Open Access Methodology

Multidimensional evaluation of performance: experimental application of the balanced scorecard in Ferrara university hospital

Adriano Verzola1*, Roberto Bentivegna2, Gianni Carandina3, Lucio Trevisani4, Pasquale Gregorio5 and Alberto Mandini1

Author Affiliations

1 Management Planning and Control, St Anna University Hospital, Ferrara, Italy

2 Medical Direction Committee, St Anna University Hospital, Ferrara, Italy

3 Analysis Laboratory, St Anna University Hospital, Ferrara, Italy

4 Digestive Endoscopy, St Anna University Hospital, Ferrara, Italy

5 Post Graduate School in Hygiene and Preventive Medicine, Ferrara University, Ferrara, Italy

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Cost Effectiveness and Resource Allocation 2009, 7:15  doi:10.1186/1478-7547-7-15

Published: 8 September 2009


Background and Aims

One of the best-known performance planning and evaluation techniques utilising both monetary and non-monetary data is the Balanced Scorecard (BSC). This is a means of rationalising the global activity of a business in the attempt to create value, and to translate the company vision into a set of tactical objectives and measurable strategies. The aim of this study was to implement and evaluate the use of BSC in two departments of the St. Anna University Hospital, Ferrara: the Analysis Laboratory and Digestive Endoscopy operating units (OU).

Materials and methods

With the collaboration of the health workers involved, a precise methodological programme was pursued: Definition of the strategic map from 4 perspectives, according to Kaplan and Norton, Definition of the Key Performance Areas (KPA), or macro-objectives, Identification of the cause-effect relationships between KPAs, Identification of the sub-objectives of each KPA, Definition of the Key Performance Indicators (KPI), Definition of the weight/importance of each objective in the global evaluation.


The information gathered permitted the definition of macro- and sub-objectives for each perspective, as well as determining the relevant indicators, standards, weights, frequency of detection and means of acquisition. Strategic maps showing the cause/effect relationships in each OU were created, as were 'evaluation panels', which describe the global performance of each department. For each perspective, the fundamental data were summarised in one table. Evaluation of each perspective yielded a positive result for the majority of the objectives, and the global result (including all 4 perspectives) was found to be satisfactory.


The Balanced Scorecard was implemented in the abovementioned OUs of St. Anna University Hospital, Ferrara, after the health workers themselves realised the need for change.

In our research the employees were pleased to be evaluated, not only for the financial outcomes, but also for the satisfaction of improving internal procedure, relationships with the community and their own growth/learning. BSC is an ideal point of contact between the financial and clinical dimensions of management. However, difficulties in its application were faced, among these, at least in the initial phase, the lack of information systems able to drive it, and the complexity of the research for specific indicators needed to be overcome. The time factor (on average, at least two years are required) and the availability of technological resources were also limiting factors.

The rapid diffusion of BSC among the principal international profit and non-profit organisations is testament to its great potential. This project could be seen as a preparatory phase in the strategical analysis of a subsequent business plan.