RESEARCH ARTICLE

DASHBOARD VISUALISATION FOR HEALTHCARE

PERFORMANCE MANAGEMENT: BALANCED SCORECARD
METRICS
Stephen Victor1, Ayesha Farooq2
1. Punjab College of Technical Education (PCTE), Ludhiana, India
2. Aligarh Muslim University(AMU), Aligarh, India

Correspondence: [email protected]

ABSTRACT

OBJECTIVE:
The increase in demand for hospitalisation in an environment of financial stress has hastened the quest for more efficient
healthcare delivery systems. In the past performance management methodologies in the healthcare sector have been
predominantly static resulting in a lack of consistency, comparability and timeliness. To mitigate these shortcomings this
research work has attempted to create a conceptual framework in the digital dashboard format.
SETTING:
Of the frameworks presently used, the Balanced Scorecard(BSC) is very popular, primarily because the BSC is a
management system (not just a measurement system) that helps an organization highlight its vision and translate them
into action.
DESIGN:
The design adopted in this research work is primarily qualitative and exploratory. The methodology includes collating KPIs
from published literature, crystallising them using the Delphi Method and applying the Likert-scale to prioritise them. To
facilitate visualisation of the prioritised KPIs in the BSC format, the construction of a digital dashboard was envisaged.
RESULTS:
A dynamic dashboard was created in the BSC format with three Key Performance Indicators(KPI) for each of the four
perspectives.
1. Financial: Return on assets, average daily collections and working capital ratio
2. Customer Perspective: Patient satisfaction, lost business – number of appointments not attended and percentage
of patients Leaving Against Medical Advice(LAMA)
3. Internal Processes: Billing and collections/posting time, emergency patients triaged within 15 minutes of arrival
and patient waiting time
4. Learning And Growth: Empowerment (decision-making & participation), employee satisfaction and strategic
alliances/partnerships

KEYWORDS

Dashboard, Balanced Scorecard (BSC), Key Performance Indicators (KPI), Performance Management, Healthcare

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INTRODUCTION DASHBOARD VISUALISATION
The utility of the dashboard has enormously increased due

The success of an organisation depends upon how its to its ability to enable decision-makers to navigate in the

performance is managed. Very often, Healthcare ever-growing complex data environment. Advanced

administrators are unable to view with clarity the overall versions of dashboards are interactive and these can drill

picture of performance. The complicated nature of i.e. help slice and dice, blending with data. [4] Dashboards

healthcare operations is a hindrance to managers to usher in a wide epistemological and internal realignment in

effectively support the organization's objectives. The data that they introduce new vistas of knowledge for monitoring.

for healthcare management which exists in a wide variety [5] Visualisation has its benefits. As Rind suggests,

of forms also needs to be analysed and managed across visualization methodologies and tools, ‘‘combine the

health service functions and departments. This diversity processing power of modern computers with human

leads to several challenges in managing healthcare cognition and visual abilities to better support analysis

operations to the extent that it is widely acknowledged and task”. [6]

described by Gartner Research, a group of IT industry

analysts as “data-rich, but information poor.” [1] The cause The advancements in visual formatting techniques add to

of this poor state could be a combination of the following the interactive nature of the dashboard. Novel features like

with varying degrees of influence: drill-down facility, outlier detection and scenario analysis
with appropriate high-end visual displays greatly enhance
• different software packages used for patient
decision-support systems. [7] The primary benefit of
admissions, treatments and discharges.
dashboards lies in the convenient form they display crucial
• financial package variations in billing and claims pieces of data that will lead to quick decision-making, cost
• varied data formats for clinical diagnosis, research reductions and superior confidence levels (8).
and laboratory tests
In an environment of complex data and emerging
These factors may not provide administrators and technologies, there are certain considerations to be kept in
managers with a clear view of an organisation’s mind while developing high-tech performance
performance. Focus on financial performance alone is management dashboards for hospitals. According to
grossly inadequate to enhance the overall performance of Ghazisaeidi, these issues are, “KPIs development, data
an organisation. Non-financial measures like customer sources, data quality, dashboards integration to source
expectations and internal efficiencies too clearly influence systems and data presentation to users”. [7] Harrington et
the performance. Over the years, the Balanced Scorecard al. have inferred that “key performance indicators,
(BSC) has been frequently applied both in academic and balanced scorecards, and sales performance figures are
corporate circles as a performance management tool. [2] some of the content appropriate on dashboards”. [10]
The BSC has been very successful because of its balanced
approach between financial and non-financial indicators Creating a BSC Dashboard requires defining all metrics
of success, internal and external constituents of the after a clear understanding of each metric including its
organization, and lag and lead indicators of performances. nomenclature, purpose, target values, ranges,
[3) measurement units, periodicity of reporting, and sourcing
of data. [11] Since the hosting of data is done in different
Using the BSC framework, dashboard visualisations were structures, an appropriate architecture can be designed
created for the Christian Medical College and Hospital and implemented. This involves managing data delivery,
(CMCH), Ludhiana, Punjab, in close coordination with their data replication methods, understanding data hosting and
administrators during the period 2017-20. Established in query formulation that leads to the construction of
1894, CMCH is one of the leading Medical Colleges in the effective dashboards. [12]
North of India.
BALANCED SCORECARD
Under Dr. Nolan Norton’s leadership, a study was
REVIEW OF LITERATURE conducted by a consulting company in 1990-1991 to
determine what successful companies were measuring.
[13] As a result of this study, the Balanced Scorecard was

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Asia Pacific Journal of Health Management 2021; 16(2):i625. doi: 10.24083/apjhm.v16i2.625
proposed in its initial form. In addition to this Professor Robert traditional financial information systems would be replaced
Kaplan (Harvard Business School), was inducted into the by non-financial information systems”. [14]
research team to provide educational support. The timing
of creating and presenting the Balanced Scorecard The “Scorecard” comprises of targets and measures for
perfectly suited the quest for performance management each of the four components of the framework namely,
systems. Eccles (1991) published the “Performance Financial, Customer, Internal Business Processes and
Measurement Manifesto” in the Harvard Business Review. In Learning and Growth. Each organisation should decide on
this article, he predicted, “a performance measurement three or four “Key Performance Indicators (KPI)” based on
revolution will take place in the next five years, during which scientific principles and arrive at target values for the KPIs.

FIGURE 1: BALANCED SCORECARD

Source: Linking the Balanced Scorecard to Strategy (15)⁠

According to a study conducted by Bain & Co., the global definition as: “How patients perceive an organization
consulting firm, 57% of companies had benefited from BSC (Customer perspective); what are financial situations
implementation with a Satisfaction Index of 3.86 on a scale (Financial Perspectives); what can we do to improve the
of 5. [16] When the BSC is integrated with the dashboard, it level of services? (Perspective of learning and growth);
ushers in an innovative way of reasoning and operating what do we want to be the best in? (Perspective of internal
that is well suited in enhancing healthcare delivery. The business processes)”. [18] It enables top-level decision-
dynamic BSC allows an organization to set targets, link makers to a have smooth transition from judgments based
metrics, understand the correlation among metrics, and on experience and intuition to fact-based decisions based
easily view trends. Ideally, the metrics are linked to an on the healthcare BSC.
organization’s overall strategy. BSC implementations are
seen to reduce ambiguities in performance evaluations The BSC and the dashboard combination can be adopted
and increase goal congruence between the various as a model for cost-effective yet credible healthcare
groups within the organisation. [17] delivery. A notable study conducted by Chow provided
insight regarding the benefits of using the BSC by
BSC IN HEALTHCARE healthcare organizations. This study documented the
Each perspective of the BSC can be applied to benefit the potential of the BSC as a management tool to meet many
management of healthcare organizations. Looking at the challenges like “changing demographics, increased
BSC from the healthcare management point of view, customer expectations, increased competition, and
Končitíková, Culík and Pavla have given a specific intensified governmental pressure”. [19]

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KEY PERFORMANCE INDICATOR (KPI) 1. Dr. J. Pramod – Ex-Director, CMC Hospital, Ludhiana,
The BSC relies heavily on the concept of Key Performance Punjab
Indicators (KPI). “KPI is a quantifiable measure used to 2. Dr. Sunil Chandy – Ex-Director, CMC Hospital, Vellore,
evaluate the success of an organization, employee etc. in TN
meeting objectives for performance”. [20] Operational
3. Dr. Abraham Joseph – Ex-Director, CIHSR, Dimapur,
excellence can be directly correlated with KPIs which
Nagaland
enable measuring and monitoring relevant parameters.
[21]. The measurement of KPIs can be done at different 4. Dr. Lionel – Ex-Medical Suptd. CMC, Vellore, TN

levels in the organisation to ensure that targets are 5. Mr. Nandakumar – Internal Audit, CMC, Vellore, TN
successfully achieved. High-level KPIs may focus on the
overall performance of the business, while low-level KPIs The entire list of collated KPIs was presented individually to
may focus on separate processes that make up for the the Delphi team members. The initial rounds of discussion
corporate entity. [22) had queries on a semi-structured format. As part of the
preliminary work, healthcare experts identified important
KPIs play a crucial role in planning, evaluating and KPIs for each of the perspectives. They were encouraged
controlling through information support, transparency to add or delete KPIs according to their appropriateness.
creation and decision-making support of the management Comments given by the participants were kept in strict
(23)⁠. Some of the major benefits of performance measures confidentiality to ensure non-interference in the opinions.
are in creating action plans and making daily decisions This was followed by the merging and synthesis of opinions
that are linked and aligned to the factors that will bring to identify the KPIs. To obtain the priority list of KPIs all the
success to the organization. Overall performance gets experts in the panel participated in a round of short-listing
enhanced when “Wider ownership, empowerment, and during which they gave their rating of importance on a five-
fulfilment are created”. [19] point Likert-scale for all KPIs.

STAGE 3: DASHBOARD DEVELOPMENT

RESEARCH METHODOLOGY
For dashboard development, the cloud-based BSC
Designer tool was used. The BSC designer facilitates the
STAGE 1: COLLATION OF KPIS FROM PUBLISHED preparation of Strategy Maps and Scorecards in the
LITERATURE
dashboard format. It provides the algorithms for setting and
In the first stage, many research publications related to
modifying target values for each of the KPIs. Being user-
Balanced Scorecard in Healthcare settings were studied.
friendly it gives dynamic features like periodic updating
This included documented cases of gainful
and reporting with appropriate visualisations. The inputs
implementation, suggested modifications and
required by the BSC Designer are ‘business goals’, ‘KPIs’
identification of successful KPIs. The search criteria were
and figures like ‘target value’, ‘actual value’ and
Healthcare Balanced Scorecard, Key Performance
‘permissible range’. Display formats available are the
Indicators in Hospitals/Healthcare Institutions, Healthcare
gauge, bar chart, pie chart, radar and graph. Data from
Performance Management. Institutions with less than 100
the IT systems of the hospital are captured and used as
beds were excluded.
inputs into the BSC Designer.

STAGE 2: USING THE DELPHI METHOD TO CRYSTALLISE

KPIS RESULTS
In the second stage, the Delphi Technique, which is one of
the most effective tools used for qualitative research within A representative list of researched literature for KPI
a specific domain of expertise was used. [25] The minimum identification in healthcare is shown in Table 1 along with
number of participants recommended for a Delphi group the salient KPIs identified.
is five. [26] The criterion of choosing was to include experts
who have had several decades of experience in specific The initial collation identified 128 KPIs which reduced to 42
fields like Clinical, Finance, Operations etc. All of them had after the Delphi round. The break-up for each of the
sufficient administrative experience in managing large perspectives is shown in Table 2
healthcare facilities. Their details are:

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TABLE 1 IDENTIFICATION OF HEALTHCARE KPIS

SL. COUNTRY/
NO. COUNTRIES PUBLICATION TITLE SALIENT KPIS IDENTIFIED

1 CANADA “Do hospital balanced scorecard Critical incidents, Commitment to transition

measures reflect cause-effect planning and follow-up, Patients who would
relationships?” (28)⁠ recommend to others

2 CHINA “Using the balanced scorecard to Expenditure on medical research, Asset

AND measure Chinese and Japanese turnover, Outpatients per year per doctor

JAPAN hospital performance” (29)

3 U.S. A “Bi Application: Dashboards for In-patient commercial revenue, Patients

Healthcare” (30) given fibrinolytic medication within 30
minutes of arrival

4 IRAN “Key performance indicators in Employee absenteeism rate, Hospital

hospital based on balanced infection rate, Current cost per bed, Bed
scorecard model” (31)⁠ turnover, Training expenditures per capita

5 MALAYSIA “Framework for implementing Asset turnover, Cost per case, Mortality
balanced scorecard in hospitals” index, Number of research projects,
(32) Outpatient waiting times

6 TAIWAN “Identifying Key Performance Exploring new markets, Reduction in

Indicator of Balanced Scorecard by overhead, Activity based costing, Utilization
Analytic Hierarchy Process” (33) of space, Employee satisfaction, Reduced
rate of no-show

7 GREECE “Strategic performance “Percentage of readmissions, Inventory

measurement in a healthcare turnover, Number of projects with other
organisation: A multiple criteria organisations, Decrease of operating
approach based on balanced expenses, Increase of liquidity”
scorecard” (34)

8 SAUDI “Developing strategic health care Average length of stay(ALOS), OR Utilization

ARABIA key performance indicators: A case Rate, ER waiting time, Outpatient
study on a tertiary care hospital” (35) satisfaction rate, Average bed occupancy
rate

9 ITALY “An integrated approach based on Percentage of patients leaving against

balanced scorecard and analytic medical advise, Pharmaceutical stock
hierarchy process for strategic turnover ratio, Rate of technical
evaluation of local healthcare obsolescence
agencies” (27)⁠

Source: Researcher’s compilation

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TABLE 2 COMPARATIVE LIST OF KPIS AFTER EACH SHORT-LISTING PROCESS

PERSPECTIVE INITIAL DELPHI ROUND LIKERT-SCALE

COLLATION

FINANCIAL 33 10 3

CUSTOMER 11 8 3

INTERNAL PROCESS 59 13 3

LEARNING AND GROWTH 25 11 3

TOTAL 128 42 9

The KPIs that were identified are: perspectives, three prioritised KPIs with the current values
I. FINANCIAL are displayed. Display in the BSC format is a handy tool that
1. Return on assets: Utilisation of each facility gives crucial information on a single screen of the hospital’s
2. Average daily collections: The revenue arising out of overall performance. Administrators can initiate corrective
hospital operations action based on dashboard visualisations. Additionally, the
3. Working capital ratio: Total current assets by total software also has a provision for alerts that will be sent to
current liabilities the responsible person automatically by email when a KPI
value goes beyond a particular upper/lower limit so that
II. CUSTOMER PERSPECTIVE course corrections could be made.
1. Patient satisfaction: Extent to which patients are
happy with the healthcare delivery LEARNING AND GROWTH PERSPECTIVE
2. Lost business – Number of appointments not The relative importance of the three KPIs was calculated
attended: Patients who fail to turn up after fixing and is shown as a Pie Chart in Figure 3. The combined score
appointments of the employee-related KPIs is 67.6%, highlighting the
3. Percentage of patients Leaving Against importance of human resources. The employee satisfaction
Medical Advice(LAMA): Dissatisfied patients who are level is shown in a gauge format. The green, amber and red
determined to leave the facility at their own risk zones are shown in the background according to preset
limits.
III. INTERNAL PROCESSES
1. Billing and collections/posting time: The amount of CUSTOMER PERSPECTIVE
time taken to prepare bills. For the customer perspective, a sample dashboard
2. Emergency patients triaged within 15 minutes of visualisation is shown in Figure 4. These covers ‘Patients
arrival: The speed at which emergency patients are Leaving Against Medical Advice’(LAMA) and ‘Skipped
attended to 3. Patient Waiting time: The time taken by the appointments’. The blue line indicates the progress which is
doctor to see the patient monitored based on a monthly average. ‘Skipped
appointments’ is shown in the traffic signal format. Since
IV. LEARNING AND GROWTH the number of skipped appointments should be as low as
1. Empowerment (decision-making & possible, the setting is done in the reversed order. A value
participation): Freedom given to the employees to make higher than the set limit is shown in ‘red’.
decisions
2. Employee satisfaction: The employee’s INTERNAL PROCESSES PERSPECTIVE
overall experience with the work and environment ‘Emergency Care’ is plotted on a graph showing

3. Strategic alliances/partnerships: Partnerships made ‘probability’ on its X-axis and ‘Impact’ on its Y-axis. See

with niche service providers Figure 5. This is a novel feature that helps administrators to
interpret the performance and take appropriate action.

The BSC developed for the Christian Medical College and This KPI is needed to keep track of how well emergency

Hospital (CMCH) is shown in Figure 2. For each of the

6
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patients are triaged within 15 minutes of arrival. It becomes Collection is shown in a graphical form. The red line
crucial to the success of large hospitals as it influences the indicates the baseline figure, the blue indicates the actual
perception of care. When patients arriving at the Trauma performance figure and the green indicates the target
Centre get immediate care they are satisfied and are likely figure. It is notable here that all three figures namely
to become brand ambassadors for the healthcare facility. baseline, target and actual performance can be modified
Since ‘Billing Time’ should be as low as possible the setting and updated as required. Working Capital Ratio is
required on the gauge is to be reversed showing green first, represented as a bar chart based on the historical data
followed by yellow, amber and red. entered into the database. The colour of the bar changes
according to the preset value. A red bar indicates that
FINANCE PERSPECTIVE corrective action needs to be initiated.
Figure 6 shows the performance of the ‘Average Daily
Collection’ and ‘Working Capital Ratio’. Average Daily

FIGURE 2. BALANCED SCORECARD

FIGURE 3. LEARNING AND GROWTH PERSPECTIVE

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FIGURE. 4. CUSTOMER PERSPECTIVE

FIGURE 5. INTERNAL PROCESSES PERSPECTIVE

FIGURE 6. FINANCE PERSPECTIVE

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DISCUSSION CONCLUSION

The World Health Organisation (WHO) has taken an Combining traditional research methodologies like
initiative to better health standards through its “Health literature searches, the Delphi method and Likert-scale with
System Metrics (HSM)”. This effort aims to provide users with versatile software tools, a user-friendly digital dashboard
“a minimal set of core indicators, that are comparable has been developed. Having many modifiable
between populations and over time, and identify the key components, the developed BSC framework can serve as
measurement issues and strategies required to report a benchmark for further formulation of specialised models
regularly on the status of the health system” (36). The HSM for applications in specific areas like diagnostics, clinical
sets the tone for data management and transforming data services and facility management. The results of this
into useful information. The critical need here is the research are expected to be of significance to hospitals
management and presentation of data when cross- looking for best practices in performance management.
functional needs arise. The research work undertaken has The outcome of this research adds to the ever-growing
endeavoured to address this important need. The BSC broad literature related to Healthcare Performance
provides an excellent framework that fits this requirement. Management systems.
The Dashboard Visualisation for Healthcare Performance
Management using BSC measurement scores over other CONFLICT OF INTEREST:
measurements such as “The Baldrige Excellence The authors declare that there is no conflict of interest.
Framework (BEF)”. The BSC presents crucial decision-aiding
information in four different perspectives leaving no gaps in
performance parameters while the BEF does not have such
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