Measuring & Managing Health Services: The Balanced Scorecard

1. Measuring & Managing Health Services: The Balanced Scorecard David Peters, Director, Future Health Systems Research Consortium Sept 28, 2006

2. “What gets measured gets managed. What gets managed gets done.” Tom Peters

3. Would This Measurement Describe Your Child?

4. Why Have a Balanced Scorecard? • Health sector is complex, has many components • Need an efficient way to assess multiple objectives • Overloaded with different types of reports • Stakeholders demand vigilance • Poor measurement can lead to crisis

5. Balanced Scorecard – Original Definition “A multi-dimensional framework for describing, implementing and managing strategy at all levels of an enterprise by linking objectives, initiatives, and measures to an organization’s strategy.” Kaplan & Norton, 1996

6. Scorecard Domains Which dimensions should we measure?

7. Balanced Scorecard: General Domains • Customer Results • Internal Processes • Staff and Organizational Growth • Financial Results • Vision & Strategy

8. Qualities of Good Scorecard Measures • Valid • Reliable • Balanced • Easily Understood • Intermediable • Agreed Upon • Limited • Specific • Measurable • Achievable Targets • Relevant • Timely

9. Presenting Scorecards: Performance Dashboards • Simple to see & interpret • Multi-dimensional measures of critical indicators of overall performance • Allows for the early detection of problems and successes • Can be benchmarked against other data

10. Afghanistan National Health Services Performance Assessment (NHSPA)

11. Developing the Balanced Scorecard Frontline providers, NGOs, MOPH, donors to agree on: • Purpose of BSC • Domains to measure • Unit of analysis • Process & frequency of review/decisions • Principles for benchmarking • Short-listing indicators based on face validity, importance, reliability

12. Afghanistan Balanced Scorecard Domains • Patient & Community Results • Staff Results • Capacity for Service Provision • Service Provision Results • Financial System Results • Overall Vision Results

13. Poor Fair Good Excellent Measuring perceptions The Naanogram • Many survey questions sought perceptions. But how to ask? • Likert scale couldn’t be understood • Money?

14. Afghanistan Sample for Balanced Scorecard

15. Afghanistan NHSPA Provincial Balanced Scorecard

16. Patients & Community Perspectives

17. Staff Perspectives

18. Service Provision

19. Overall Vision

20. Identifying Exceptional Provincial Performance

21. Balanced Scorecard: Improvements • Progress has been made in most areas • Improvements in 22 out of 29 indicators • Areas of largest improvement include: • Shura-e-Sehie activity • Salary payments current • Laboratory functionality • Drug availability • Meeting minimum staffing guidelines

22. Balanced Scorecard: Problems • Improvement not consistent across all provinces or aspects of service delivery • Areas of concern: • Time spent with patients • Facility infrastructure • Sharps disposal • User fee guidelines • Patient records

23. Balanced Scorecard on Contract Performance: Cumulative Ratings

24. Some Final Thoughts

25. Successful Scorecards • Focus on significant, success-determining measures of organization’s total performance • Based on timely information • Predictive (leading) indicators more useful than trailing indicators

26. “You can’t fatten a cow by weighing it”