THE TERTIARY CARE HOSPITAL SYSTEM

UTILIZATION OF THE BALANCED SCORECARD

Nancy Southerland September 14, 2014

AbstractThe tertiary care hospital has as its primary responsibility to deliver health care to the most sick and severely ill. The management of the critically ill is seen 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 business processes, and learning and growth dimensions are part of the balanced

scorecard perspectives. Through use of the balanced scorecard in the tertiary care hospital, the wrath of the cost driver of the therapeutic management and intervention of the

critically ill is assuaged. Tertiary care hospitals are able to deliver solid operating margins while ensuring patient satisfaction with good clinical outcome of the critically ill while

experiencing much employee engagement. The tertiary care hospital enjoys the interconnectedness of the dimensions realizing quickly that over time all the Balance

Scorecard perspectives are financial dimensions.

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

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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,

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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

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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.

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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

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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.

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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

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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).

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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

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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).

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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

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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,

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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).

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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

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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

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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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