Applying the balanced scorecard to local public health performance measurement: deliberations and decisions

BMC Public Health Correspondence Applying the balanced scorecard to local public health performance measurement: deliberations and decisions Erica Weir 1 Nadine d'Entremont 1 Shelley Stalker 1 Karim Kurji 1 Victoria Robinson 0 0 Institute of Medical Science, University of Toronto , Toronto , Canada 1 Public Health Branch, Community and Health Services Department, Regional Municipality of York , Newmarket , Canada Background: All aspects of the heath care sector are being asked to account for their performance. This poses unique challenges for local public health units with their traditional focus on population health and their emphasis on disease prevention, health promotion and protection. Reliance on measures of health status provides an imprecise and partial picture of the performance of a health unit. In 2004 the provincial Institute for Clinical Evaluative Sciences based in Ontario, Canada introduced a public-health specific balanced scorecard framework. We present the conceptual deliberations and decisions undertaken by a health unit while adopting the framework. Discussion: Posing, pondering and answering key questions assisted in applying the framework and developing indicators. Questions such as: Who should be involved in developing performance indicators? What level of performance should be measured? Who is the primary intended audience? Where and how do we begin? What types of indicators should populate the health status and determinants quadrant? What types of indicators should populate the resources and services quadrant? What type of indicators should populate the community engagement quadrant? What types of indicators should populate the integration and responsiveness quadrants? Should we try to link the quadrants? What comparators do we use? How do we move from a baseline report card to a continuous quality improvement management tool? Summary: An inclusive, participatory process was chosen for defining and creating indicators to populate the four quadrants. Examples of indicators that populate the four quadrants of the scorecard are presented and key decisions are highlighted that facilitated the process. - Background All aspects of the healthcare sector are being asked to account for their performance and to demonstrate efficiency and effectiveness in providing services to their clients. This requirement poses unique challenges for local public health units, with their traditional focus on population health and their emphasis on disease prevention, health promotion and health protection. Multiple factors determine public health outcomes [1], such as socio-economic factors, lifestyle, gender and genetics, yet only a few of these factors fall directly under the local health unit's programmatic responsibility and influence (Table 1). In Ontario, Canada, health units are mandated to provide a limited range of programs [2] and are resourced accordingly. Consequently the overall health status of the residents within a health unit [3] presents only a partial and imprecise picture of the performance of the health unit. In the past few years a growing number of healthcare provider organizations have adopted the balanced scorecard (BSC) framework to develop a more comprehensive set of performance indicators. The BSC is a management tool, originally applied to businesses in the private sector, developed by Kaplan and Norton in 1992 [4]. Its creators describe it as "a multidimensional framework for describing, implementing and managing strategy at all levels of an enterprise by linking objectives, initiatives and measures to an organization's strategy" [4]. Their tool broadened the traditional notion held by private sector companies that performance is indicated by financial measures solely, by integrating financial measures with other key performance indicators linked to three additional areas: customer preferences, internal business processes and organization growth, learning and development. A BSC includes performance measures in all four quadrants. About a decade after Kaplan and Norton developed the BSC, a number of healthcare organizations in various healthcare settings throughout North America and abroad started to adapt and implement the BSC framework for their organizations. In Ontario, for example, over the past few years Cancer Care Ontario [5], the Ontario Hospital Association [6] and the University Health Network [7] have all adopted the BSC as their performance management tool. The four original quadrants were slightly modified to better reflect performance of publicly funded healthcare organizations rather than for-profit private businesses. The financial quadrant contains indicators of efficiency and asset utilization. The customer preferences quadrant contains measures of quality care and seamless service. The business process quadrant contains measure of continuous quality improvement and integrated service design and the learning and growth quadrant contains measures of human capital and strategic competencies. In 2004 the Institute for Clinical Evaluative Science (ICES), based in Ontario, Canada, released a report, "Developing a BSC for Public Health" [8] that introduced a public health specific BSC framework for performance measurement. Public health's focus on prevention and health promotion, often for entire populations, distinguishes it from many other areas of healthcare that are more patient and treatment focused. The four quadrants were further adapted to include not only traditional measures of performance such as health status, but also measures relating to the structures and processes within the local public health unit (Figure 1). Equal Access To ensure that all Ontarians have access to public health programs. Health Hazard Investigation To prevent or reduce adverse health outcomes resulting from exposure to health hazards as defined in the Health Protection and Promotion Act and including biological, physical, and chemical agents, natural or manmade. Program Planning and Evaluation To ensure that local programs address the health needs of the community, with costeffective, efficient, evidence-based approaches. Chronic Disease Prevention To reduce the premature mortality and morbidity from preventable chronic diseases. Early Detection of Cancer To reduce mortality from breast cancer and cervical cancer by increasing early detection. Injury Prevention Including Substance Abuse Prevention To reduce disability, morbidity and mortality caused by motorized vehicles, bicycle crashes, alcohol and other substances, falls in the elderly and to prevent drowning in specific recreational water facilities. Sexual Health To promote healthy sexuality. Reproductive Health To support healthy pregnancies. Child Health To promote the health of children and youth. Control of Infectious Diseases To reduce the incidence of infectious diseases of public health importance. Food Safety To improve the health of the population by reducing (...truncated)