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  Leadership in Health Services From unbalanced to balanced: performance measures in a Vietnamese hospital Luu Trong Tuan  Article information: To cite this document:Luu Trong Tuan, (2012), From unbalanced to balanced: performance measures in a Vietnamese hospital ,Leadership in Health Services, Vol. 25 Iss 4 pp. 288 - 305 Permanent link to this document: http://dx.doi.org/10.1108/17511871211268937 Downloaded on: 31 January 2016, At: 08:36 (PT)References: this document contains references to 66 other documents.To copy this document: permissions@emeraldinsight.comThe fulltext of this document has been downloaded 705 times since 2012* Users who downloaded this article also downloaded: Beata Kollberg, Mattias Elg, (2011), The practice of the Balanced Scorecard in health care services ,International Journal of Productivity and Performance Management, Vol. 60 Iss 5 pp. 427-445 http://dx.doi.org/10.1108/17410401111140374Yiannis Koumpouros, (2013), Balanced scorecard: application in the General Panarcadian Hospital of Tripolis, Greece , International Journal of Health Care Quality Assurance, Vol. 26 Iss 4 pp. 286-307 http://dx.doi.org/10.1108/09526861311319546Bruce Gurd, Tian Gao, (2007), Lives in the balance: an analysis of the balanced scorecard (BSC) inhealthcare organizations , International Journal of Productivity and Performance Management, Vol. 57 Iss 1pp. 6-21 http://dx.doi.org/10.1108/17410400810841209 Access to this document was granted through an Emerald subscription provided by emerald-srm:126209 [] For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald forAuthors service information about how to choose which publication to write for and submission guidelinesare available for all. Please visit www.emeraldinsight.com/authors for more information.  About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The companymanages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well asproviding an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committeeon Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archivepreservation. *Related content and download information correct at time of download.    D  o  w  n   l  o  a   d  e   d   b  y   F   l  o  r   i   d  a   A   t   l  a  n   t   i  c   U  n   i  v  e  r  s   i   t  y   A   t   0   8  :   3   6   3   1   J  a  n  u  a  r  y   2   0   1   6   (   P   T   )  From unbalanced to balanced:performance measures in aVietnamese hospital Luu Trong Tuan University of Finance-Marketing, Ho Chi Minh City, Viet Nam Abstract Purpose  – From the data derived from a Vietnamese hospital, this study seeks to discern whichorganisational culture types, leadership styles, and trust types pave the path for the implementation of the balanced scorecard (BSC) system. Design/methodology/approach  – The study uses a case research approach with a triangulation of data collation methods encompassing access to documents, field observations, and interviews.The in-depth interviews with 37 hospital members and field observations were conducted during21 months from March 2009 to November 2010. Findings  – The findings show that features relating to organisational change in terms of organisational culture, leadership style, and trust can impact the success of BSC implementation;nonetheless, the opposite direction can merely be encountered in the relationship between leadershipstyle and BSC implementation. Originality/value  – The study offers insights into a successful model of BSC implementation in thehealthcare sector built on such antecedents as organisational culture, leadership, and trust. Keywords  Balanced scorecard, Organisational culture, Leadership, Trust, Vietnam,Health services sector Paper type  Research paper 1. Introduction Numerous organisations are launching the balanced scorecard (BSC) to steerperformance (LaChance, 2006). The BSC permits organisations to highlight bothfinancial and nonfinancial performance metrics in four perspectives for building andimplementing organisational strategy (Herath  et al. , 2010) and aligning organisationalperformancewithorganisational visionandstrategy.Theapplication ofBSCsinhealthcare settings is rising as well (Gurd and Gao, 2007). In healthcare, the BSC is the “mealfor today”, with consultants buttressing this “miraculous treatment” (Aidemark, 2001,p. 23). However, even though several workshops and conferences on performancemanagement as well as BSC have occurred in major cities in Vietnam, the applicationof this performance measurement system has been limited to few manufacturing andservices companies, and virtually no healthcare services.Organisational culture, from Osburn’s (2008) stance, is a spirit cultivated by theshared values of the organisational members. Culture also acts as an intellectual andsentimental paradigm (Barker, 1992) that navigates the life of organisational membersand can block the acquiescence of alternative cultures. It is the harmony betweenmembers’ individual cultural heritage and the organisational culture or “uniquecommon psychology” that produces confidence, comfort, and trust (Vaill, 1989). Herath et al.  (2010) maintain that a culture of open reporting around the BSC is indispensablefor its effective implementation. The findings from Lau and Berry’s (2010) study reveal The current issue and full text archive of this journal is available at www.emeraldinsight.com/1751-1879.htm LHS25,4 288 Leadership in Health ServicesVol. 25 No. 4, 2012pp. 288-305 q Emerald Group Publishing Limited1751-1879DOI 10.1108/17511871211268937    D  o  w  n   l  o  a   d  e   d   b  y   F   l  o  r   i   d  a   A   t   l  a  n   t   i  c   U  n   i  v  e  r  s   i   t  y   A   t   0   8  :   3   6   3   1   J  a  n  u  a  r  y   2   0   1   6   (   P   T   )  that members perceive the use of nonfinancial metrics as fair through theaugmentation of the trust they have in their leaders.From the perspective of attributiontheory (Calder,1977),leadersare accountablefororganisational outcomes. Leadership is also viewed as an endogenous factorinteracting with a multiplicity of other organisational variables including culture toimpact organisational outcomes, to potentially impact the success of the BSCimplementation.In light of the diverse views, the question of how organisational culture, leadership,and trust influence the BSC implementation, a domain where little evidence of in-depthinvestigation, especially in healthcare service, exists, will be unpacked through thiscase study of a hospital in Vietnam.This introductory section will be followed by a succinct overview of the construct“balanced scorecard”, and its potential antecedents such as organisational culture,leadership, and trust. Then the depiction of the research methodology will bridge thisliterature survey with the study’s empirical findings, which are then recapitulated andindicative of practical as well as further research implications. 2. Literature review  2.1 Organisational change in healthcare organisations Increasing market pressures compel organisations to swap large portions of theirsecure traditions for untested paths into the future (Wesley, 1996). Three types of change organisations tend to undergo include: developmental change: naturaldevelopment; transitional change: evolve gradually to a “known state”; andtransformational change: journeying into the unknown. Transformational changeentails not merely structures and processes but also values and inherent culture of thehealthcare organisation(NHS Institutefor Innovationand Improvement, 2006). InGargand Singh’s (2002) view, the fixed norms of culture may act as resistance to change dueto apprehension amongst its members.Ginsburg and Tregunno (2005) discuss the impact of culture and leadership onorganisational change in healthcare organisations. Lukas  et al.  (2007) found fiveinteractive elements crucial to successful transformation of patient care:(1) Impetus to transform.(2) Leadership commitment to quality.(3) Improvement initiatives that actively immerse medical staff in meaningfulproblem solving.(4) Alignmentto attain consistency of organisational goals with resourceallocationand deeds at all levels of the organisation.(5) Integration to bridge traditional intra-organisational boundaries amongindividual components.Theseelements drive change byinfluencingthe componentsof the complexhealth careorganisation in which they operate:(1) Mission, vision, and strategies.(2) Operational functions and processes. Fromunbalanced tobalanced 289    D  o  w  n   l  o  a   d  e   d   b  y   F   l  o  r   i   d  a   A   t   l  a  n   t   i  c   U  n   i  v  e  r  s   i   t  y   A   t   0   8  :   3   6   3   1   J  a  n  u  a  r  y   2   0   1   6   (   P   T   )  (3) Infrastructure such as information technology and human resources thatsupport the delivery of patient care.(4) Culture.  2.2 Balanced scorecard  As the findings from Lau and Berry’s (2010) study reveals, the implementation of nonfinancial measures was seen by organisational members as fair. These effects,nonetheless, are found to be indirect via the augmentation of member role clarity, andthe augmentation of the trust between subordinates and leaders. Numerous modelshave been constructed on a fusion of financial and non-financial information. Dixon et al.  (1990) present an integrated performance measurement system wherebycosts-and-performance knowledge is acquired and utilised in the strategicmanagement cycle. Lynch and Cross (1991) introduce a performance pyramid thatlinks strategy and operations by translating strategic goals from the top down andmeasures from the bottom up, while Atkinson  et al.  (1997) build a stakeholder modelthat includes measurement for the primary and secondary goals of environmental andprocess stakeholders. Kaplan and Norton (1996) unveil a balanced scorecard – anintegrative framework – fusing financial, customer, internal process, and learning andgrowth perspectives steered by organisational vision and strategy.Balanced scorecard, from Aidemark  et al. ’s (2010) standpoint, is adopted formeasurements linked with the organisational strategy. How balanced scorecardapproach may be used in implementing organisational management strategies isillustrated by Rasila  et al.  (2010). Herath  et al.  (2010) demonstrate how the collaborativeBSC model can be implemented in Microsoft Excel by practitioners to minimise BSCconflicts. Funck (2007) examines how the balanced scorecard (BSC)has been translatedto suit the public healthcare environment.BSC has been adopted by a wide range of healthcare organisations, includingnational healthcare organisations, hospitals, and psychiatric centres (Zelman  et al. ,2003). BSC is used in 65 per cent of Swedish emergency hospitals (Aidemark  et al. ,2010). Aidemark (2010) observed that the balanced scorecard (BSC) enables the controlof health care quality. Chan and Seaman’s (2009) study divulges that patientsatisfaction is the most critical facet of the balanced scorecard in healthcare services.However, research by Aidemark  et al.  (2010) found that performance monitoring is of secondary magnitude, even in emergency hospitals with more than five years’experience with the BSC. Moreover, the BSC is virtually never used in the hospitals’reward systems. Astoundingly, strategy on service innovation within the BSCframework negatively impacts the organisational outcome of patient satisfaction. Gurdand Gao (2007) even more surprisingly found that the health of the patients was not aspivotal as it should be in the development of the BSC in Chinese hospitals.  2.3 Organisational culture A universal definition of organisational culture has proven elusive (Lewis, 2002),nonetheless, one of the most common definitions of organisational culture involves aset of beliefs, values, and behaviour patterns shaping the members’ behaviour andforming the core identity of organisations (Deshpande and Farley, 1999).Expanding Schein’s (1985) definition with the notion of understandings, Daft (2005)views organisational culture as a set of key assumptions, norms, values, and LHS25,4 290    D  o  w  n   l  o  a   d  e   d   b  y   F   l  o  r   i   d  a   A   t   l  a  n   t   i  c   U  n   i  v  e  r  s   i   t  y   A   t   0   8  :   3   6   3   1   J  a  n  u  a  r  y   2   0   1   6   (   P   T   )
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