1. THE TERTIARY CARE HOSPITAL
SYSTEM
UTILIZATION OF THE BALANCED SCORECARD
Nancy Southerland
September 14, 2014
Abstract
The tertiary carehospital has asits primary responsibility to deliver health care to the most sick
and severely ill.The management of the critically ill isseen as a wrathful driver of costs within
the confines of the tertiary care hospital both in the United States and abroad.Through
utilization of the Balanced Scorecard not only are the needed financial metrics elevated but the
added dimensions of customer (both internal and external), internal businessprocesses,and
learningand growth dimensions arepartof the balanced scorecard perspectives.Through use of
the balanced scorecard in thetertiary carehospital,the wrath of the cost driver of the
therapeutic management and intervention of the critically ill isassuaged.Tertiary carehospitals
are ableto deliver solid operatingmargins whileensuringpatientsatisfaction with good clinical
outcome of the critically ill whileexperiencingmuch employee engagement. The tertiary care
hospital enjoys the interconnectedness of the dimensions realizingquickly thatover time all the
BalanceScorecard perspectives arefinancial dimensions.

2. 1
Introduction
The tertiary care hospital industry/business has been in a state of distinct challenge at home
and abroad for multiple decades. For multiple decades entrepreneurs and businessmen failed to
see even the hospital system particularly the tertiary care hospital/business system as a strategic
business unit primarily because of the care being provided to people. This blinding of eyes has
been removed with ubiquitous stated health care reforms and pressure upon hospitals to make the
black far exceed the red. Pressure has been even more predominant upon the larger tertiary care
hospital system/business unit verses the smaller community hospital since chronic disease is a
cost driver that affects the tertiary care hospital system with greater vengeance. In fact, many
tertiary care hospitals have struggled to maintain a solid operating margin in these challenging
days.
This paper puts forward the deliverance of the global tertiary care hospital/business system
through the utilization of the Balanced Scorecard. As stated, pressure has been more
predominant upon the larger tertiary care hospital/business system given chronic disease,
intensive care, surgery intensive care, etc. are all wrathful cost drivers. In fact, all chronic disease
states requiring therapeutic intervention and treatment are cost drivers. These circumstances
affect the global tertiary care hospital/business system more exponentially since their patient
base has these greater concentrations. Initially, the balanced scorecard can offer the tertiary care
hospital/business system key metrics in order to evaluate adverse patient occurrences alerting
management that their morbidity issues do not meet quality standards when their mortality rates
are acceptable (Dey, 2008). Since morbidity occurrences are cost drivers which reduce operating
margins, we see the major impedes of utilization of the Balanced Scorecard would be to lower
the cost drivers of the management of the critically ill which are the primary patient base in the

3. 2
tertiary care hospital/business system. The major success of the Balanced Scorecard within the
tertiary hospital care system has shed light upon the shortcomings of financed-based
performance measurement models (Dey, 2008). In fact, the Balanced Scorecard serves as a
workhorse to combat the ever consistent business challenges within the tertiary care
hospital/business system.
While the Balanced Score offers significant advantages in the deliverance of financial metrics
within the confines of the tertiary care hospital system, reliance alone upon financial measures of
performance is insufficient for the management of such a complex organization such as the
tertiary hospital care system (Dunn, 2006). The tertiary care hospital/business system is as
intensive and massive as any corporation/organization with the need of a paradigm shift. This is
accomplished by the Balanced Scorecard performance measurement with the assessment of more
than financial metrics. The performance indicators of significant value to this business system of
the tertiary care hospital/business system are non-financial performance indicators i.e. patient
focused (customer), operational (internal processes), and/or learning/growth (employee) as well
the critically need financial metrics (Dunn, 2006).
Scope of the Analysis
Therefore, this paper will examine the utilization of the balanced score among four identified
tertiary care hospital systems. Duke University Hospital System, a leading academic medical
center of 957 beds, is located in Durham, North Carolina (Silow-Carroll, 2008). Duke is a large,
full-service tertiary and quaternary care hospital and is a member of the Duke Health System,
which includes the Duke University School of Medicine, the Duke School of Nursing, the Duke
Clinic, and other member hospitals (Silow-Carroll, 2008). Likewise, further collaboration of the
change initiatives of the Balanced Scorecard within the Beaumont Hospitals of Royal Oak,

4. 3
Michigan, a suburb outside of Detroit, will be presented. Beaumont Healthcare System is an
1100-bed tertiary care, teaching, research, and referral center and is one of the busiest hospitals
in the United States (Larson, 2007). Hospitals admissions are recorded at 56,000 for the year
2013 (Becker’s Hospital Review, 2014).
Subsequent discussion of the use of the Balanced Scorecard at Yale-New Haven Health
System which is located in New Haven, Connecticut will be presented. Yale-New Haven Health
System is a 944-bed tertiary referral center and is the primary teaching hospital for Yale
University School of Medicine and includes the 201-bed Yale-New Haven Children’s Hospital
and the 76-bed Yale-New Haven Psychiatric Hospital (Gumbus, 2003). Lastly, as the United
States serves the globe and stands as a global leader, discussion of Mackay Memorial Hospital’s
implementation of the Balanced Scorecard will be provided. Mackay Memorial Hospital is an
accredited medical center, teaching hospital, and tertiary care hospital located in Taipei, Taiwan.
Mackay Memorial Hospital, with a bed size of 2149 beds and more than 9000 outpatient visits
per day, attributes implementing the Balanced Scorecard from the direct influence of the
American healthcare industry (Wen-Cheng, 2008) The Balanced Scorecard was implemented
five years past the United States (Wen-Cheng, 2008).
The Literature
Wilsey (2014) positions the Balanced Score as a strategic planning and management system
that has been used to align business activities to the vision and strategy of the organization; a
strategic planning and management system to improve internal and external communications;
and a strategic planning and management system to help monitor organization performance
against strategic goals. In fact, the innovators of the Balanced Scorecard system, Kaplan and
Norton, published their first work in 1992. The Balanced Scorecard has been called one of the

5. 4
most important management innovations of the 20th century (Zelman, 2003). Since the
introduction of this new innovation, there has been a plethora of literature published both in
academia and in industry. The Balanced Scorecard has survived the test of time well into the 21st
century with more than half of major companies in the United States, Europe, and Asia using
Balanced Scorecard approaches (Wilsey, 2014). As with any new innovation, the product and/or
innovation can be expected to go through a product life cycle i.e. introduction, growth, maturity,
and decline. The balanced scorecard as far as its use in healthcare is in its growth phase (Zelman,
2003). Thus, the purpose of this paper is to provide proof text of the validity of the Balanced
Scorecard in the tertiary care hospital/business system so as to grow its usage.
Likewise, the first published articles with the use of the Balanced Scorecard in healthcare
appeared in 1994 with subsequent copious publications in a multiplicity of trade journals and
academia (Zelman, 2003). Hospitals cited in the balanced scorecard literature include academic,
military, health science centers, community, and specialty hospitals (Zelman, 2003). In this
examination of the balanced scorecard in the tertiary-care hospital, Zelman et al. (2003) have
stood out in all reference lists/research readings and will serve as a cohesive binding unit to this
research/work to add to the collaboration of the Balanced Scorecard in the utilization in the
tertiary care hospital system. Likewise, Zelman et al. (2003) argues the importance of the
Balanced Score findings amongst the identified hospitals as particularly important since the
findings may serve as input or even as a catalyst for policy formulation and/or change by federal,
state, and local governments. Policy formation is a particular key concern as we have seen in
significant changes in healthcare in 2014. The need is so great since medical costs continue to
rise and consume an ever increasing proportion of Gross National Product.

6. 5
Furthermore, Hansel (2009) identifies a major problem among the large hospital i.e. the
tertiary care hospital system has the difficulty dealing with massive amounts of data from an IT
department that may/may not be in useable format. The Balanced Scorecard is the solution to this
identified problem and allows the institution to identify the key metrics which really drive
performance across while creating synergy among the patient i.e. the customer and the employee,
the internal customer.
Subsequently, the thrust of this examination is to assess and make evaluation of the utility of
the Balanced Scorecard in the tertiary care hospital with the above stated selections. Therefore,
Silow-Carroll (2008) through the Commonwealth Fund, which has as its mission to promote a
high performance health care system as well as to improve health care practice and policy, offers
a thorough discussion of the findings of the Balanced Scorecard system at Duke University.
Briggs (2010) further evaluates Duke University and the utilization and implementation of the
Balanced Scorecard emphasizing the exponential quantifiable growth in internal customer use of
the Balanced Scorecard within Duke University being up 207%. This is definite
employer/employee engagement. Likewise, Larson (2007) provided evaluation of Beaumont
Hospitals identifying the Balanced Scorecard as an innovated solution (a definite change agent).
Gumbus et al. (2003) assessed supply chain savings in one calendar year at a Yale-New Haven
Hospital of $750,000 with the utilization of the Balanced Scorecard within the confines of the
hospital/business system.
Lastly, since the utilization of the Balanced Scorecard in the United States Hospital Systems
have served as a benchmark for the global tertiary hospital system, this paper will further the
collaboration in the discussion of the United States in this leadership role to our global
neighbors. As developing nations continue to look to the United States, this paper will also

7. 6
provide an assessment of the Balanced Scorecard in a tertiary care hospital system outside the
United States as well with discussion of comparative results to the United States hospitals
provided. Therefore, Wen-Cheng et al. (2008) examines the utilization of the Balanced Score in
a tertiary hospital system in Taiwan identifying tremendous performance improvement with
implementation of this change initiative called the Balanced Scorecard.
The Analysis
Duke University Hospital System
Duke University Hospital System holds the distinction of the top 5 percent of more than 700
large hospitals (300 plus beds) in the portion of patients who gave a rating of 9 or 10 when they
rate their hospital overall (Silow-Caroll, 2008). This is a category of distinction as a leading
tertiary/quaternary care hospital with 957 beds (Silow-Caroll, 2008). Thus, ensuring and
improving patient satisfaction to receive marks such as theses requires both an organizational
strategy as well as tactical strategies. A hospital wide thrust must be done to employ and sustain
a culture that emphasizes patient satisfaction, for it takes a team to impact patient satisfaction to
this high level. When a tertiary hospital care system implements a “Patient Satisfaction
University” as part of implementation of the balanced scorecard, one would surmise that the
ramifications will only be positive (Silow-Caroll, 2008). That is exactly the results at Duke.
Thus, Duke employs the Balanced Score card in which patient satisfaction is assessed in
manager and clinical unit evaluations and is included in performance improvement plans (Silow-
Caroll, 2008). Evaluations within Duke University Health System are based upon a Balanced
Scorecard.

8. 7
The Balanced Scorecard at Duke is a management tool in which customer service (measured
through outpatient and inpatient patient satisfaction in each unit) is one of the quadrants along
with finances, work culture, and clinical quality (Silow-Caroll, 2008). In fact, the customer
service quadrant has a goal statement to continuously improve both internal and external
customers (Silow-Caroll, 2008). In this we see the attitude that is pervasive throughout the
corporate culture of Duke, “that it takes teamwork to drive patient satisfaction to the level of
distinction”. Thus, the internal customer is deemed just as important as the external customer to
Duke.
Likewise, directly across customer service is the quadrant that houses work culture with
stated goal to consistently improve the work culture consistent with the Duke University
Hospital System value proposition (Silow-Caroll, 2008). Duke measures through surveys
employee’s assessments of their satisfaction and engagement within the confines of their
workplace about such aspects such as their ability to grow, to improve, to learn, and to accelerate
in their career pathways. The utility of the Balanced Scorecard system is clearly seen as we see
that the staff of Duke receive their commitment for training and job enhancement in reference to
patient interactions, which in turns improves patient satisfaction. Therefore, this supports the
interconnectedness of the four quadrants. Ultimately, the interconnectedness drives the financial
dynamics of the Duke.
Having begun the journey with the Balanced Scorecard in 2001 as a 60 page slide
presentation, Duke has now grown into 300 cards and 10,000 data points updated monthly and
used extensively (Briggs, 2010). The Balanced Scorecard system having gone through much
evolution from four now incorporates five cascade levels that plot trends of 5200 measures and
has much impact on decision making within the Duke University (Briggs, 2010). Hager, who is

9. 8
Director of Performance Services at Duke University, feels that the reputation of Duke having
success in performance management and operations, including Duke’s benchmarking ability to
maintain a solid operating margin in such a challenging industry, feels distinctly this level of
performance is due to the continued successful penetration and use of the Balanced Scorecard
within the tertiary care hospital/business system (Briggs, 2010).
Beaumont Hospitals
Similarly, this paper examines the utilization of the Balanced Scorecard in the Beaumont
Hospitals of Royal Oak, a suburb outside of Detroit. Beaumont Hospitals is an 1100-bed tertiary
care, teaching, research, and referral center and is part of another hospital system with 329 beds
(Larson, 2007). The entire hospital system employees 16,000 employees and is the third largest
employer in the county (Larson, 2007). Beaumont Hospitals is a leader in the industry and has
maintained ranking in Solucient’s Top 100 Hospitals list for several years as well as being
named as one of America’s Best Hospitals by U.S. News and World Reports (Larson, 2007).
Despite the years of success, the board of directors and management felt that change was
needed. Patient satisfaction scores were a solid B average and employee engagement scores
indicated room for improvement (Larson, 2007). In addition, patient volumes were becoming
very flat in a shrinking market with more and more competition for fewer patients and dollars
(Larson, 2007). The local economy had also been suffering the loss of the automotive industry.
Past evaluations of net income were a meager 2% despite higher patient volumes recorded at the
time and investments in new technologies and buildings (Larson, 2007).

10. 9
The board of directors felt that the utilization of the balanced score system would change
theses parameters. The four parameters of this change initiative are customer satisfaction,
quality, finances, and grow and organizational development (Larson, 2007). The CEO is
identified as saying that this only the beginning of the journey but the implementation of the
Balanced Scorecard system has brought the 16,000 employees of the organization working
together with a clearer understanding of their role in the success of the organization. In fact,
employee engagement survey participate rates have increased from 41% to 61% (Larson, 2007).
We can see from our examination of the Balanced Scorecard at Beaumont Hospitals that the
business environment is one of intense pressure not only internally from the cost drivers of the
tertiary care patients themselves but also from the forces from outside the hospital as indicated
by the loss of the patient volume since the local economy was failing. The tertiary care hospital
faces the pressure to maintain and increase quality of care. The Balanced Scorecard has been a
management tool to provide a relief valve for Beaumont Hospitals so that the financial metrics of
revenues and operating costs are adequately attended yet also provide attention to other non-
financial metrics such as quality, patient satisfaction, and staff retention. Since ultimately all the
metrics have such interconnectedness, they eventually turn out to affect the financial aspects of
the business and are seen as drivers of financial success. Thus, Beaumont Hospitals, is being
delivered through the utilization of the Balanced Scorecard system.
Yale-New Haven Health Systems
Bridgeport Hospital
Since the Balanced Scorecard provides a distinct, unique advantage as a framework for the
measurement of performance in a complex and changing medical environment coupled with

11. 10
what appears to be received as a change initiative when 70% of all change initiatives fail, we
further the evaluation of the Balanced Scorecard management tool as we assess the three year
journey of organizational and financial health of Bridgeport Hospital, a member of Yale-New
Haven Hospital Systems of New Haven, Connecticut (Gumbus, 2003). Bridgeport Hospital,
though thoroughly capitated, had been experiencing losses (a $1,000,000 per year operating loss)
due to financial pressures that are inherent in tertiary care hospital as the federal government,
managed care, and the shift to outpatient care forces downsizes and even hospital closures
(Gumbus, 2003). Thus, all management groups including the Board of Directors came in
agreement to map out the strategy to bring Bridgeport back to financial health again.
As indicated earlier, the Balanced Scorecard has served as a workhorse in the tertiary care
hospital. Therefore, at Bridgeport, in order to reach the strategic objective, a plan to utilize the
Balanced Scorecard system was created so that financial health could be restored. The four most
important strategic dimensions on the card were Organizational Health, Quality and Process
Improvement, Volume and Market Share Growth, and Financial Health (Gumbus, 2003). Further
evolution of the Balanced Scorecard system at Bridgeport took place as the hospital expanded
emphasis from strategic planning at rollout to human resource development and the dimension of
Organizational Health to have linkage to compensation and appraisal. The hospital has made
excellent customer service a contingency for performance rewards further reiterating the
emphasis and linkage of the Organizational Health quadrant of the Balanced Score to
compensation and evaluation of employees. For example, performance indicators driving
customer service such as: I will introduce myself to patients 100% of the time; I will knock
when entering room or coworker office; I will say hello to those I pass in the hallway; and I will
provide assistance to patients and guests were measured (Gumbus, 2003).

12. 11
Likewise, with the maturing of the use of the Balanced Scorecard at Bridgeport, the further
linking of capital budgeting to the financial health quadrant was established with the three major
areas of capital projects being Clinical, Non-clinical, and Information Systems now resulting into
the Balanced Scorecard system at Bridgeport having five dimensions (Gumbus, 2003).
With that said, we see the extreme adaptability of the Balanced Scorecard to grow with the
utilization within the tertiary care hospital/business system. The Balanced Scorecard has further
added benefit of adding medical staff engagement in the planning and measuring of results. At
Bridgeport, patient satisfaction scores have also risen. The understanding of marketing the
hospital to the community as well as marketing the physician became prevalent. Full grasp of
patient flow as well as the understanding for the establishment of a wellness center was
established (Gumbus, 2003). Pertinent quantifiable results with this change initative were
achieved including $750,000 cost savings in supply chain management (Gumbus, 2003). While
Bridgeport Hospital retained the financial measures of Balanced Scorecard, the financial drivers
of success, likewise, were incorporated in the card i.e. volume, and market share growth, doctors
and staff, satisfied patients, expert clinical care providers, and quality clinical outcomes all
attributing to becoming a permanent part of the strategic process at Bridgeport Hospital
(Gumbus, 2003). The Balance Scorecard has become a way of life at Bridgeport making it a way
to compete and survive in this competitive tertiary care marketplace.
Mackay Memorial Hospital
Furthermore, as we examine the significant advantages of the Balanced Scorecard in the
tertiary care system, it is prudent to see if there are same results outside the United States in
developing nations. The same needs in the American tertiary care hospital care system such as
the identified Duke University System, Beaumont Hospitals, and Yale-New Haven Hospital

13. 12
System in this research are also needed cross-culturally. Therefore, we examine the performance
measurement of Mackay Memorial Hospital in Taiwan which is a 2149 bed tertiary care hospital
with 9000 outpatient visits per day (Wen-Cheng, 2008). In fact, greater financial press has
come upon Taiwan’s healthcare institutions since they have become integrated health systems
comprising hospital systems, outpatient clinics, home health services, and nursing homes
(Wen-Cheng, 2008).
Mackay Memorial Hospital, is an integrated institution that includes academic and medical
systems and is the oldest and largest tertiary care hospital employing 4660 and 639 staff
physicians (Wen-Cheng, 2008). We have established the therapeutic intervention of the
chronically ill as a major cost driver of the tertiary care hospital necessitating the need for relief
at Mackay Memorial Hospital since the hospital bears the burden as the largest tertiary care
provider in Taiwan.
Mackay Memorial Hospital was perhaps the first hospital in Taiwan to develop its Balanced
Scorecard for the entire organization verses isolating the scorecard system to a single
department. The United States was used as a benchmark standard giving the board of directors
and senior management the confidence to go hospital wide verses isolating to a single
department. This was done to relieve the financial burden of the patient base of the tertiary care
population identified. Therefore, Mackay Memorial Hospital adopted the Balanced Scorecard in
response to the Board of Directors and formed the Balanced Scorecard Executive Team,
comprised of both the board and senior management. Initially, the Balanced Scorecard Executive
Team with its subgroups based on the four perspectives or quadrants of the Balanced Scorecard:
1) financial 2) customer 3) internal business processes 4) learning and growth had the
responsibility for translating Mackay’s mission, core values, and vision into strategic objectives,

14. 13
and operational measures pertaining to a specific perspective (Wen-Cheng, 2008). Subsequently,
we see the addition of a fifth perspective i.e. social commitment with an indicator being the
number of visits of the disadvantaged since Mackay is a Christian hospital and has as its mission
statement to provide care for the disadvantaged.
After two years of implementation, the Balanced Scorecard was felt to be a routine
management system and continual process at Mackay Hospital. Further benefits reached at the
four year mark were that managers were perceived more credible before the Board of Directors
since they now have better understanding and awareness about the measures and target results
for which the CEO, other top executives, and other managers would be accountable for (Wen-
Cheng, 2008). Likewise, the implementation of the Balanced Scorecard allowed board members
and executives to speed up their decisions on large investments in intangible assets (Wen-Cheng,
2008).
In the evaluations of financial metric, Mackay’s revenues for the years 2003, 2004, and 2005
were $8516 million, $9394 million, and $9256 million respectively (Wen-Cheng, 2008). The
Balance Scorecard is attributing to a steady growth in revenues. This is impressive, for the value
of Case Mix Index (CMI) changed from 1.03 to 1.16 within 3 years, meaning that Mackay cared
more and more for the acutely and severely ill patients (Wen-Cheng, 2008). Therefore, we can
see the Balanced Scorecard alleviating some of the pressure within the tertiary care hospital
system that has pandemic a cost driver of the more acutely and severely ill patient. Similarly,
patient satisfaction rose from 83.3% in 2003 to 85.79% in 2005 (Wen-Cheng, 2008). Further, an
improvement in time in those patients admitted to the ICU from the ER in less than 3 hours is
seen showing an increment from 47.83% in 2004 to 82.45% in 2005 (Wen-Cheng, 2008).

15. 14
Conclusively, the Balanced Scorecard at Mackay Hospital began and continues to be an excellent
performance and strategic management tool.
Recommendations and Implementation
As identified within this research, much has been achieved utilizing the Balanced Scorecard
in the tertiary care hospital system. Despite the tremendous results that have been shown in the
elevation of financial and non-financial metric, there is still the pandemic rise of the health care
dollar at home and globally with the tremendous need for the health care dollar expenditure to be
curtailed. Thus, further discussion will be that hospitals that have traditionally focused on
serving the ill and injured should provide both community health care and institutional health
care to improve the overall health of populations; therefore, preventing the necessity of health
care dollars by increasing the community health status (Olden, 2008). It is accepted knowledge
that health scholars, professional associations, health management texts, and health care leaders
have further emphasized that hospitals are notably responsible for improving the health of their
local populations rather than just caring for the sick and informed (Olden, 2008). Therein lies the
significant benefit of the Balanced Scorecard system as a management tool i.e. its adaptability to
an ever changing medical climate.
Therefore, it is recommended that hospital leaders take the next step and modify the Balanced
Scorecards to include community health status that is demanded by all of the stakeholders and
that is already included in most hospital’s vision, mission, and long range plans (Olden, 2008). In
implementation, the tertiary care hospital must continue to reflect the traditional quadrants of
financial, customer, learning and growth, and internal business process but also must reflect their
work to improve community health status. Hospitals should then include community health

16. 15
measures-both leading and lagging indicators-in their balanced scorecards with direct link
strategy and resource allocation to progress towards those goals (Olden, 2008).
Hospital leaders will have to select appropriate Balanced Scorecard targets and measures i.e.
actual health outcomes for the community population which are the lagging measures and the
leading measures which are activities, processes, and resources the hospital intends to allocate to
achieve the health status goals and outcomes-the process drivers (Olden, 2008). In doing so, the
hospital system becomes externally focused by including appropriate indigenous community
health measures to their Balanced Scorecard. The increase in community health lowers the
necessity for the health care dollar i.e. the health care expenditure. The tertiary care hospital
system, which has a primary cost driver the critically ill, benefits from the increase in the
community health status of a community since the community health status is elevating and is
not as sick nor critically ill. The community health status can be added as one of the dimensions
on the Balanced Scorecard within the business unit of the tertiary care hospital system.
Summary
In conclusion, the management of the tertiary care hospital is even more stringent and
difficult due to its primary population base being the critically ill. The critically ill and their
management and therapeutic intervention are the primarily cost drivers within the tertiary care
hospital. The Balanced Scorecard has been shown in this research to provide the necessary relief
if not deliverance to the identified tertiary care hospital systems of Duke University Hospital
System, Beaumont Hospital Systems, Bridgeport Hospital of Yale-New Haven Hospital
Systems- all of the United States- and Mackay Memorial Hospital of Taiwan. The Balanced
Scorecard management tool has been implemented with the typical dimensions of not only

17. 16
financial metrics, but also customer, learning and growth, and internal businesses processes in
these tertiary care hospitals.
One primary significant benefit that has been seen is that the Balanced Scorecard is
adaptability in the tertiary care hospital system in day-to-day business operations as seen in the
capability of Bridgeport Hospital adding the dimension of Capital Budgeting to the financial
dimension once they had become adept with usage of the Balanced Scorecard within their
institution. We have further stated the increase results in patient satisfaction and employee
engagement in all tertiary care hospitals examined. Given that the tertiary care hospitals
researched have seen improvement in their operating margins as well as other financial metrics,
the Balanced Scorecard will continue to be an excellent strategic and performance management
choice by boards and senior management within the tertiary care hospital system. Likewise, as
we have examined the potential of the Balanced Scorecard as a management tool for the tertiary
care hospital, the adaptability to include all stakeholders by adding community health status to
the dimensions of the Balanced Scorecard even raises the value of the tool exponentially giving
opportunity to prevent the necessity of the health care dollar beforehand. As indicated, the
Balanced Scorecard which is in the growth phase is truly an innovation with much promise on
the horizon.
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