title: Understanding the context of balanced scorecard implementation: a hospital-based case study in Pakistan.
abstract: BACKGROUND
  As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital.
  
  
  METHODS
  Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs and reporting of performance based on the BSC during administrative meetings. Pettigrew and Whipp's context (why), process (how) and content (what) framework of strategic change was used to guide data collection and analysis. Data collection methods included quantitative tools (a validated culture assessment questionnaire) and qualitative approaches including key informant interviews and participant observation.
  
  
  RESULTS
  Method triangulation provided common and contrasting results between the four units. A participatory culture, supportive leadership, financial and non-financial incentives, the presentation of clear direction by integrating support for the BSC in policies, resources, and routine activities emerged as desirable attributes for BSC implementation. The two units that lagged behind were more involved in direct inpatient care and carried a considerable clinical workload. Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming implementation challenges in two clinical units that were relatively ahead in BSC implementation. It was noted that, rather than seeking to replace existing information systems, initiatives such as the BSC could be readily adopted if they are built on existing infrastructures and data networks.
  
  
  CONCLUSIONS
  Variable levels of the BSC implementation were observed in this study. Those intending to apply the BSC in other hospital settings need to ensure a participatory culture, clear institutional mandate, appropriate leadership support, proper reward and recognition system, and sensitization to BSC benefits.
authors: Department of Community Health Sciences, Aga Khan University, PO Box 3500, Stadium Road, Karachi, Pakistan. fauziah.rabbani@aku.edu
authors: Fauziah
authors: F
authors: Rabbani
authors: Sabrina Nh
authors: SN
authors: Lalji
authors: Farhat
authors: F
authors: Abbas
authors: Sm Wasim
authors: SW
authors: Jafri
authors: Junaid A
authors: JA
authors: Razzak
authors: Naheed
authors: N
authors: Nabi
authors: Firdous
authors: F
authors: Jahan
authors: Agha
authors: A
authors: Ajmal
authors: Max
authors: M
authors: Petzold
authors: Mats
authors: M
authors: Brommels
authors: Goran
authors: G
authors: Tomson
mesh_terms: D003362:Cost-Benefit Analysis; D003625:Data Collection; D017598:Efficiency, Organizational; D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D007255:Information Services; D007407:Interviews as Topic; D017146:Models, Organizational; D019982:Organizational Case Studies; D009937:Organizational Objectives; D010154:Pakistan; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011795:Surveys and Questionnaires