Seven Challenges for the Implementation of Balanced Scorecard in Hospitals

The article presents a literature review on performance measurement in health care institutions. This survey identifies seven main challenges to the implementation of the Balanced Scorecard (BSC). The external environment poses three different challenges: more rigorous regulation processes, increasingly diverse customer needs and stiffer competition. In the internal environment, the main challenges to health care management are: conflicts between management and physicians' interests, conflicts among value proposals for different kinds of customers, lack of performance measurement methods and inefficient information systems. The empirical part of the article discusses the use of performance measurement techniques by a sample of 15 Brazilian hospitals. The article shows that all the seven challenges found in the international literature are also present in the Brazilian healthcare institutions. Among other conclusions, its shows that healthcare institutions in Brazil make use of several performance measures in day-to-day management. However, the information produced by these measures is not linked to the hospitals' strategic planning. In general, the indicators are traditional and well-known and can be applied to any sector of activity. Only some financial and internal process indicators were specific to hospitals' needs and could also be found in the international literature. The indicators were distributed unequally across the four BSC perspectives. Much more accurate indicators were available for the financial and internal process approaches than for the other two approaches (clients and learning and growth). Performance measurement systems can thus be said to be much needed in Brazilian hospitals, and the focal task in implementing them is to link them with the strategic plan design. This article was presented at the 3rd CONFERENCE ON PERFORMANCE MEASUREMENT AND MANAGEMENT CONTROL, Nice, September 22-23, 2005