The balanced scorecard and environmental dimensions: evidence from an Australian heath care study

The balanced scorecard and environmental dimensions: evidence from an Australian heath care study

The purpose of this thesis is to explore the integration of the environmental dimension into a balanced scorecard (BSC) in a regional public healthcare organisation in Australia. Significant information, such as sustainability issues, including environmental and social sustainability, was not considered in Kaplan and Norton’s original BSC. It therefore needs to be updated to include several elements including environmental issues. The thesis considers three objectives. The first objective is to investigate the ways the environmental dimension can be adapted and incorporated into the BSC in a public healthcare context. The second objective is to investigate the barriers and motivations of integrating environmental performance into the BSC. The third objective is to examine how a public hospital constructs a BSC which incorporates endogenous (internally generated) environmental activities and exogenous (externally generated) environmental events. Three separate journal publications have been developed to address these three objectives. Qualitative data was collected from semi-structured interviews with individuals employed in management, medical, and operational roles in a large public hospital. Secondary data was collected through document analysis (including annual reports, strategic plans, and information sourced from the hospital website).

The first paper reports that four different approaches are possible to incorporate the environmental dimension into the BSC. These approaches are fully integrated, partially integrated, a separate additional perspective and differentiation. Selection of the appropriate response is dependent upon the origin of the environmental activities and events. In relation to the stakeholder theory, the findings of paper one suggest that healthcare providers recognise the critical nature of environmental performance in creating value for both internal and external stakeholders. Such findings may encourage organisations to clearly identify their target stakeholders before developing a bespoke BSC. The results from the second paper reinforced the contingent nature of the chosen model and highlight the importance of organisational vision and environmental strategy as formative factors. This paper also identified sources of resistance to incorporating the environmental dimension in the BSC. These included the role of environmental disclosure, insufficient sustainability BSC knowledge, the lack of BSC champion’s support, organisational culture, and limited environmental commitment practices. The second paper’s findings also revealed actions which can be taken to support the decision to integrate environmental performance in the BSC. These included updating the information system, appointing sustainability champions, articulating financial motivations, and recognising external pressures. Linking with the theoretical perspective, concepts from institutional theory have used to illustrate how institutional factors (professional sustainability expertise and realisation of financial benefits) and reflexive isomorphism (associated with external pressure by government) can be conceptually integrated to better understand organisational applications of the BSC. Finally, the third paper concludes that it is necessary to differentiate between an organisation’s environmental interventions and external environmental interventions. The BSC is a useful tool to monitor the hospital’s environmental practices and enable the organisation to effectively manage the impacts of non-organisational actions such as climate change, natural disasters and pandemics. This paper also explains how the possible use of attribution theory may help differentiate between internally generated environmental activities (controllable) and externally generated environmental events (uncontrollable).

The three papers that form this thesis provide a substantive contribution to the literature. The research provides impetus for health care organisations to consider the benefits of including the environmental components as a part of the BSC. Moreover, it offers new avenues for future academic research which explores the role of performance measurement in environmental sustainability.