Leadership in Health Services

From unbalanced to balanced: performance measures in a Vietnamese hospital

Luu Trong Tuan
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Luu Trong Tuan, (2012),"From unbalanced to balanced: performance measures in a Vietnamese hospital",
Leadership in Health Services, Vol. 25 Iss 4 pp. 288 - 305
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LHS
25,4 From unbalanced to balanced:
performance measures in a
Vietnamese hospital
288
Luu Trong Tuan
University of Finance-Marketing, Ho Chi Minh City, Viet Nam

Abstract
Purpose From the data derived from a Vietnamese hospital, this study seeks to discern which
organisational culture types, leadership styles, and trust types pave the path for the implementation of
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the balanced scorecard (BSC) system.

Design/methodology/approach The study uses a case research approach with a triangulation of
data collation methods encompassing access to documents, field observations, and interviews.
The in-depth interviews with 37 hospital members and field observations were conducted during
21 months from March 2009 to November 2010.
Findings The findings show that features relating to organisational change in terms of
organisational culture, leadership style, and trust can impact the success of BSC implementation;
nonetheless, the opposite direction can merely be encountered in the relationship between leadership
style and BSC implementation.
Originality/value The study offers insights into a successful model of BSC implementation in the
healthcare sector built on such antecedents as organisational culture, leadership, and trust.
Keywords Balanced scorecard, Organisational culture, Leadership, Trust, Vietnam,
Health services sector
Paper type Research paper

Leadership in Health Services
Vol. 25 No. 4, 2012
pp. 288-305
q Emerald Group Publishing Limited
1751-1879
DOI 10.1108/17511871211268937
1. Introduction
Numerous organisations are launching the balanced scorecard (BSC) to steer
performance (LaChance, 2006). The BSC permits organisations to highlight both
financial and nonfinancial performance metrics in four perspectives for building and
implementing organisational strategy (Herath et al., 2010) and aligning organisational
performance with organisational vision and strategy. The application of BSCs in health
care settings is rising as well (Gurd and Gao, 2007). In healthcare, the BSC is the meal
for today, with consultants buttressing this miraculous treatment (Aidemark, 2001,
p. 23). However, even though several workshops and conferences on performance
management as well as BSC have occurred in major cities in Vietnam, the application
of this performance measurement system has been limited to few manufacturing and
services companies, and virtually no healthcare services.
Organisational culture, from Osburns (2008) stance, is a spirit cultivated by the
shared values of the organisational members. Culture also acts as an intellectual and
sentimental paradigm (Barker, 1992) that navigates the life of organisational members
and can block the acquiescence of alternative cultures. It is the harmony between
members individual cultural heritage and the organisational culture or unique
common psychology that produces confidence, comfort, and trust (Vaill, 1989). Herath
et al. (2010) maintain that a culture of open reporting around the BSC is indispensable
for its effective implementation. The findings from Lau and Berrys (2010) study reveal
 that members perceive the use of nonfinancial metrics as fair through the From
augmentation of the trust they have in their leaders. unbalanced to
From the perspective of attribution theory (Calder, 1977), leaders are accountable for
organisational outcomes. Leadership is also viewed as an endogenous factor balanced
interacting with a multiplicity of other organisational variables including culture to
impact organisational outcomes, to potentially impact the success of the BSC
implementation. 289
In light of the diverse views, the question of how organisational culture, leadership,
and trust influence the BSC implementation, a domain where little evidence of in-depth
investigation, especially in healthcare service, exists, will be unpacked through this
case study of a hospital in Vietnam.
This introductory section will be followed by a succinct overview of the construct
balanced scorecard, and its potential antecedents such as organisational culture,
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leadership, and trust. Then the depiction of the research methodology will bridge this
literature survey with the studys empirical findings, which are then recapitulated and
indicative of practical as well as further research implications.

2. Literature review
2.1 Organisational change in healthcare organisations
Increasing market pressures compel organisations to swap large portions of their
secure traditions for untested paths into the future (Wesley, 1996). Three types of
change organisations tend to undergo include: developmental change: natural
development; transitional change: evolve gradually to a known state; and
transformational change: journeying into the unknown. Transformational change
entails not merely structures and processes but also values and inherent culture of the
healthcare organisation (NHS Institute for Innovation and Improvement, 2006). In Garg
and Singhs (2002) view, the fixed norms of culture may act as resistance to change due
to apprehension amongst its members.
Ginsburg and Tregunno (2005) discuss the impact of culture and leadership on
organisational change in healthcare organisations. Lukas et al. (2007) found five
interactive elements crucial to successful transformation of patient care:
(1) Impetus to transform.
(2) Leadership commitment to quality.
(3) Improvement initiatives that actively immerse medical staff in meaningful
problem solving.
(4) Alignment to attain consistency of organisational goals with resource allocation
and deeds at all levels of the organisation.
(5) Integration to bridge traditional intra-organisational boundaries among
individual components.

These elements drive change by influencing the components of the complex health care
organisation in which they operate:
(1) Mission, vision, and strategies.
(2) Operational functions and processes.
 LHS (3) Infrastructure such as information technology and human resources that
25,4 support the delivery of patient care.
(4) Culture.

2.2 Balanced scorecard

As the findings from Lau and Berrys (2010) study reveals, the implementation of
290 nonfinancial measures was seen by organisational members as fair. These effects,
nonetheless, are found to be indirect via the augmentation of member role clarity, and
the augmentation of the trust between subordinates and leaders. Numerous models
have been constructed on a fusion of financial and non-financial information. Dixon
et al. (1990) present an integrated performance measurement system whereby
costs-and-performance knowledge is acquired and utilised in the strategic
management cycle. Lynch and Cross (1991) introduce a performance pyramid that
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links strategy and operations by translating strategic goals from the top down and
measures from the bottom up, while Atkinson et al. (1997) build a stakeholder model
that includes measurement for the primary and secondary goals of environmental and
process stakeholders. Kaplan and Norton (1996) unveil a balanced scorecard an
integrative framework fusing financial, customer, internal process, and learning and
growth perspectives steered by organisational vision and strategy.
Balanced scorecard, from Aidemark et al.s (2010) standpoint, is adopted for
measurements linked with the organisational strategy. How balanced scorecard
approach may be used in implementing organisational management strategies is
illustrated by Rasila et al. (2010). Herath et al. (2010) demonstrate how the collaborative
BSC model can be implemented in Microsoft Excel by practitioners to minimise BSC
conflicts. Funck (2007) examines how the balanced scorecard (BSC) has been translated
to suit the public healthcare environment.
BSC has been adopted by a wide range of healthcare organisations, including
national healthcare organisations, hospitals, and psychiatric centres (Zelman et al.,
2003). BSC is used in 65 per cent of Swedish emergency hospitals (Aidemark et al.,
2010). Aidemark (2010) observed that the balanced scorecard (BSC) enables the control
of health care quality. Chan and Seamans (2009) study divulges that patient
satisfaction is the most critical facet of the balanced scorecard in healthcare services.
However, research by Aidemark et al. (2010) found that performance monitoring is of
secondary magnitude, even in emergency hospitals with more than five years
experience with the BSC. Moreover, the BSC is virtually never used in the hospitals
reward systems. Astoundingly, strategy on service innovation within the BSC
framework negatively impacts the organisational outcome of patient satisfaction. Gurd
and Gao (2007) even more surprisingly found that the health of the patients was not as
pivotal as it should be in the development of the BSC in Chinese hospitals.

2.3 Organisational culture

A universal definition of organisational culture has proven elusive (Lewis, 2002),
nonetheless, one of the most common definitions of organisational culture involves a
set of beliefs, values, and behaviour patterns shaping the members behaviour and
forming the core identity of organisations (Deshpande and Farley, 1999).
Expanding Scheins (1985) definition with the notion of understandings, Daft (2005)
views organisational culture as a set of key assumptions, norms, values, and
 understandings that is shared by members of an organisation and taught to new From
members as correct. unbalanced to
However, Alutto (2002) highlights that a definition of culture recognising variability
in the uniformity of common norms and values is particularly relevant for balanced
understanding organisational behaviour. Tyrrell (2000) explicated that organisational
culture is constantly being negotiated since it is an emergent property of human
interaction. The beliefs and values that emerge from the ongoing negotiation and 291
practices among organisational members become a source of reference for what is
deemed acceptable or unacceptable in an organisation in terms of right and wrong
behaviour (Kusluvan and Karamustafa, 2003). Moreover, successfully reacting to
changes in the global marketplace requires a flexible and adaptable organisational
culture (Elashmawi, 2000).
Quinn and Rohrbaughs (1983) the Competing Values Framework (CVF) was
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developed by Quinn (1988) into a model of organisational culture predicated on two

dimensions: organisational process (organic vs mechanistic) and organisational
orientation (internal vs external). The first dimension and the second dimension are
denoted by the vertical axis and the horizontal axis respectively, whose intersection
produces four quadrants displaying four culture types labelled as adhocracy, clan,
hierarchy and market. Four sets of attributes of organisational culture types in
CVF-based model are displayed in Table I.
Whereas an individual may self-select into a certain profession or industry,
nationality temporally precedes entry into an organisation, and thus may be deemed a
determinant of schema formation linked with organisational culture. The national
culture at which an organisation is located has significant impact on its organisational
culture (Dastmalchian et al., 2000).
Financial and human resource allocations and use in Vietnam were determined, and
plans for the whole countrys economy were built by the Central State Planning
Committee until its renovation (Doi moi ) in 1986. Human resource policy and planning

Adhocracy Clan Hierarchy Market

Dominant Adaptability, Cohesiveness, Regulations, order, Market knowledge

attributes creativity and affiliativeness, sense alignment, sharing,
innovation, of family uniformity competitiveness
entrepreneurship
Dominant Change agent, Mentor, facilitator Monitor, Reactive,
leadership innovator, coordinator, achievement-
opportunity creator, administrator oriented
entrepreneur,
strategist
Bonding Flexibility, vision Interpersonal Rules, policies, Customer-
orientation, thick cohesion, teamwork, procedures, and centeredness,
consent belonging, loyalty calculation competition
Table I.
Strategic Toward innovation, Toward human Toward stability, Toward competitive Attributes of
emphasis value creation, resources predictability, advantage and organisational culture
sustainability development, smooth operations market superiority types in CVF-based
commitment model
 LHS in each organisation were governed by the patron organisation, normally one level up
25,4 the hierarchical system. Thus, hierarchy culture with control processes and internal
maintenance predominated among the state-owned organisations as the robust impact
of the Vietnamese governments lasting centrally planned and subsidised economy
intensified by a close-door policy.
Since renovation and the open-door policy, other sectors such as private domestic,
292 joint venture, and foreign-invested organisations including hospitals have emerged.
However, CEOs in most domestic private hospitals and in certain joint venture and
foreign-invested hospitals were from management positions of state-owned hospitals,
so tended to nurture hierarchy culture again in their new working environments.

2.4 Leadership
The most influential contingency approach to leadership is the path-goal theory
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developed by Robert House (Robbins, 2005). From path-goal theory perspective, the
principal goal of the leader is to help subordinates reach their own goals effectively,
and to provide them with the necessary resources and direction to attain their own
goals as well as those of the organisation (Silverthorne, 2001).
The terms transformational and transactional (Burns, 1978) have become pivotal to
the research of leadership and tend to be utilised to make a distinction between
leadership and management. Transformational leadership can be distinguished from
transactional leadership in that transformational leaders are depicted as self-defining
(Kuhnert, 1994), while transactional leaders are more adapted to the rules and their
application, or driven by external contingencies. Transformational leadership and
transactional leadership can be measured using Bass and Avolios (1995) multifactor
leadership questionnaire MLQ 5X (MLQ leader form form 5X) comprising nine
separate scales, five of which represent aspects of transformational leadership, and
four of which represent aspects of transactional leadership (see Table II).
An example of transactional leadership is management-by-exception, whereas
examples of transformational leadership include the leaders providing a sense of
vision, challenging the status quo and providing stimulation and inspiration
(Bass, 1990).
Leadership at the clinical level has evolved within a framework of service groupings
predicated on clinical specialties such as primary health care, internal medicine,
surgery, mental health, and child health (Malcolm and Barnett, 1994). Edmonstones
(2009) study of the National Health Service in the UK revolves around the
disconnected hierarchy in healthcare organisations and suggests that clinical
leadership is the elephant in the room often unaddressed or overlooked.
One dissection of failures of care in which patients lives are harmed or lost divulged
that these problems seem to happen in organisations with inadequate or weak

Transformational leadership Transactional leadership

Idealized influence (attributed) Contingent reward

Idealized influence (behaviour) Management by exception active
Table II. Inspirational motivation Management by exception passive
MLQ 5X leadership Intellectual stimulation Laissez-faire
scales Individualized consideration
 leadership, and several other factors found are leadership-related (Walshe, 2003). From
Strong clinical leadership is presumably the most crucial single determinant of the unbalanced to
progress of clinical quality improvement in healthcare organisations (Walshe, 1995).
The need for strong leadership for quality improvement in healthcare organisations is balanced
highlighted as in New Zealand (National Health Committee, 2001). Vaughn et al.s
(2006) research reveals that hospital leadership engagement in quality improvement
reinforces quality improvement activities within hospitals. Their research also reports 293
that higher quality index scores are linked with hospitals where the leaders expend
more than 25 per cent of their time on quality issues, base the senior executives
compensation partially on quality improvement performance, and engage in a high
degree of interaction with the medical staff on quality strategy. In a study of 2,200 US
community acute hospitals, the impacts of top leadership on the level of physician
involvement in quality improvement was appraised (Weiner et al., 1997).
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2.5 Trust
Trust is not merely a psychological state predicated on expectations and on perceived
motives and intentions of others, but also a manifestation of behaviour towards others
(Costa, 2003) comprising the three ensuing stages or types:
(1) Calculus-based trust. Calculus-based trust, as portrayed by Lewicki and Bunker
(1995), is a trust built on perceived benefits and outcomes, balanced by the costs
of sustaining the relationship. It is a trust predicated on deterrence or the
balance of outcomes realised by the trustor and trustee. Its hallmark is control
of behaviours.
(2) Knowledge-based trust. Exercise of control characterises calculus-based trust
whereas exchange of information promotes knowledge-based trust. While
calculus-based trust is contingent on deterrence, knowledge-based trust
depends on how well the trustor can realise and foresee the trustees actions as
alleged by Lewicki and Bunker (1995, p. 149): The better I know the other, the
better I can trust what the other will do because I can accurately predict how
they will respond in most situations. The limits of trust and untrustworthiness
can also be detected by knowledge-based trust through information capital.
(3) Identity-based trust. Identity-based trust is deemed to be a product of reciprocal
understanding. At this [. . .] level of trust, trust exists because the parties
effectively understand, agree with and endorse each others wants; this mutual
understanding is developed to the point that each can effectively act for the
other (Lewicki and Bunker, 1995, p. 151). Each party understands the others
and understands prerequisites for sustaining the trusting relationship.
As Atwater (1988, p. 305) observes, [. . .] the more trust and loyalty expressed by
subordinates toward their supervisor the more positively the supervisor was perceived
to behave, denoting that attitudes of trust and commitment among followers and
leaders were predictors of supportive leadership behaviours. Trust in this view
appears to be built on communication of values, vision, and strategy.

3. Methodology
Case study research, as described by Creswell (2007, p. 73) stance, involves the study of
a phenomenon examined via one or more cases within a setting. This research pursues
 LHS Yins (1989) case research method comprising five steps: building of a theoretical
25,4 framework, choice of the case, design of the case research protocol, collation of case
research proof, and dissection of case research proof.

3.1 The theoretical framework

294 This study was guided by the following research question:
Do organisational culture, leadership style, and trust impact the success of the BSC system
implementation and vice versa?
However, as Yin (1989) suggests, the theoretical framework for the case research
encompasses theoretical propositions that can act as guidelines for the research and be
utilised for case research data analysis. The case research framework was built on the
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ensuing propositions:
P1a. Adhocracy culture and market culture promote BSC implementation.
P1b. Clan culture and hierarchy culture do not promote BSC implementation.
P2a. Transformational leadership promotes BSC implementation.
P2b. Transactional leadership does not promote BSC implementation.
P3a. Knowledge-based trust and identity-based trust promote BSC
implementation.
P3b. Calculus-based trust does not promote BSC implementation.
P4. BSC implementation influences organisational culture, leadership style, and
trust.
Figure 1 depicts the case research framework displaying the linkages among
organisational culture type, leadership style, trust, and BSC implementation.

Figure 1.
The case research
framework
 3.2 Choice of the case From
Hospital A, a joint venture hospital in Vietnam, was chosen for this case research based unbalanced to
on the two dimensions its ownership and its level of process technology
sophistication. Since most leaders in the joint venture hospital were from management balanced
positions of state-owned hospitals, they may carry values and leadership styles from
their previous workplaces to the new working environment, so it can be observed if
these values and leadership styles can be changed with the implementation of the BSC 295
system. A state-owned hospital, on the contrary, under the robust impact of the
Vietnamese governments lasting centrally planned and subsidised economy, may not
be able to change its culture of policies and rules, so some BSC measures may not be
favourably adopted.
Hospital A, furthermore, has a high level of process technology, namely more than
50 per cent of the service value of the hospital was yielded with computer-controlled
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process technology. As profound use of computer-controlled process technology is

linked with sophisticated information systems, failure of the implementation of BSC
measures, if it occurs, cannot be ascribed to low sophistication of the information
system.

3.3 The case research protocol

Eisenhardt (1989) and Yin (1989) both underscored the need for a case research
protocol utilised as a guide in conducting case research. According to Miles and
Huberman (1994), such a protocol should outline the rules and procedures governing
the conduct of the researcher and the research. Case research protocols also ensure
uniformity in researches where data are to be collated in multiple locations over an
extended period.
The main points in the case research protocol developed for this study include:
(1) Overview of the case study research.
(2) Procedure.
(3) Interview questions. The questions refer to the background of the hospital, the
background of the interviewee, hospital attributes, dominant organisational
culture type, leadership style, trust, and BSC implementation. Questions on
organisational culture were derived from Deshpande et al.s (1993) scenarios
depicting the dominant attributes of each of the four culture types as displayed
in Table I. Questions to measure leadership styles were adapted from Bass and
Avolios (1995) multifactor leadership questionnaire (MLQ leader form
form 5X). Questions to measure three types of trust, calculus-, knowledge-, and
identity-based trust, were adapted from Nguyens (2005) measurement
predicated on researches by Cummings and Bromiley (1996) and Nooteboom
et al. (1997).
(4) Reminders.
(5) Guide for the case research report.

3.4 Collation of case research proof

A triangulation of data collation methods including access to documents, field
observations, and interviews was used. The hospitals brochure, website, and
publications about the hospital encompassing newspapers and magazine articles were
 LHS collated before, during and after the interviews and field observations which were
25,4 conducted by the author during 21 months from March 2009 to November 2010. Field
observations, in which observable things were taken note of, were done concomitantly
with the interviews. In-depth interviews with the chief executive officer (CEO), the chief
medical officer (CMO), five head doctors, fifteen doctors, five head nurses, and ten
nurses were conducted. Interviews commenced with a request for a brief depiction of
296 the interviewees themselves, the hospital and its history, and nature of operations. The
preponderance of time in each interview revolved around issues involving
organisational culture, leadership, trust, and BSC implementation. Interviews were
conducted in Vietnamese language. All interviews were implemented at the hospital.
Interviews averaged 90 minutes, and all were tape-recorded. The interview tapes were
then verbatim transcribed.
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3.5 Dissection of case study proof

Pattern-matching and explanation-building modes of dissection were resorted to in this
case research. Pattern matching is the endeavour of the case researcher to find
qualitative or quantitative proof in the case that the effect association for each causal
path in the theoretical model under consideration was of non-zero value and was of the
anticipated sign. Stated another way, pattern matching involves comparing an
empirically based pattern with one or more predicted patterns.
Explanation-building is a supplement to pattern matching. Explanation-building
seeks to build explanations about the case predicated on the case data.

4. Findings from the case research

4.1 The linkages amongst the implementation of balanced scorecard and its antecedents
in the researched case
A timeline map was utilised to map the critical events of the process of BSC system
implementation and dynamics in organisational culture, leadership style, and trust
(see Figure 2).
The BSC system program was launched at Hospital A following the attendance of
its board of directors (BOD) at a conference on performance management at which the
author was one of the speakers.
The BSC system was linked to the Intranet site of the hospital, thus enabling the
hospital members to access and view the performance information at all times.
At the outset, there was intermittent use of the BSC system since the BSC system
was a change whereas the CEO, the chief medical officer (CMO), and the head doctor of
the Department of X were adopting transactional leadership style. They purely drove
their staff to perform according to expectations, as Masi and Cooke (2000) observe in a
transactional leadership:
Our CEO is a punctual person and he wants us to be punctual, too. As doctors, we fully agree
with this form of accuracy as well as accuracy in diagnosis and treatment. However, he also
asks us to follow the hospital treatment plan accurately. We have to reluctantly leave new
treatment methods we have devised behind. We still miss the days when there was no
silhouette of CEO but merely silhouette of the teachers such as Prof. C and Dr. T. We still miss
the days when no rules other than rules from hearts for patients subsisted (a doctor from the
department X).
 From
unbalanced to
balanced

297
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Figure 2.
The linkages between BSC
system implementation
and its antecedents in case
of hospital A

Accompanying the dominant transactional leadership styles of the CEO and the CMO
there was a hierarchy culture with such dominant attributes as rules, procedures
(Deshpande et al., 1993), and homogeneity prevailing through the hospital as observed
by a doctor from department Y:
If you are walking in our hospital, you may hit the rules. The hospital is inherently stifled
with the odour of ether and medicine, and even more suffocated with rules. Policies request us
to prescribe medicines from the hospitals list of medicines, to invite these specific doctors for
consultation, and not to examine patients without payment receipts. I myself have, time after
time, broken this rule to prioritise a patients examination based on the severity of her or his
dyspnea.
The head doctor of department Y, on the contrary, displayed transformational
leadership style. However, his transformational leadership style alone was unable to
immerse his department in the implementation of the BSC system when the CEO and
the CMO highlighted task orientation toward numerical productivity goals such as the
number of patient visits, patients length of stay, the number of subclinical tests, and
profitability.
Similar to the CEO and the CMO, the head doctor of Department Xpreferred
immersing his staff in tasks, operating within the existing environment, circumventing
vulnerabilities, and focusing on predictability rather than change (a transactional
leadership style) (Bass, 1990). The head doctor of the Department of Y, in contrast,
sought to generate change and transform the prodromal stage of the performance
management crisis in the hospital (Fink, 1986) into developmental challenges (Hunter,
2006). Thus, while the information on how the BSC measures were aligned with the
hospital vision and strategy was communicated through department Y, most members
of department X were not aware of this alignment.
 LHS However, without the support and encouragement from the top management
25,4 members such as the CEO and the CMO, most members in the hospital neglected this
balanced system. The lack of drive from the top management yielded a loss of
confidence and consequent suspension of the BSC system despite Shanes (1995) claim
that leadership that promotes innovation is not limited to leadership from the upper
rungs of the organisational hierarchy.
298 Under the dome of transformational leadership, knowledge-based trust grew in
Department Y, but not in other departments:
The head doctor is experienced in both treatment as well as HR issues. He knows how to work
with people, how to engage people [. . .] He is understanding, helpful and sharing. His
knowledge is at the mentor level (a doctor from the department Y).
Out of the blue, two doctors in department X left the hospital, taking away a number of
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patients who appreciated their effective medical treatment and advice. Some doctors in
department Y also claimed that without the transformational leadership behaviour of
their head doctor, they would have left the hospital like these two doctors.
Ultimately discerning and deciding to tackle this issue, the CEO invited consultants
including the author, who recommended the use of daily key performance indicators
(KPIs). Paradoxically, all the required information was available on the existing BSC
system but was not being used except by department Y, which was applying few
non-financial measures such as patient satisfaction, recommendations from former
patients, learning, and minimised abuse of antibiotics without antibiotic susceptibility
testing, which aimed at drug resistance reduction. The head doctor of department Y
pointed out the attributes of this balanced system as well as its experimental
implementation in department Y to the CEO. Consequently, the CEO commenced to
look at the BSC measures and realised that this balanced system voiced the hospital
vision and strategy and that his leadership style was inhibiting its implementation.
Realising increased dissatisfaction in several stakeholders, especially patients, the
CEO commenced generating change, starting with the adoption of a transformational
leadership style, as suggested by Bass (1990) that [. . .] when a firm is faced with a
turbulent market-place [. . .] then transformational leadership needs to be nurtured at
all levels in the firm (Bass, 1990, p. 639). He removed some policies on medical
prescription plan and patients length of stay from the measurement of productivity.
He encouraged that as a change in performance measurement, the BSC system be used
on a daily basis to communicate performance information between CEO, management
team, and the clinical and subclinical departments. The CEOs openness to change was
found through an interview:
Our CEO turned to say, Do belong to this hospital and we belong to you in a way that this
hospital is a laboratory for you to experiment your new formula. It can be a failure at the first
try. Adjust the parameters and resume the experiment. I remember Thomas Alva Edison
tested more than hundred times for a successful invention (a doctor from the department Z).
This encouragement by the CEO gave rise to the chief medical officer (CMO) and the
head doctor of department X adopting a transformational style. This adaptation of
leadership style in the top management, over a 18-month period, coupled with training
and coaching on BSC system, led to the extensive use of the BSC measures across all
levels of the hospital that produced significant improvements in internal medical
treatment and surgical treatment, employee commitment, patient satisfaction, and
 market share. One crucial factor contributing to increased patient satisfaction was that From
the hospital revoked the policy of pre-payment of surgical operation fee when patients unbalanced to
registered for heart operations even though patients may wait months to a year to be
scheduled for heart operations.
balanced
The BSC system was seen not as a set of performance metrics but as guidelines for
hospital members behaviours, as reflected in some members attitudes:
299
As a compass, the BSC reminds us of the direction in our medical practice. We have reduced
the use of broad-spectrum antibiotics and prescribed antibiotics according to antibiotic
susceptibility testing. Bed covers are now changed at least twice a day and wards are
sterilised at least twice a day as well in order to reduce hospital infections. The BSC reminds
us of smiles sent to patients notwithstanding pressure from patient overload. Our CEO
always encourages us to view every day as Patients Day (a doctor from department X).
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Many pharmaceutical firms offer our hospital as well as physicians high commissions to get
their products prioritised in our prescriptions. However, we no longer prioritise commission
in our choice of pharmaceutical products, but look at their treatment effectiveness. Our CEO
did ask a pharmaceutical firm, instead of offering commissions, as a social responsibility, to
decorate clinical wards with cartoon characters for little patients so that they can occasionally
forget their subcostal pains or dyspnea (a doctor from department Y).

We nurses usually joke to each other, Smiles, please, the BSC is watching you. Deep down,
the BSC has changed and navigated our behaviors (a nurse).
After 21 months since the launching of the BSC system program, most hospital
members developed identity-based trust as they understood the short-term as well as
long-term strategies in the BSC system and were activated to implement it. The
implementation of the BSC, along with the dissemination of transformational
leadership, were shaping a market- or patient-orientated culture in the hospital:
Innovations, not any titles or awards, are the main impetus converting our hospital a leader in
cardiology field. Innovations contribute to patients word of mouth on the hospital services.
The hospitals emphasis on customers and innovation is expressed through the incorporation
of the BSC measures on these dimensions into the hospitals performance measurement
system (a doctor in department Z).
In a nutshell, the original hierarchy culture, together with dominant transactional
leadership style, which are based on rules and tasks, did not generate the right
environment for the hospital to adopt the BSC system as a tool of managing the
performance of its members. The leaders evidently needed some form of internal
stimuli (in this case, drainage of expertise) and external stimuli (diminished patient
retention) to shock their leadership style into transformational leadership. This
transformational leadership style was instrumental in driving the implementation of
the BSC system in the hospital.
Once the BSC system was in place and members at all levels experienced positive
results through its use, the overall culture of the hospital strongly shifted to market
culture. Clinical and subclinical departments use the BSC measures to drive their
performance as well as nourish improvements without being told what to do by the
management.
 LHS 5. Discussion
25,4 From this case research, which demonstrates the successful implementation of the BSC
at Hospital A, emerges a pattern as regards the relationships amongst BSC
implementation and its antecedents such as organisational culture, leadership style,
and trust.

300 5.1 Influence of leadership style on BSC implementation

The data emerging from the case denotes that leadership style promoted the BSC
implementation as depicted by P2a. Leadership style also shaped the organisational
culture into a more innovative one (market culture type in this hospital), then together
with the new organisational culture type, augmented the process of BSC
implementation.
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Transformational leadership style, in addition, transformed transactional leaders

into transformational leaders, especially through synergising with the new culture
cultivated by transformational leadership itself, as in the case, the CEOs
transformation leadership style shaped the market culture in the hospital, then
synergise with this new culture, changed the chief medical officer (CMO) and the head
doctor of department X into transformational leaders.

5.2 Influence of organisational culture on BSC implementation

The hospital exhibited hierarchy culture type at the outset of the process of BSC
implementation. Consistent with P1a, the above discussion on leadership and BSC
implementation denotes that organisational culture interacted with transformational
leadership to yield the joint effect on the implementation of this balanced performance
measurement system.

5.3 Influence of trust on BSC implementation

Analogous to organisational culture, such innovative trusts as knowledge-based trust
and identity-based trust were nourished by transformational leadership, and together
with it, promoted the application of the BSC measures, which partially substantiated
P3a.
The synergy effect of organisational culture, leadership, and trust on BSC
implementation was encountered in the case.

5.4 Influence of BSC implementation on organisational culture, leadership, and trust

Data from the case indicates that, with the consciousness of the BSC system as a
mechanism to address all stakeholders interests, the CEO of the hospital adapted his
leadership style from transactional to transformational. Nonetheless, the impact of this
balanced performance measurement system on the other constructs is not quite lucid
from the data, so P4 was marginally corroborated. In this case study, BSC
implementation influenced leadership style, which in turn influenced organisational
culture, and trust. Thus, P4 that BSC implementation influence organisational culture,
leadership style, and trust was marginally corroborated, as merely the bi-directional
relationship pattern between leadership style and BSC implementation emerged from
the data.
 6. Conclusion From
In a nutshell, the findings from the case research indicate that there is a linkage pattern unbalanced to
among organisational culture, leadership, trust, and BSC implementation. Specifically,
organisational culture, leadership style, and trust can influence the success of the BSC balanced
initiative; however, the opposite direction can also be discerned in the relationship
between leadership style and BSC implementation, denoting a developmental
interaction between BSC and leadership. 301
The case also demonstrates that if it is successfully implemented, the BSC system,
together with the synergy effect of more innovative leadership and culture, can lead to
more transformational styles.
This relationship denotes that, to successfully implement the BSC system, the
hospital needs to nurture a new organisational culture type which is more innovative
and to make the transition from old to new culture type.
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The final observation from the case is that leaders do not readily change their
leadership styles. Internal and external stimuli may play a crucial role in motivating
leaders, whether intrinsically or instrumentally, to change their leadership styles.
Working together, strategy maps and balanced scorecards are a framework for
change (Harich, 2004); however, the findings indicate that successful implementation
of BSC also needs changes in such antecedents as organisational culture, leadership,
and trust. In the most favourable cases, leaders can concomitantly adapt these
antecedents into more effective ones; nonetheless, leaders can also focus on one
antecedent, as in this case, the leadership. If leaders find that the dynamic nature of this
antecedent is higher than that of the others, it can activate the others.
The BSC approach may need some ample changes in culture within the organisation
(Chavan, 2009). Organisational culture tends to be deemed a rather inert antecedent.
However, organisational culture can be more swiftly activated if leaders
transformational leadership reaches a high distribution level or has a strong chain
reaction from member to member, not in a hierarchical sequence, but in diverse
directions. Even if this form of distributed leadership extends beyond organisational
members toward other stakeholders, it can extensively impact artefacts of
organisational culture such as legends as well as consolidate trust.
Other organisational attributes can participate in the chain reaction from leadership
to the success of BSC implementation such as employees knowledge sharing or
scenario planning. Herath et al. (2010) allege that information sharing around the BSC
is essential for its effective implementation. Othman (2008) argues that the use of
scenario planning can overcome the lack of external orientation in the BSC. Scenario
planning also makes the BSC more reflective of future changes. Thus, the investigation
of the mediating role of these attributes in the successful implementation of BSC can
provide new paths for research.

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About the author

Luu Trong Tuan is currently a Business Administration (BA) Teacher at National University of
Ho Chi Minh City. He received his masters degree from Victoria University, Australia, in 2004.
His research interest resides in organisational behaviour, business ethics, performance
management, and marketing. Luu Trong Tuan can be contacted at: luutrongtuan@vnn.vn

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