The current issue and full text archive of this journal is available at

[Link]/[Link]

Using BSC to
Using the balanced scorecard to measure hospital
measure Chinese and Japanese performance
hospital performance
339
Xiao-yun Chen
Finance Department, China-Japan Friendship Hospital, Beijing,
People’s Republic of China
Kazunobu Yamauchi and Ken Kato
Department of Medical Information and Management Science,
Graduate School of Medicine, Nagoya University, Nagoya, Japan, and
Akio Nishimura and Katuski Ito
Graduate School of Medicine, Nagoya University, Nagoya, Japan

Abstract
Purpose – The objective of the paper is to confirm the feasibility and value of using the balanced
scorecard (BSC) to measure performance in two hospitals in different countries.
Design/methodology/approach – One hospital from China and another from Japan were chosen
and key indicators were selected according to the BSC framework. A comparative hospital
performance measurement model was set up using the BSC framework to comprehensively compare
hospital performance in two countries.
Findings – The BSC was found to be effective for underlining existing problems and identifying
opportunities for improvements. The BSC also revealed the hospitals’ contribution to performance
improvement of each country’s total health system.
Research limitations/implications – Hospital performance comparisons between countries using
the BSC depend on the selection of feasible and appropriate key performance indicators, which is
occasionally limited by data collection problems.
Originality/value – The first use of the BSC to compare hospital performance between China and
Japan shows benefits that not only suggests performance improvements in individual hospitals but
also reveals effective health factors allowing implementation of valid national health policies.
Keywords Balanced scorecard, Hospitals, Performance measurement (quality), China, Japan
Paper type Research paper

Introduction
Some healthcare providers are adopting multi-dimensional performance assessment
systems to help them achieve their missions. The balanced scorecard (BSC) is
increasingly being used as one such system, notably as an expanded set of
performance indicators. Two large-scale efforts have recently been undertaken in
Canada and the US that used BSC as a framework for comparing performance between
services and identifying areas for improvement (Zelman et al., 2003). Researchers from International Journal of Health Care
Michigan University recently examined the validity, reliability and sensitivity of Quality Assurance
Vol. 19 No. 4, 2006
pp. 339-350
q Emerald Group Publishing Limited
Authors wish to thank Dr Karthik Balakrishnan (USA) for proof-reading the manuscript and Dr 0952-6862
Nobuyuki Hamajima (Japan) for assisting with statistical analyses. DOI 10.1108/09526860610671391
IJHCQA BSC-oriented comparative indicators used for measuring overall organizational
19,4 performance between competitors. In doing so, seven multidimensional hospital
performance indicators, which could be used to compare performance between
hospitals inside the US, emerged (Griffith et al., 2002).
A WHO (2003a, b) European group aimed to build and validate a flexible and
comprehensive hospital performance assessment model – a benchmarking network at
340 the international level, allowed participants to compare their performance with peer
hospitals using appropriate performance indicators. This WHO project is still in the pilot
study stage, and its model is under development. While the BSC has been used as a
framework for comparing hospital performance for many years, most studies are done in
single countries (Zelman et al., 2003). Here, we want to use BSC to compare hospital
performance between different countries. China and Japan are two East Asian countries
that have interacted and co-operated for many years. However, the Chinese and Japanese
health systems differ greatly. According to one WHO (2000) report, which provided a
new method for health system performance assessment by ranking 191 member
countries’ performance. Japan was seen to be one of the highest performing countries in
the world, while China was ranked 144th among all member countries. It is hoped that
the approach we take to measuring hospital performance between the two countries will
help managers and practitioners understand the ranking differences.
The level of Japanese health system performance stems from its well-designed national
health policy. Japan’s health care system is a “public contract model.” The whole
population is covered by different types of public health insurance, while modest
co-payments are needed to support the fee-for-service payment system. Seventy percent of
beds and 80 percent of hospitals are privately owned, which form another characteristic of
the Japanese system. Purchasing health services for the entire population is directly or
indirectly under the control of statutory and compulsory health insurance, and insurers
operate fairly passively under rules set by the government. In short, the Japanese
government plays at least three significant roles in its health care system:
(1) regulatory role from overall system building and planning to micro-level
regulation;
(2) insurer role in which the government manages some types of health insurance;
and
(3) small-scale provider role, supplying medical services to patients through
national hospitals and health centers (Hyoung-Sun and Hurst, 2001).

Meanwhile, China developed perhaps the largest national healthcare network in the
world. Its government insurance, labor insurance and the urban collective medical
care schemes cover almost all urban residents and the rural collective medical care
scheme protects 90 percent of the rural population in the peak period of the mid 1970s
(Dong, 2002; Bogg et al., 1996). However, China’s system almost collapsed, especially in
rural areas when market-oriented reforms began in 1978. It was estimated that
44 percent of urban residents were not covered by any health insurance system and
87 percent of rural residents had to pay their medical costs in 1998 (MoH P. R. China,
1998). Since, 1998, a new urban employees’ basic health care insurance scheme has
developed, and a reform of rural districts aimed to establish a new rural cooperative
medical insurance system began in 2003. Since, then the insured population has been
increasing.
 All Chinese healthcare institutions were publicly owned and administered Using BSC to
hierarchically before 1978, and most health care provider resources were concentrated measure hospital
in urban areas, especially big cities. Private practice was permitted at former communal
clinics in rural areas after 1980, and by 1985 private clinics replaced “collectively run performance
health stations” as dominant health institutions at village level. In the cities,
government-owned hospitals still occupied a dominant position, but hospital
privatization was permitted in 2000 (Huang, 2002). The Chinese government attempted 341
to improve hospital efficiency by introducing competition. It encouraged public health
care institutions to be autonomous and it permitted private practice. These actions,
however, were unsatisfactory as medical costs escalated and access to health care services
fell (Eggleston and Yip, 2004). The government’s share of total health expenditure
decreased and subsidies to government-owned hospitals reduced accordingly. The
market-oriented reforms weakened the government’s leading role in establishing a
national health system, which led to increasing criticisms (MoH P.R. China, 2004).

Methods
The BSC key comparative performance indicators are used in this paper to compare
Chinese and Japanese hospital performance. The intention was to help the authors
comprehend differences between the two countries’ hospitals. In addition, we discuss
the feasibility and value of using the BSC to measure hospital performance
internationally. Two peer hospitals were selected for study – C, a national hospital in
Beijing, China; the other, N, a national hospital in Nagoya, Japan. Both are controlled
by the central government.
The two pilot hospitals are engaged in care, education and research, and the number
of beds, physicians and clinical departments are similar. More than 90 percent of their
clinical departments have common features (Table I). The total staff of hospital C is
greater, however, and a large difference is seen in “other staff” which is mainly hospital
clerks – a distinct characteristic in China together with its larger population. The
numbers of physicians per bed in the two hospitals, on the other hand, are similar (0.46
and 0.49).
Valid performance comparisons demand rigorous, standardized assessment criteria
and methods, especially when they are used to compare countries (Shaw, 2003). The
BSC is a performance measure that focuses on tracking key metrics grouped according
to four perspectives (financial, internal business processes, customer, learning and
growth), which together constitute a balanced view of an organization (Kaplan and
Norton, 1992). Clear definitions of each perspective are given by the Michigan
University researchers:
.
financial – performance and resource management;
.
internal business processes – cost, quality, efficiency and other characteristics of
goods or services;
.
customer – measures of satisfaction, market share and competitive position;
.
learning and growth – ability to respond to changes in technology, customer
attitudes and economic environment (Griffith et al., 2002).

In our study, we used the same definitions before choosing and confirming common
but feasible key performance indicators (KPIs), which constitute the main
IJHCQA
Indicator Hospital C (China) Hospital N (Japan)
19,4
Surroundings
Population of city/district 1,607,000 2,172,000 (2,000)
Area of city/district 471 Km2 326 Km2
Total number of beds in the city/district 11,037 (2,002) 21,558
342 Hospitals with over 1,000 beds in city/district 2 2
Hospitals
Number of beds 1,300 1,035
Number of clinical departments 40 34
Total assets (US$) 60,557,545 186,715,456
Total staff 2,627 1,483
Physician 604 (23.0 percent) 507 (34.2 percent)
Nurse 781 (29.7 percent) 601 (40.5 percent)
Pharmacist 114 (4.3 percent) 45 (3.0 percent)
Other medical staff 457 (17.4 percent) 146 (9.8 percent)
Other staff 671 (25.5 percent) 184 (12.4 percent)
Physicians per bed 0.46 0.49
Total revenue (US$) 67,116,535 181,103,813
Notes: Total asset and total revenue expressed in US$ calculated using exchange rates of December
Table I. 31, 2003. All data are from 2003 except where noted in parentheses. The numbers related the
A general overview of the surroundings of hospital C are just those of one district of the city where it locates, because the
two hospitals influences from district are greater than from city there. But for hospital N, it refers to the entire city

characteristics of each perspective. These should be in-keeping with each

organization’s mission. Each key indicator was tested whether it was suitable for
the two hospitals’ practice using iterative discussions, redefining calculation methods
and affirming data acquisition. These included the views of independent hospital
managers and academics from Japan’s Nagoya University. Consequently, of the nine
BSC-orientated comparative hospital performance indicators proposed by Michigan
University researchers were considered first: cash flow margin; asset turnover; cost per
case; mortality; complications index; customer perspective; occupancy; change in
occupancy; learning and growth; length of stay; outpatient activity (Griffith et al.,
2002).
We believe that while most of these indicators, proposed by US researchers, can be
used to compare hospital performance in China and Japan, some need to be modified
because they are unsuitable for the two countries’ situations. The cost per case
indicator, for example, cannot be used directly because of Japan’s and China’s different
economic backgrounds, so it was modified to change of cost per case. Similarly, total
profit margin was used instead of cash flow margin in order to simplify analysis. The
complications index indicator was abandoned because the two hospitals’ definitions
were different and because there were data collection difficulties. The length of stay
indicator is usually used to measure internal product efficiency in the two countries,
which was moved from learning and growth to the internal business processes
perspective. Of the two occupancy datasets, which are normally used as efficiency
indicators, occupancy was chosen as an internal business processes indicator.
Some indicators proposed by the WHO European experts group in 2003 were
subsequently accepted and put into the BSC’s four perspectives. Patient satisfaction
and outpatient waiting times were included in the customer perspective, and staff Using BSC to
satisfaction and staff turnover were included in the internal business processes measure hospital
perspective. Consequently, we propose eight key comparative indicators, which were
thought to be well-suited to the two hospitals in our study (Table II). performance
The common comparative indicators now in the BSC framework were set up to
measure Chinese and Japanese hospitals’ performance (Figure 1). A simple definition
and calculation of each indicator is given in Table III. 343
Data for each indicator were collected in 2003 from the two hospitals’ information
and statistics departments according to the definition of each indicator mentioned
above. The fiscal year of study in Japan was from April 2003 to March 2004, while in
China it is from January to December 2003. However, the difference was not felt to
affect our hospital comparisons. Statistical significance was tested using two-tailed x2
tests.

Results
From a financial perspective, total profit margin and asset turnover in Chinese hospital
C was higher than Japanese hospital N, as was the change of cost per case compared
with the previous year. The biggest expenditure was purchasing materials in the
Chinese hospital, and in Japan, staff salary (Table IV).
There was no significant difference in staff satisfaction rates between the two
hospitals ( p ¼ 0.846), yet hospital N’s staff turnover was significantly higher than
hospital C’s ( p , 0.001). From the hospital productive efficiency indicators, hospital
C’s length of stay was shorter, and its bed occupancy was slightly higher than the
hospital N’s though differences were not statistically significant. Outpatients,

Perspective Other comparative indicators Justification

Financial Personnel expenditure as a Helps us to understand hospital

percentage of total patient revenue. expenditure
Material cost as a percentage of
total patient revenue
Internal business processes Outpatients per year per doctor. Good indicator for showing
Emergency patients per year per internal operating efficiency such
doctor. Admitted inpatients per as staff productivity
year per doctor
Medical accident leading to law Medical accidents are an important
suit rates indicator of internal product
quality. The number of cases
suited to court can only be used
because of differences in the
definition of accidents between the
two countries
Learning and growth Expenditure on medical research. Medical research is needed to
Academic papers written in develop hospitals. Academic
English per year per medical staff papers act as an indicator to of Table II.
member medical research, and English Other comparative
publications usually mean hospital performance
international level research. These indicators suitable for use
are easily compared in China and Japan
IJHCQA
19,4

344

Figure 1.
Comparative BSC hospital
performance measurement
framework in China and
Japan

emergency patients, and inpatient indicators were statistically significant. From the
main internal product quality indicators, mortality and medical accident leading to law
suits rate, hospital C’s data were significantly lower than the hospital N ( p , 0.001 and
p ¼ 0.025, respectively).
The two hospitals’ patient satisfaction rates were not significantly different
( p ¼ 0.902), while hospital C’s outpatient waiting times were longer even though
outpatient activity was higher. Hospital N spent more money on medical research and
academic papers written in English were greater in number – reaching statistical
significance ( p , 0.001).

Discussion
The BSC revealed the differences between the two countries
Applying BSC to hospital performance measurement in different countries provides a new
performance measurement approach. In our study, performance differences between the
two individual hospitals were revealed by comparing BSC KPIs. On the one hand, all
indicators in the financial and internal business processes perspectives suggested that
Hospital C was better at internal operations and in better financial condition than Hospital
N. These benefits may have arisen from the positive effects of the market-oriented health
 Using BSC to
Perspective Indicators Definition of calculation
measure hospital
Financial Total profit margin (Total operating revenue – total performance
operating expenses)/total
operating revenue
Asset turnover Total revenue/total assets
Change of cost per case (Reported year operating expense 345
per discharge – preceding year
operating expense per
discharge)/reported year operating
expense per discharge
Personnel expenditure as a percent Total payments to staff/total
of total patient revenue patient revenue
Material cost as a percent of total Costs of medical material and
patient revenue office expendable supplies/total
patient revenue
Internal business processes Staff satisfaction Number of staffs expressed
“satisfaction” in surveys/total
surveyed staffs
Staff turnover Staff leaving the hospital in one
year/total staffs
Length of stay Total number of days in
inpatient/number of discharges
Occupancy Average daily census/beds in
service
Outpatients per year per doctor Outpatients/year/doctors
Emergency patients per year per Emergency patients/year/doctors
doctor
Admitted inpatients per year per Admitted inpatients/year/doctors
doctor
Mortality Deaths/total admitted inpatients
per year
Medical accidents leading to law Number of medical accidents
suit rate leading to law suit a
year/total admitted inpatients a
year
Customer Patient satisfaction Number of patients expressed
“satisfaction” in survey/total
surveyed patients
Outpatient waiting times The time which elapses between
the request by a patient for a
consultant and attendance on
the patient in a consultation
room
Learning and growth Expenditure on medical research Expenditure on medical
research/total operating
revenue
Academic papers written in Academic papers written in
English per year per medical staff English which published in
member professional journal/number of
medical staffs
Outpatient activity Net outpatient revenue/net patient Table III.
revenue BSC definitions
 19,4

346

hospitals
Table IV.
IJHCQA

from the two objective

Data for each indicator
Date
Perspective Indicators C hospital (China) N hospital (Japan) p-value

Financial Total profit margin 20.747 percent 27.429 percent NA

Asset turnover 1.11 0.96 NA
Change of cost per case 22.62 percent 21.57 percent NA
Personnel expenditure as a percent 19.35 percent 53.29 percent NA
of total patient revenue
Material cost as a percent of total 48.13 percent 37.28 percent NA
patient revenue
Internal business Staff satisfaction Satisfied/total 418/613 (68.18 percent) 606/903 (67.11 percent) 0.846
processes
Staff turnover Staffs left 34/2627 (1.3 percent) 102/1483 (6.9 percent) , 0.001
hospital/total staffs
Length of stay 18.5 21.7 NA
Occupancy Daily census/beds 1182/1300 (90.9 percent) 857/1035 (82.8 percent) 0.126
Outpatients per year per doctor Outpatients/doctors 773,724/604 (1,281) 459,342/507 (906) , 0.001
Emergency patients per year per Emergency 121,404/604 (201) 8,619/507 (17) , 0.001
doctor patients/doctors
Admitted inpatients per year per Inpatients/doctors 22,348/604 (37) 13,329/507 (26) , 0.001
doctor
Mortality Deaths/inpatients 514/22,348 (2.3 percent) 413/13,329 (3.1 percent) , 0.001
Medical accident leading to law Accidents/inpatients 0/22,348 (0) 3/13,329 (0.023 percent) 0.025
suits rate
Customer Patient satisfaction Satisfied/total 726/873 (83.13 percent) 945/1,127 (83.89 percent) 0.902
Outpatient waiting times (minutes) 90 20 NA
Learning and Expenditure on medical research 0.3 percent 2.1 percent NA
growth
Academic papers written in Papers/doctors 4/604 (0.006) 248/507 (0.49) , 0.001
English per year per medical staff
member
Outpatient activity 45.01 percent 20.48 percent NA
2
Notes: p-value from two-tailed x tests. NA means Not Applicable, because the data are not dichotomous. Figures for calculation of each indicator which
is appropriate to using x 2 tests are listed according to the definition in Table III, and numbers in parenthesis were actual figures of each indicator
reform in China. For example, the government subsidy of large public hospitals in China is Using BSC to
very low and the survival pressure from market competition is higher. hospital C’s measure hospital
managers, therefore, may focus more on enhancing financial status and improving
operating efficiency. In Japan, on the other hand, government hospitals receive more performance
government funding and competition between hospitals is less owing to robust health care
planning in each community. This showed one negative effect – inefficiency, which can
also be seen in Japanese public health facilities. It may also explain why the Japanese 347
government concentrated on improving hospital management efficiency in recent years,
especially in the national hospitals. On the other hand, the various customers, learning and
growth indicators are not all in agreement, but some pointers, outpatient waiting times for
example, were longer in the Chinese hospital, and research expenditure was limited. The
difference between the two hospitals’ outpatient waiting time may be the result of a more
efficient outpatient appointment system in Japan, instead of the larger number of
outpatients per doctor in Chinese hospital C. Hospital managers in China seem to have
concentrated on gaining more short-term benefits, which meant long-term developments
were ignored. The latter may explain the lower medical research and the smaller number
of published academic papers.
Performance measurement systems should aim to improve hospital efficiency and
effectiveness, rather than identifying individual failures (Shaw, 2003). The goal of
measuring hospital performance in different countries is to identify opportunities to
improve performance. The differences between the two hospitals suggest that hospital
N can still benefit from efforts to improve financial status and internal management.
Hospital C managers, on the other hand, need to reduce their outpatient waiting times,
and should reconsider whether managers need to strengthen continuing development,
for example, by investing in medical research.
The hospitals’ performance differed from general expectation, which made us think
more about the relationship between hospital and total health system performance.
Considering the differences mentioned above, the Chinese hospital is not
comprehensively worse than the Japanese hospital. However, on a WHO level, Japan
is ranked higher than China. The diverging results at the hospital level and the system
level suggest that deeper research can be meaningful.
The other way of comparing hospital performance between different countries lies
in revealing the degree to which hospitals contribute to the country’s health system.
Recent models of measuring comprehensive health system performance, such as the
Dutch framework that combines BSC with the Lalonde model (Ten Asbroek et al., 2004)
are based on the “cure factor.” This factor, usually relegated to hospitals, is just one of
many elements that contribute to the performance of a country’s health system. Other
factors include “prevention,” “welfare,” “lifestyle,” “environment,” etc. so a
comprehensive consideration is needed. However, hospitals are generally thought to
be an important part of any health system and consume a major part of national health
resources (WHO, 2003a, b). In our study, the difference between the two hospitals
cannot represent their countries, but if further studies on larger numbers of hospitals
reach the same conclusions as our report then it suggests that the “cure factor” may not
be the primary reason for an improving or deteriorating health system performance. It
may indicate, on the other hand, that hospital performance is not the primary
determinant of health system function, therefore, improving hospital performance
alone will not lead to overall health system improvements.
IJHCQA Using BSC in different countries
19,4 We feel that BSC has been used effectively as a framework to organize various
comparative indicators to benchmark and recommend ways of improving Chinese
and Japanese hospital performance. In its original form, the BSC provides a
framework for implementing a four-area strategy. Typically, managers define the
organization’s goals and measure progress based on these areas (Wyatt, 2004).
348 When we use BSC to compare hospital performance in different countries, it can
provide a clear and comprehensive understanding of organizational performance
and can suggest areas for improvement. Measuring hospital performance in
different countries, however, is limited by data collection problems. The availability
of different KPI data will influence the nature and value of BSC for measuring
measure hospital performance. In our study, concentrating on four BSC perspectives
– financial, internal business processes, customer, learning and growth, we think
the KPIs used in the financial and internal business processes areas are enough to
represent these perspectives, while in the other two areas – customer, learning and
growth perspective, KPIs were found wanting. For example, in the customer area, if
data on the protection of patient rights and privacy is available then it will make
the comparison complete. In the learning and growth area, indicators measuring the
use of new technology and staff training are important and need to be collected.
Nevertheless, we found that most KPIs were feasible in the two hospitals, and that
the data were available.
Choosing effective KPIs is the main challenge for measuring hospital performance
in different countries, and this study provides some insights. First, expressing
indicators as ratios or proportions is a good way to make the indicators comparable.
For example, the cost per case indicator cannot be used meaningfully in different
countries. After modifying it to change of cost per case, however, the data made sense.
Second, disease specific indicators can expose new performance differences. For
example, we can get more information from the indicator length of stay disease
specific, even though the indicator length of stay has meaning. A similar situation
occurs with mortality. For some indicators such as re-admission and hospital acquired
infection rates, we must track specific diseases or cases, as it is difficult to acquire
general data. Third, the chosen KPIs must be relevant to each country’s situation, and
different hospital missions must also influence selection. For example, the indicators
application of new technology in hospital and expenditure on staff training were
thought to be good indicators that reflect learning and growth, but were abandoned
after we found that the two hospitals’ management systems and cultures were
different.

Conclusions and recommendations

The BSC framework not only encourages hospital performance indicators across
different countries to be expanded but also helps us to comprehensively compare
and analyze hospital performance. Using BSC to compare two Chinese and
Japanese hospitals raised service problems while identifying improvement
opportunities. Further use of the BSC to measure hospital performance in
different countries may reveal the health factors that most contribute to good
performance while encouraging development and implementation of relevant Using BSC to
national health policies. measure hospital
performance
References
Bogg, L., Dong, H., Wang, K., Cai, W. and Vinod, D. (1996), “The cost of coverage: rural health
insurance in China”, Health Policy Plan, Vol. 11 No. 3, pp. 238-52.
349
Dong, W-Z. (2002), “Health care reform in urban China”, Working Paper 2001/2, Munk Centre for
International Studies at the University of Toronto, available at: [Link]/cphs/
WORKINGPAPERS/CPHS2001_Weizhen_Dong.pd
Eggleston, K. and Yip, W. (2004), “Hospital competition under regulated prices: application to
urban health sector reforms in China”, International Journal of Health Care Finance and
Economics, Vol. 4 No. 4, pp. 343-68.
Griffith, J.R., Alexander, J.A. and Jelinek, R.C. (2002), “Measuring comparative hospital
performance”, Journal of Healthcare Management, Vol. 47 No. 1, pp. 41-57.
Huang, Y-Z. (2002), “The paradoxical transition in China’s health system”, Harvard Health Policy
Review, Vol. 3 No. 1.
Hyoung-Sun, J. and Hurst, J. (2001), “An assessment of the performance of the Japanese
health care system”, OECD Labour Market and Social Policy – Occasional Papers,
No. 56, OECD Head of Publications Service, available at: [Link]/dataoecd/18/
16/[Link]
Kaplan, R.S. and Norton, D.P. (1992), “The balanced scorecard: measures that drive
performance”, Harvard Business Review, Vol. 70 No. 1, pp. 71-9.
MoH PR China (1998) Research on National Health Services – Analysis Report of the National
Health Services Survey in 1998, MoH P. R. China, Beijing, available at: [Link]/
news/more_index.aspx?tp_class ¼ C304&url_addr ¼ /news/sub_index.aspx
MoH PR China (2004), “China health annual statistics 2004”, MoH P. R. China, Beijing, available
at: [Link]/news/sub_index.aspx?tp_class ¼ C3
Shaw, C. (2003), “How can hospital performance be measured and monitored?”, WHO Regional
Office for Europe’s Health Evidence Network (HEN), WHO Regional Office for Europe,
available at: [Link]/document/[Link]
Ten Asbroek, A.H.A., Arah, O.A., Geelhoed, J., Custers, T.D., Delnoij, M. and Klazinga, N.S.
(2004), “Developing a national performance indicator framework for the Dutch
health system”, International Journal of Quality in Health Care, Vol. 16, Supplement 1,
pp. i65-i71.
WHO (2000), “Health systems: improving performance”, The World Health Report 2000, WHO,
Geneva.
WHO, Regional Office for Europe (2003a), “Measuring hospital performance to improve the
quality of care in Europe: a need for clarifying the concepts and defining the main
dimensions”, Report on a WHO Workshop Barcelona, Spain, January, available at: www.
[Link]/Document/[Link]
WHO, Regional Office for Europe (2003b), “Selection of indicators for hospital performance
measurement”, Report on the 3rd and 4th WHO Workshop Barcelona, Spain, June and
September, available at: [Link]/document/[Link]
Wyatt, J. (2004), “Scorecards, dashboards, and KPIs – keys to integrated performance
measurement”, Healthcare Financial Management, Vol. 58 No. 2, pp. 76-80.
IJHCQA Zelman, W.N., Pink, G.H. and Mathias, C.B. (2003), “Use of the balance scorecard in health care”,
Journal of Health Care Finance, Vol. 29 No. 4, pp. 1-16.
19,4
Further reading
Schmidt, S., Bateman, I., Breinlinger-O’Reilly, J. and Smith, P. (2006), “A management approach
that drives actions strategically-balanced scorecard in a mental health trust”, International
350 Journal of Healthcare Quality Assurance, Vol. 19 No. 2, pp. 119-35.

Corresponding author
Xiao-yun Chen can be contacted at: kevin_xychen@[Link]

To purchase reprints of this article please e-mail: reprints@[Link]

Or visit our web site for further details: [Link]/reprints