رویکرد عمومی و اختصاصی رسمی سازی برای کارت امتیازی متوازن : یک سیستم خبره با کاربرد در مراقبت های بهداشتی

The Balanced Scorecard (BSC) presents the essentials of strategic and performance management in clear, straightforward manner which is also usable in health care. If a BSC for a clinical department is an agreement, the first question to consider is the method by which it can be ascertained whether a strategy has been accomplished. There are many different techniques like AHP (analytic hierarchy process) and fuzzy systems to calculate indices. However, how does a formalized mathematical groundwork looks like that integrates current approaches and is still general enough to incorporate future expert systems with applications? The purpose of this paper is the formalization of BSC evaluation by respecting current research. The formalized expert system was implemented in an information system for health care management.

Any hospital is confronted by substantial society changes due to a variety of factors such as increasing life expectancy and population ageing, economical pressure and competition, limited resources as well as shrinking and tight budgets, new governmental deregulations and liberalization. In order to cope with the changing nature of this environment, which is also aggravated by deep structural reorganization, it is important to accomplish success goals with a tool of strategic management such as a Balanced Scorecard. In order to support strategy and performance management, Robert Kaplan and David Norton’s “Balanced Scorecard” concept (Kaplan, 1992) may be used. It is a tool of strategic management, strategic communication and performance management, providing frequently measured performance and regular reviewing and refinement strategy with an ongoing evaluation process of clinical indicators. A BSC design and implementation process can be separated into four stages: (1) translating the vision and gaining consensus; (2) communicating the objectives, setting the goals, and linking strategies; (3) setting targets, allocating resources, and establishing milestones; (4) and feedback and learning (Stewart & Bestor, 2000). Types of performance indicators and factors are termed as “perspectives”. These perspectives as in the original definition are differentiated into a financial, a customer, and a process and innovation perspective. The simply monitoring of key financial indicators, which have often been historical in nature and concentrated almost exclusively on lagging indicators are hiding the key drivers. Examples of Balanced Scorecards in health care can be found for a burn centre (Wachtel, Hartford, & Hughes, 1999), a kidney transplant (Colaneri, 1999), an ambulant treatment (Curtright, Stolp-Smith, & Edell, 2000), an electronic patient record (Gordon & Geiger, 1999), a children’s hospital (Meliones, 2000), dialysis (Peters, 1999), anesthesiology (Zbinden, 2002), cardiology (Chang, 2002), behaviour therapy (Santiago, 1999), information strategy of Canadian NHS (Protti, 2002), and indicator system for Dutch health system (Asbroek et al., 2004). These articles give a brief overview about BSCs and their development and application in healthcare management. Strategic management is an externally oriented philosophy of managing an organization that links strategic thinking and analysis to organizational action (Ginter, Swayne, & Duncan, 2002). The strategic process can be presented as a model where key elements include an environment scanning, strategy formulation, strategic implementation as well as a strategic evaluation (Wheelen & Hunger, 2004). The following points should be noted in connection with the practical implementation of clinical Balanced Scorecards: 1. Which indicators are relevant for the clinical Balanced Scorecard? The proposed strategic management system should enable hospital managers, not just to be informed about financial indicators but also about specific requirements that are relevant to health care. Indicators consist of various measures that may be expressed or implied. Not all the indicators are of equal importance and the healthcare manager has to seek so to classify them according to their importance. However, this is beyond the scope of this paper which focuses on the evaluation. 2. How to evaluate indicators of a clinical Balanced Scorecard? The main focus of this study is how to present the multitude of indicators in an adequate way for managing purposes. First of all, it is necessary to answer the utilization of each individual indicator. This means to which degree is a specific target for an indicator accomplished. Secondly, how can these indicators be aggregated in a general way on the foundation of an appropriate metric into a single performance index for each perspective and on BSC level these perspective indices into one entire BSC index. Although many publications ( Asbroek et al., 2004, Colaneri, 1999, Curtright et al., 2000, Chang, 2002, Gordon and Geiger, 1999, Meliones, 2000, Peters, 1999, Protti, 2002, Santiago, 1999, Wachtel et al., 1999 and Zbinden, 2002) describe Balanced Scorecards in health care only few like ( Tarantino, 2003 and Griffith and White, 2005) show how an overall index can be computed. This study therefore aims to formalize the computation of an index both for entire BSC and for each perspective. Therefore it uses concepts of decision theory that give a profound base for formalization. The method part of this paper shows a general definition of an indicator system for each perspective in a BSC for a clinical application and how a utility function can be defined. In addition to utility functions a formalization of a general approach as utility values can be aggregated into an index for a perspective and an entire BSC. The definition is general and implies no assumptions of the implemented utility functions and aggregation. Unlike, the general definition the result section of this paper explicitly defines a specific set of utilization functions and the manner of aggregation. With regard to the formalization an implementation was made with co-operation with an orthopedics department.

Besides administration of a clinical BSC in a data-warehouse a formalized way of evaluation is necessary. Doing so, decision theory may be used to utilize and aggregate indicators and in different levels of complexity. Therefore, a general formalization for the evaluation of a BSC was introduced and specific utilization functions implemented for clinical applications. Examples are given for different extends of aggregation. An increasing aggregation value is characterized by a decreasing complexity of interacting perspectives and indicators which give a fast glance of the overall performance. In addition the hierarchical approach allows detailed views on the performance of single indicators. Utilization made with indicators fall into three categories; those that are: indicators for maximization; indicators for minimization and indicators for stabilization Utilization values are aggregated, according to the manner in which they are weighted, into perspective indices and then into a single and overall index. As a conclusion the new system gives representation of performance in an effective manner.