The Deployment of Balanced Scorecard Perspectives and Dimensions to Improve Hospitals? Performance

Introduction The balanced scorecard (BSC) is a comprehensive performance evaluation (PE) tool. Stakeholders such as patients and healthcare workers (HCWs) are rarely engaged in BSC implementation at health care organizations (HCOs). The four core studies of this dissertation aim to 1. assess the impact of BSC implementation on HCWs? satisfaction, patient satisfaction, and financial performance, 2. identify all the perspectives, dimensions, and key performance indicators (KPIs) that are important and most frequently used in BSC implementations, and 3- develop two instruments to engage patients and HCWs in BSC (BSC-PATIENT and BSC-HCW1, respectively). Moreover, the dissertation aims to perform four implementations to draw recommendations for health policy makers. Methods The search strategies of two systematic reviews were customized for the PubMed, Embase, Cochrane, Google Scholar databases and Google?s search engine in adherence with PRISMA guidelines. After removing the duplicates in End Note and accomplishing the screening steps, the measured outcomes were extracted from the final resulting studies. The KPIs were categorized and regrouped using thematic analysis. The risk of bias (ROB) was evaluated. The resulting perspectives and dimensions were used as a guide for the first and second implementations. To develop the BSC-PATIENT and BSC-HCW1, the Delphi technique was used to generate the items and test the content validity, followed by translation and pretesting at one hospital. Then, a convenience sample of 1000 patients and 800 HCWs was recruited at 14 hospitals with the maximum variation technique between January and October 2021. Construct validity was tested through exploratory factor analysis, confirmatory factor analysis, composite reliability, interitem correlation, and corrected item total correlation. The developed tools were used to engage patients, doctors, and nurses in the PE of Palestinian hospitals by assessing their experiences and attitudes. The differences in evaluations based on patient admission status and HCWs? profession were analyzed using the Mann?Whitney U test. Causal relationships were analyzed using multiple linear regression and path analysis to draw BSC strategic maps. Multicollinearities and autocorrelation were tested. For the statistical analysis of the cross-sectional studies, IBM SPSS, IBM Amos, and R softwares were utilized. Results A positive impact of the BSC was found on the three measured outcomes in 20 studies but to a lesser extent on HCW satisfaction. The thematic analysis of the extracted 797 KPIs resulted in 45 subdimensions and 13 major dimensions. The ROB was either moderate or high. The best model of BSC-PATIENT and BSC-HCW1 comprised ten constructs with 36 items and nine factors with 28 items, respectively. The instruments? psychometric characteristics showed adequacy. The first and second implementations revealed gaps in performance and drew recommendations. At the third implementation, 740 questionnaires were retrieved. The mean score for the patient care experience factor was the lowest. The experience factors of information, patient care, services, and building had the highest impact on attitudes. Significant differences based on patient admission were found. At the fourth implementation, 454 questionnaires were retrieved. No differences between physicians? and nurses? evaluations were found. HCWs? workload time-life balance, quality and development initiatives, and managerial performance evaluation have a direct effect on improving HCWs? loyalty attitudes. HCWs? engagement, managerial performance evaluation, and loyalty attitudes have a direct effect on enhancing HCWs? respect toward managers. Quality and development initiatives, HCWs? loyalty attitudes, and workload time-life balance had a direct effect on improving perceived patient respect toward HCWs. Neither multicollinearity nor autocorrelation existed. Conclusion This dissertation proves the effectiveness of the BSC and solves the categorization dilemma of BSC dimensions. BSC-PATIENT and BSC-HCW1 are the first self-administered questionnaires specifically developed to engage patients and HCWs in BSC, respectively. The implementation of BSC-PATIENT at Palestinian hospitals provides strong evidence for the impact of patients? information experience on their attitudes. Palestinian health policy makers must prioritize the design and delivery of patient education programs into their action plans and encourage two-way information communication with patients. The implementation of BSC-HCW1 recommends improving low-performing indicators, such as the time spent with patients, HCWs? knowledge of medications and diseases, the quality of hospital equipment and maintenance, and the inclusion of strengths and weaknesses in HCWs? evaluations to enhance HCWs? loyalty and reduce their attempts to leave. For Palestinian hospital managers to be respected more, they must include HCWs in their action plans and explain their evaluation criteria. Patients will respect Palestinian HCWs more if they prioritize their education and work quality, spend more time with patients, and reflect more loyalty. The results can be generalized in Palestine since it encompassed 30% of Palestinian hospitals from all categories.