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Background: The successful utilization of the balanced scorecard (BSC) framework in health care has been demonstrated in the literature. Given these successes, a financially struggling hospital implemented a BSC framework intervention which attempted a culture change centered upon patient satisfaction which it hoped would translate to improved financial stability. Despite the evidence of BSC successes, the intervention, entitled Route 99, did not succeed in this hospital.

Purpose: This case study was conducted to identify learnable lessons and confounding factors associated with the successes and failures of Route 99. Metrics for patient satisfaction and employee satisfaction were examined as reflections of the intervention, the BSC framework, and the confounding financial condition of the hospital.

Methodology: Through case study methodology, mean quarterly patient satisfaction scores tabulated by an outside vendor for inpatient and outpatient services were divided into four time intervals and compared through analysis of variance. Employee satisfaction was measured through a hospital-provided 12-question employee survey, administered through convenience sampling at the beginning and 7 months into Route 99. Each question utilized a 5-point Likert scale and generated two samples which were verified for sample independence through chi-square analysis. Mann-Whitney U test was used for comparison.

Findings: Inpatient patient satisfaction scores exhibited a nonsignificant upward trend. However, the analysis of variance demonstrated a significant rise in outpatient patient satisfaction (p < .05). An interesting finding was that employee satisfaction declined (p < .05) significantly for supervisors and directors in three areas. The inverse relationship between patient satisfaction and employee satisfaction is in contrast to that found in the literature by the authors.

Practice Implications: Examination of the BSC framework, the hospital's financial standing, and the metrics for patient satisfaction and employee satisfaction illuminated the importance of management transparency, leadership support, appropriate metric selection, and the strength of the BSC under turbulent circumstances.


This is a non-final version of an article published in final form in Lorden, A., Coustasse, A., & Singh, K. P. (2008). The balanced scorecard framework - A case study of patient and employee satisfaction: What happens when it does not work as planned? Health Care Management Review, 33(2), 145-155.

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