Document Type : Original Article


1 Department of Health Services Administration

2 Al-Zahra Academic Medical Center, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Growth and development in any country’s national health system, without an
efficient evaluation system, lacks the basic concepts and tools necessary for fulfilling the
system’s goals. The balanced scorecard (BSC) is a technique widely used to measure the
performance of an organization. The basic core of the BSC is guided by the organization’s
vision and strategies, which are the bases for the formation of four perspectives of BSC. The
goal of this research is the performance evaluation of Al-Zahra Academic Medical Center in
Isfahan University of Medical Sciences, based on Iran BSC model. Materials and Methods:
This is a combination (quantitative–qualitative) research which was done at Al-Zahra Academic
Medical Center in Isfahan University of Medical Sciences in 2011. The research populations
were hospital managers at different levels. Sampling method was purposive sampling in which
the key informed personnel participated in determining the performance indicators of hospital
as the BSC team members in focused discussion groups. After determining the conceptual
elements in focused discussion groups, the performance objectives (targets) and indicators
of hospital were determined and sorted in perspectives by the group discussion participants
. Following that, the performance indicators were calculated by the experts according to the
predetermined objectives; then, the score of each indicator and the mean score of each
perspective were calculated. Results: Research findings included development of the organizational mission, vision, values, objectives, and strategies. The strategies agreed upon by
the participants in the focus discussion group included five strategies, which were customer
satisfaction, continuous quality improvement, development of human resources, supporting
innovation, expansion of services and improving the productivity. Research participants also
agreed upon four perspectives for the Al-Zahra hospital BSC. In the patients and community
perspective (customer), two objectives and three indicators were agreed upon, with a mean
score of 75.9%. In the internal process perspective, 4 objectives and 14 indicators were agreed  upon, with a mean score of 79.37%. In the learning and growth perspective, four objectives
and eight indicators were agreed upon, with a mean score of 81.11%. Finally, in the financial
perspective, two objectives and five indicators were agreed upon, with a mean score of 67.15%.
Conclusion: One way to create demand for hospital services is performance evaluation by
paying close attention to all BSC perspectives, especially the non-financial perspectives such
as customers and internal processes perspectives. In this study, the BSC showed the differences in performance level of the organization in different perspectives, which would assist the
hospital managers improve their performance indicators. The learning and growth perspective
obtained the highest score, and the financial perspective obtained the least score. Since the
learning and growth perspective acts as a base for all other perspectives and they depend
on it, hospitals must continuously improve the service processes and the quality of services
by educating staff and updating their policies and procedures. This can increase customer
satisfaction and productivity and finally improve the BSC in financial perspective.


1. Glickman SW, Baggett KA, Krubert CG, Peterson ED, Schulman KA.
Promoting quality: the health-care organization from a management
perspective. Int J Qual Health Care 2007;19:341-8.
2. McKee M, Healy J. Hospitals in a Changing Europe. Oxford: Open
University Press; 2002.
3. Raeisi AR. Comparative study of hospital information accreditation
management system in selected countries and suggestion of
suitable model for Iran [Ph.D. Thesis]. Tehran: Iran University of
Medical Sciences, School of Management and Medical Information
Science; 2005.
4. Asif Syed M, Christopher Bresson, Mark Moskowitz. IT Framework
for the Implementation of Balanced Scorecard in Healthcare
Systems. New Haven, CT: Yale New Haven Health System; 2007.
p. 1-12.
5. Kaplan RS, Norton DP (Author). Akbari H, Soltani M, Maleki A
(translators). Strategy map, change the intangible assets to tangible
outcomes, Asia publication, first edition. Tehran: 2005.
6. Kaplan RS and Norton DP. The Execution Premium: Linking Strategy
to operations for competitive advantage. Translated By M.R, Atefi.
Tehran: 2009 [In Persian].
7. Pieper SK. Reading the right signals: How to Strategically Manage
with Scorecards. Healthc Exec 2005;20:8-14.
8. Kaplan RS, Norton DP (Author), Bakhtiary P (translator). Strategyfocused Organization. Industrial Management organization
publication, second edition, Tehran: 2007.
9. Rigby DK. Management Tools and Techniques: A Survey. California
Management Review, 2001;43(2).
10. Kaplan RS, Norton DP. The Balanced Scorecard: Translating
Strategy in to Action. Cambridge: Hardward Business School
Press; 1996.
11. MacKinney AC, Wolf G. Cooperative Opportunities for Balanced
Scorecard Driven Strategic Planning and the Potential Relevance
to Population Health Initiatives. MBA of Stroud water Associates
for and with the Rural Wisconsin Health Cooperative April 30, 2004.
12. Kaplan RS, Norton DP. Why Does Business Need a Balanced
Scorecard?. J Cost Manage 1997;111:5-11.
13. Bruce G, Tian G. An analysis of the BSC in health care organization.
Int J Product Perform Manage 2008;57:6-21.
14. Balanced Scorecards for Small rural hospital: Concept Overview
and Implementation Guidance the Mountain States Group, Inc. via
funding provided by the United States Department of Health and
Human Services, Program Support Center, Contract Number, 98-
282. Available from:
15. Zelman WN, Pink H, Matthias Catherine. Use of the BalancedScorecard in healthcare. J Healthc Financ 2003;29:1-16.
16. Vatankhah S, Salemi A. Survey the evaluation system of hospitals
under supervision of Iran Medical Science University by using of
balanced scorecard. Health Manag 2010;12:49-58.
17. Begloo Amin Ghasem. Designing a Model of Performance
Evaluation for Iranian Public Hospitals Using the BSC [Ph.D. Thesis].
Tehran: Islamic Azad University Science and Research Branch.
2008 [In Persian].
18. Niven PR, Bakhtiari P, et al (translators). Balanced Scorecard Step by
Step. Industrial Management organization publication; 2007. p. 265.
19. Chen X, Yamauchi K, Kato K, Nishimura A, Ito K. Using the balanced
scorecard to measure Chinese and Japanese hospital performance.
Int J Health Care Qual Assur 2006;19:339-50.
20. Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G. A
Balanced Scorecard for Health Services in Afghanistan. Bull World
Health Organ 2007;85:146-51.
21. Urrutia I, Eriksen S. Application of Balanced Scorecard in Spanish
Private Health care Management. Journal of Measuring Business
Excellence, ABI/INFORM Global (2005);9(4):p.16-26.
22. Christopher JL Murray and David B Evans. World Health
Organization Geneva 2003.
23. Yaghoubi M, Yarmohammadian MH, Raeisi A, Javadi M,
Saghaiannejad Isfahani S. The Relationship between the
Organizational Justice and Organizational Citizenship Behavior
among Medical Records Staffs of Selected Hospitals of Isfahan.
Health Information Management 2011; 7 (Special Issue): p. 515.
24. Raeisi A, Farahabadi ME, Nazari M. Emergency Department policy
and procedure manual(translation). Medical Sciences University
Publication of Isfahan 2010; p.1-23. Development of human
resourcesDevelopment of human resources
25. Barati A, Malaki M, Golestani M, Emani M. Evaluation of staff
performance management system for Semnan Amir Al-Momenin
hospital using Balanced Scorecard. J Health Manage 2006;9:47-54.
26. Ontario hospital Association. Hospital Report 2007: Acute Care.
Toronto: 2007; p. 3-88.
27. Griffith JR, Jeffrey AA, Warden GL. Measuring Comparation Hospital
Performance. J Healthc Manage 2002;47:41-57.
28. GaoTian, Gurd Bruce. Gurd B. Lives in the Balance: Managing with
the Scorecard in not-for-profit healthcare setting. Australia and
New Zealand Third Sector Research. Eighth Biennial Conference.
Navigating New Waters; 2006; p.1-25.
29. Santiago JM. Use of the balanced scorecard to improve the quality
of behavioral health care. Psychiatr Serv 1999;50:1571-6.
30. Yarmohammadian MH, Foroughi Abari AA, Najafi P, Shahtalebi
Badri, Fooladvand Maryam, Shahtalebi Somayeh . An Integrated
Strategic Quality Model (ISQM) for Non-governmental University:
Case of IAU- Khorasgan Campus (IAUK); 2009.
31. Yarmohammadian MH, Raeisi A, Haghshenas A, Asgari H (2009a) .
New Integrated Model for Strategic Planning in Higher Education,
6th International Conference on Management, Greater Noida,India.
Dec. 28, 2008-Jan 1, 2009.
32. Yarmohammadian MH, Foroughi Abari AA, Anasri M, Kiani H,
(2009b). Using strategic Planning Model to Improve Iran Higher
Education NG-NP, Intl Conference on Technology and Business
Management, Al Ghuraair University, UAE, March 29-April 1, 2009.