The dynamic use of a balanced scorecard in an Italian public hospital.

PURPOSE: This paper aims to analyse the dynamic use of the balanced scorecard (BSC) in an Italian public hospital. DESIGN/METHODOLOGY/APPROACH: A longitudinal case study was conducted at an Italian public teaching hospital over a period of 5 years. The emergence of dynamic use of BSC was traced over a different combination of social, political, economic and organizational realities. A deeper understanding of these realities requires the adoption of a holistic approach to BSC use. Henri's types of system use (i.e., monitoring, attention focussing, strategic decision-making and legitimizing) frame this approach in a more concrete manner. FINDINGS: This study adds to the debate on whether BSC is used for aspects other than monitoring in public contexts. The case study offers the first example of a legitimizing use of the system and a first longitudinal case study that traces a dynamic use of BSC: the use evolves from monitoring and attention focussing to monitoring and legitimization. Norms, political parties and top managers play a determining role in this process. ORIGINALITY/VALUE: Through a longitudinal approach, this study presents how BSC can be a dynamic tool steered by legitimacy pressures. The longitudinal study explores how social, political, economic and organizational context shape the implementation and the revision of BSC affecting the use of the tool by top managers. The browse of this dynamism is supported by Henri's type of use along with an in-depth analysis of the BSC literature evolution in terms of its 'static, dynamic and expected' use.

Efficiency as a domain of health care systems: a phenomenographic approach.

PURPOSE: This paper focuses on efficiency as a central theme of the Italian health care reforms, combining macrolevel policies with microlevel (i.e., operating room) perceptions of the concept. DESIGN/METHODOLOGY/APPROACH: According to the phenomenographic approach, this analysis investigates how the components of a surgical team (22 semistructured interviews) experience efficiency in their daily workflows. FINDINGS: The main findings show that the concept of efficiency is multidimensional. According to participants' perspective, several categories of efficiency collected in an outcome space emphasize an holistic view of efficiency driving health policies and strategies. SOCIAL IMPLICATIONS: The suggestion of further relationships between perspectives and other constructs (i.e., quality, safety, patient focus, process) at micro and macro level could enhance the impact of health reforms. ORIGINALITY/VALUE: A qualitative approach conducted at microlevel help to recognize the phenomenon (of efficiency), engaging the individual conception that practitioners have of the health efficiency.