic’s staff and operations?
7
How is the BSC different from what performance
measurement systems already existed in your clinical clinic?
What might helped or hinder the BSC implementation
activities in your clinic?
Unconstructive
7
Table 4.3: Analysis of interview feedback
80
Only 2 finance related personnel had an understanding of the Balanced Scorecard prior to the
researcher explaining the concept, leading to constructive feedback on most interview pointers.
Initially 37 critical success factors were listed from feedback from respondents, and these where
short-listed to the 20 used in the proposed Balanced Scorecard. Performance measurement and
management is weak under the current setup, with the management practice only being carried
out on average once every three years hence there is need to improve the current performance
management culture.
ADP has sufficient financial resources, as they have posted profits for the two previous financial
periods (2018 and 2019) and are sufficiently liquid, and the necessary budgetary flexibility. A
consultant may need to hired on a contract basis to oversee the technical aspects of the
implementation, as evinced by four of the interview respondents.
The BSC is expected to improve operations at ADP, resulting in higher liquidity, revenue, less
expenses, higher customer and employee satisfaction as well as a better ADP reputation.
Management also anticipate that they will have more practical knowledge following a system
reorganisation based on the intended BSC implementation. However, three respondents felt BSC
would result in more work for employees, with many feeling strained already under the current load.
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4.5 Designing the BSC Using Formal Consensus Technique
An expert multidisciplinary panel was involved in selecting indicators and designing the BSC. A
modified Delphi Group Technique was used to reach consensus about indicators for an
institutional level BSC. Following an extensive review of existing internal documents (periodical
quality assurance, patient and employee satisfaction surveys and financial reports), a preliminary
list of 50 indicators was formulated in line with dental practices strategic plan. No indicators were
removed from consideration at this phase of the activity. The next step was to prioritize key
performance indicators based on the criteria described under the Data Analysis section.
The panel used the modified Delphi technique during face to face meetings to individually rate
each indicator on a scale of 1–9 for the above criteria. All criteria were given equal weightage.
Twenty indicators (receiving a median score of 7 or more) were finally selected (see the following
table.) . These indicators were distributed across all 4 quadrants of BSC: financial perspective
(n=4), internal business (n=7), human resource perspective (n=4) and patient satisfaction
perspective (n=5).
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Shortlisted List of Indicators for the ADP Balanced Scorecard.
INDICATORS
Financial Perspective (FP)
•
Annual Patient Value
•
Length of procedure
•
Daily census
•
Net operating margin
•
Overall FP Median
Median
8.00
7.00
8.00
9.00
8.00
Internal Business Perspective (IBP): Clinical Outcomes (efficiency and quality)
Denture and crown delivery time
•
Percentage of new patients
•
Avoidable patient revisits
•
Incidence of drug reactions
•
Nosocomial infection
•
Dental procedure injuries
•
Overall IBP Median
Human Resource Perspective (HRP)
8.00
8.00
7.00
7.00
8.00
8.00
•
Satisfaction with job
•
Satisfaction with colleagues
•
Satisfaction with dental facilities
•
Satisfaction with organization
•
Annual Production per full time employee
•
Overall HRP Median
Patient Satisfaction Perspective (PSP)
8.00
7.00
8.00
8.00
7.00
7.00
•
•
•
•
•
•
•
7.40
Satisfaction with dentists
Patient Complaints
Satisfaction with reception and support services
7.00
8.00
7.00
Satisfaction with dental assistants’ services
Proportion of patients recommending ADP to their
families and friends
Overall PSP Median
7.40
7.00
8.00
Table 4.4: Shortlisted List of Indicators for the ADP Balanced Scorecard
83
4.6 Summary of Results
BSC compels individual clinicians and managers to jointly work towards improving
performance. The Delphi group process led to a pragmatic interpretation of existing data
resulting in the design of a scorecard with comprehensive indicators in multiple dimensions.
A need for stringent definitions, international benchmarking and standardized measurement
methods was identified. This scorecard is now ready to be implemented by this hospital as a
performance management tool, subject to a culture study, to determine the appropriateness of
the timing of the implementation.
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Chapter 5: Conclusion and Recommendations
5.1 Introduction
In this section, the researcher will interpret the meaning of the research results, showing the link
between the results and the literature review, showing the points of similarity and departures with
theory and previous research findings on the topic.
5.2 Summary of Findings
5.2.1 Feasibility of BSC in the HICs
The study demonstrates increasing use of BSC in HICs. It was observed that the theory and
concepts of the BSC have been applied among all types of healthcare organizations and on a large
scale. The systematic review showed that BSC promoted integration and facilitation of clinical,
operational and financial indicators in HICs with greater employee motivation and patient
satisfaction, which is a goal that health care organizations in both HICs and LICs are today aiming
for.
The Campania Regional Government applied the BSC and was successful in overcoming the
surmounting deficit incurred within the region’s health services (Impagliazzo et al., 2009).
These studies complement the findings from this study , emphasizing that BSC application must
be adapted to suit specific organizational contexts (Guifang, 2009). Hospitals initially used the
BSC to avoid barriers such as financial pressure however BSC has since evolved to achieve the
mission and vision of the organization as well (Schalm, 2008).
5.2.2 Feasibility of BSC in LIC settings
Despite the positive outcomes demonstrated in the HICs, caution was warranted in the use of BSC
within the LIC health care settings. This caution is supported by the realities of health care systems
in LICs and LMIC settings. In terms of health care financing, these countries spend less than US$
85
34 per capita annually on health, and are marked by weak governance, bureaucratic culture and
lack of accountability mechanisms (Nishtar, 2009; Siddiqi et al., 2009). Compliance to PM and
maintaining quality information systems (requirement for effective BSC) can therefore be only
partially feasible. Moreover, lack of accountability impairs sustainability of initiatives such as the
BSC. Health delivery systems lack quality and strategic planning due to which objectivity of the
BSC will remain a challenge. Also, with poor central government spending on health and
constrained resources, cost- effectiveness of BSC is an issue.
At the time when the current study was conducted no studies of BSC application in the context of
LICs could be identified. An experience of using BSC has now been documented from
Afghanistan where BSC has been applied at a national (macro) level by the Ministry of Public
Health (MOPH) to demonstrate how provinces and the country are doing in delivering the basic
package of health services (Peters et al., 2007). In the absence of a routine system to collect
information on health services, the MOPH chose to initiate a program to monitor health services
through household surveys and annual surveys of health facilities. There were obstacles to
developing a BSC based on surveys, including the lack of a sampling frame, insecurity, bad roads
and poor communications etc. Once operational, the BSC proved to be a useful tool to summarize
the multidimensional nature of health services and enabled managers to benchmark performance
and identify strengths and weaknesses in the Afghan context. Recently, in a Chinese hospital,
BSC was integrated with an incentive plan in the nursing field resulting in improved performance
(Chu, 2009).
These examples further support findings from the current study. Due consideration to variable
levels of feasibility is required while implementing BSC in LICs. It is to be mentioned that prior
to launching the BSC it was anticipated that most of the desired prerequisites for BSC
implementation i.e willingness of leadership, presence of good quality information systems,
86
functional strategic plan and optimal resources are in place in ADP. Therefore, the current study
used the current information data base to design the BSC and study IV was rolled-out as an
implementation case study of BSC.
5.2.3 Paucity of Analytical Studies On BSC in Health Care
It can be seen from the systematic review in that BSC experience has mostly been described as
case studies in health care. There is uncertainty not only about the effectiveness of BSC but also
how to evaluate such effectiveness. In health care the effectiveness of clinical interventions is
assessed on the basis of evidence from experimental studies and randomized clinical trials (the
‘gold standard’) as called for in 1972 by Archie Cochrane (Cochrane and Silagy,1999). This
evidence-based approach however does not neatly fit current state of maturity in management
research (Thor, 2007). This is so because the methodological orientation in health care
management seeks to unpack the mechanism of how complex programmes work (or why they
fail) in particular contexts and settings (Pawson et al., 2005). Therefore, the implementation of
evidence based practice in health care management is unlikely simply to follow the established
clinical model (Walshe and Rundall, 2001).
Moreover, studies reveal that no coordinated effort has been undertaken to conduct and
periodically update systematic reviews for healthcare managers and policy makers (Lavis et al.,
2005). Little if any attempt has been made to adapt existing reviews for enhancing their local
applicability (Lavis et al.,2006). Despite the nature of qualitative data available, the current study
blended features common to systematic reviews (Pai et al., 2004) with interpretative data analysis
and synthesis while reporting experience of BSC use in HICs and its applicability in the LIC
context.
87
5.2.4 Indicator Selection and Measurement Issues
It is to be mentioned that the primary search for indicators was not exhaustive in since the starting
point was limited by data which were already being collected by ADP, as well as feedback from
interview respondents. These indicators were relevant to ongoing management processes in
finance, marketing, and human resource departments of the study hospital and to the current
hospital quality accreditation plans. However, certain valuable and relevant indicators for the BSC
may have been overlooked or were not available. Besides the indicators shortlisted in this study,
BSCs in other settings have come up with more sophisticated indicators on survival rates and age,
sex and disease- specific mortality and morbidity ratios etc (Robinson et al., 2003; Schalm, 2008;
ten Asbroek et al., 2004; Wachtel et al., 1999). The BSC developed in this setting did not have
some of these more analytical indicators. Such lack of in-depth outcome data has been listed
elsewhere as a BSC implementation challenge (Schalm, 2008). On the other hand many of the
current indicators in the internal business quadrant of the BSC are driven by the need to collect
data for accreditation at this clinic (ADP).
Besides the issue of completeness of the data sets, the results from this investigation also reflect
limitations of routinely collected data. Certain indicators selected for BSC had relatively lower
face validity as assessed by their median ratings. This was mainly due to lack of standardized
definitions and measurement techniques, reliable instruments, adequate sample sizes and response
rates etc. Other studies (Baker and Pink, 1995; Zeitlin et al., 2003) have also noted that
methodological shortcomings of many indicators have generated skepticism about the data
sources, consistency of reporting, derivation of the numbers and their usefulness in offering
analogous estimates. However, starting with the search of more sophisticated and comprehensive
indicators would have required more efforts, time, and resources and was simply not feasible
within the scope of this study. Due to restricted resources and capacities in LICs it has already
been recommended that only a limited set of indicators should be selected (Larson and Mercer,
88
2004). Relying on existing information system and using standard steps of Delphi technique, this
BSC with 20 indicators was derived. As such this is a preliminary step towards defining a more
inclusive and comparable set of indicators for use across LIC and HIC hospital settings.
Other studies while selecting regionally comparable indicators, have given the criterion
‘feasibility’ a lesser weightage. This is because limited information about data sets in other
countries is available (Mc Loughlin et al., 2006). Since the BSC indicators in this study were
derived specifically for the study clinic from already ongoing information system, ‘feasibility’ of
acquiring the information was not an issue in this study. An equal weightage was thus given to all
criteria while short listing indicators for the study.
89
5.3 Conclusions
In this thesis I have set out to contribute to the limited body of empirical evidence about the use
and applicability of the Balanced Scorecard in a LIC dental setting. It has been explored how
HICs have used the BSC for improved performance management and how the experience can be
transferred to the context of LICs. Importance of organizational culture and leadership in initiating
and implementing the BSC has been emphasized. I have pointed out the value of
a
multidisciplinary panel in selecting indicators for BSC using formal consensus methods.
Moreover the case has been argued for using existing dental clinic data to select indicators for the
BSC, despite the inherent limitations of data quality management in LICs.
The key conclusions from this thesis are:
Direct evidence describing BSC use in a LIC health care setting or why such an
implementation is hindered or how it could be facilitated has not been demonstrated
Delphi process is useful in selecting indicators for BSC with consensus. Measurement
issues related to indicators pose a methodological challenge.
Committed leadership, quality information systems, participatory culture and
multidisciplinary team approaches can enhance feasibility of BSC implementation
90
5.4 Recommendations of the Study
Studies show that BSC implementation is usually unsuccessful where the concept is not
communicated properly. It is recommended that extensive training courses be conducted to spread
the awareness of BSC. Kaplan and Norton (2001a) and Hao et al. (2012) suggest using multiple
communication tools to ensure that employees get the right message i.e. quarterly town meetings,
brochures, monthly newsletters, education programs, and company intranet. It is recommended
that all of these means of communication are used at KFSH. Further, Mooraj et al. (1999) suggest
that organisations should apply a combination of top-down and bottom-up communication
strategies to implement BSC and to ensure the involvement of the full organisation. It is also
recommended that the importance of external stakeholders is considered by including them in the
communication loop.
5.5 Limitations of the study
5.5.1 Challenges of doing research in one’s own organization
The author of this study subject is a former employee of the same organization, having only been
transferred in May 2020. This has the potential of introducing an observation bias and affecting
team dynamics. It is possible that some respondents showed greater enthusiasm because of the
presence of the researcher (Hawthorne effect). Influence of the Hawthorne effect seems unlikely
to have affected results were corroborated by interviews and document analysis to increase the
objectivity and neutrality of results. Similar strategies to decrease the effect of observer on study
participants have been described by Pettigrew (Pettigrew, 1999).
There is a paucity of literature on the hurdles that employees face while using their own
organization as the study site. Some of the challenges that were encountered in the study were the
ethical concerns on part of a few staff members about the anonymity and confidentiality of their
views with regards to their unit’s/department’s leadership as the author of this thesis was also
91
working in the same organization. Other studies have pointed out that in relationships within an
organization subordinates usually have to encounter certain repercussions from their supervisor
if their views about the leader are openly expressed (Coghlan and Brannick, 2001a). It has been
reported elsewhere that combining action research role with regular organizational assignments
creates a role duality and measures need to be taken to reduce the observation bias (Coghlan and
Casey 2001b; Sellgren, 2007b).
92
5.5.2 Limitation of Study Questionnaire
Questionnaires have limitations. The main limitation is that they rely on perceptions of the
individuals (Arvonen, 2002). Another concern is that these questionnaires do not measure real
behavior, just the attitude of the employees about their organization and leadership. The study
participants were well conversant in English. However the questionnaire was not pretested due to
time constraints. Despite these measures, cautious interpretation of results is important as the
questionnaire was not locally validated.
5.5.3 Generalizability
The study recognized that Zimbabwe does not have a national medical institution database.
Therefore, the indicators developed for BSC in this hospital cannot be necessarily applicable to
other dental settings in Zimbabwe. However there are several studies on BSC (described above)
which came up with similar set of indicators using a consensus process.
Overall generalizability of this study to other private or faith-based clinic settings within and
outside Zimbabwe should be carefully interpreted as the study is based ADP data only. However,
it seems feasible that findings could apply to dental clinics which are similar to ADP. At least
three other dental facilities in Bulawayo are comparable to the study clinic in terms of dental
facilities and information technology infrastructure. Additional research is warranted to further
develop the contextual understanding of BSC design and broaden the evidence base generated
through this study.
93
5.6 Recommendation for further studies
The current study concluded that committed leadership, participatory culture, quality information
systems, viable strategic plans, and optimum resources are essential prerequisites for BSC
implementation. These issues will need to be looked at in-depth before the BSC can be implemented
successfully. The study identified organizational culture assessment as a key prerequisite prior to BSC
application. Other studies also recommend that prior to rolling the BSC an assessment of ‘strategic
readiness’ be conducted because success of BSC implementation will ultimately
depend on the
culture of the organization being appropriate and receptive (Kaplan and Norton, 2004; Schalm, 2008).
Rabbani (2010) identified organizational culture assessment as a key prerequisite prior to BSC
application. Other studies also recommend that prior to rolling the BSC an assessment of
‘strategic readiness’ be conducted because success of BSC implementation will ultimately
depend on the culture of the organization being appropriate and receptive (Kaplan and Norton,
2004; Schalm, 2008).
Rabbani (2010) goes on to futher advocate that wise process and takes more time to manifest. It is
advocated that multiple cycles of BSC execution are required for its complete implementation
(Quality Insights of Pennsylvania, 2009). No conclusions on BSC effectiveness in bringing about
a change in the indicators can be drawn from this thesis.
94
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Appendices
103
APPENDIX 1: DATA
EXTRACTION FORM FOR
SYSTEMATIC REVIEW
104
SYSTEMATIC REVIEW: DATA EXTRACTION FORM
Balanced Scorecard in Health care
Article Reference #
Date
Name of Extractor
Name of Journal
Language of article
Year of Publication
Authors
Full text
available
1. Yes
2. No
Name of Organization where BSC implemented
Does this study
involve BSC
application
1. Yes
2. No
3. Other PM
initiative
related to BSC
Study Design 1. General
discussion of
BSC principles
2. Case study
3. Quasi
experimental
design
4. Case Control
study
5. Cohort study
6. RCT
7. Other
Study outcomes
1. Well described
2. Partially
described
3. Not described/
evaluated
4. Not applicable
Briefly describe the study results with implications:
Selection criteria met:
1. Yes
2. No
105
Analysis of the applicability of the Balanced Scorecard concept to faith-based health
institutions in Zimbabwe: The case of Adventist Dental Practice
APPENDIX 2: KEY
INFORMANT GUIDE
106
Analysis of the applicability of the Balanced Scorecard concept to faith-based health
institutions in Zimbabwe: The case of Adventist Dental Practice
Demographic Data
Gender :
__________
Age:
_______ years
Qualification:
________________________________________________________
Position:
________________________________________________________
Tenure at ADP:
_______ years
Key informant interview guide
a) What would you describe as the critical success factors for ADP?
b) In what way is performance measurement carried out at ADP?
c) How is the BSC different from what performance measurement systems already
existed in your clinical clinic?
d) What resources if any, can be allocated for BSC implementation
e) How do you expect the implementation of the BSC to affect the clinic’s staff and
operations?
f) What might helped or hinder the BSC implementation activities in your clinic?
Interview guide developed based on Pettigrew and Whip’ s conceptual framework (WHAT, WHY, HOW)
107
Analysis of the applicability of the Balanced Scorecard concept to faith-based health
institutions in Zimbabwe: The case of Adventist Dental Practice
APPENDIX 3: AUTHORIZATION
TO CARRY OUT THE
RESEARCH
108
Analysis of the applicability of the Balanced Scorecard concept to faith-based health
institutions in Zimbabwe: The case of Adventist Dental Practice
1895 Mahatshula North
Bulawayo
12 May 2020
The Medical Director
Adventist Dental Practice
Suburbs
Dear Sir
Re: Request for permission to carry out a research at Adventist Dental Practice
I am kindly requesting permission to carry out my research at your institution. My
dissertation is entitled “Analysis of the applicability of the Balanced Scorecard concept to
faith-based health institutions in Zimbabwe: The case of Adventist Dental Practice.” This
research, while being a requirement for my Master of Science degree in Accounting and
Finance with Lupane State University, will also benefit your institution by providing
financial management insights and beneficial customer feedback.
It is in this light that I am requesting permission to carry out the above mentioned study. I
will need to gather facts by means of questionnaires and interviews with willing
administrators, employees and patients. I also intend to analyse some patient records and
business documents. The deadline for submission is end of this month (May 2020) so the
request is a bit urgent. I anticipate a favourable response.
Yours sincerely
Dumisani Dlodlo
109
Analysis of the applicability of the Balanced Scorecard concept to faith-based health
institutions in Zimbabwe: The case of Adventist Dental Practice
Adventist Dental Practice
41 Lawley Road
Suburbs
Bulawayo
14 May 2020
Dear Mr. Dlodlo
Re: Request for permission to carry out a research at Adventist Dental Practice
Your request dated 12 May 2020 refers. I am pleased to authorize your request to carry out
the said research. We trust that the study will be of benefit to us as an organization as well.
We wish you the best in your studies.
Yours sincerely
Dr. Jesse Agra
Medical Director
110