This thesis aims to evaluate the implementation of the Balanced Scorecard (BSC) based on a case organization; the King Faisal Specialist Hospital and Research Centre (KFSH-RC). The study is an exploratory investigation. Understanding BSC perspectives is important for academic comprehension and is crucial for successful implementation. BSC at KFSH-RC includes five main perspectives: Quality of Care; Medical Care; Employees; Financial; and Education and Research (learning and growth). The thesis tackles two main anecdotal, practice-based arguments: BSC helps achieve business strategy, and the implementation of BSC has often fallen short of the assertions made about its potential for impact. A case study with a triangulation approach is justified and pursued. This study contributes to the literature in different ways. The application of the BSC has received limited attention in healthcare organisations in general, and in the Middle East and North Africa (MENA) in particular, and may be one of the first to explore such issues, across management and professional groups, to research BSC in the healthcare organisation in the KSA. It distinguishes between the understanding of financial and non-financial perspectives; and the researcher has developed a conceptual framework, which reflects the main elements of BSC implementation. Quantitative data analysis from the case study indicates that staff members at the KFSH possess only a shallow understanding of various BSC perspectives. The study revealed a consistent lack of understanding of BSC by the department employees, due to their lack of interest. The results show that performance measures following the implementation of BSC created no significant improvement. It also confirms that even some senior managers face difficulties understanding BSC perspectives. The qualitative-based findings indicate that the level of understanding of BSC for clinical services is not significantly different from that for non-clinical services; staff members of the KFSH resist the implementation of BSC in the early stages; and there is 'autocratic' leadership style at the KFSH inhibited the flow of information. The power distance and autocratic leadership style, in combination with an inadequate launch of BSC, fail to follow the implementation steps recommended by both Kaplan and Norton (2001a) and Kotter (1996). These organisational dynamics, it will be argued, are understated in the original BSC methodology, a view consistent with the findings of Woodley (2006) and may be especially so in environments with strong professional norms such as hospitals. The implications for the study and practice of non-profit organisations wishing to adopt methodology developed initially in a commercial context, is considered.

Patient satisfaction dimensions have a wide ranging and significant impact on organizational performance in the healthcare industry. In addition, the Centers for Medicare and Medicaid Services Hospital Value Based Purchasing (HVBP) Program links patient satisfaction to Medicare reimbursement, putting millions of dollars at risk for health systems. A gap in the literature exists in the exploration of how a patient's experience in the emergency department affects their satisfaction with inpatient services. In a multiple regression analysis, the relationship between HVBP Patient Experience of Care and hospital level factors including emergency department wait times are explored. Results indicate a statistically significant relationship between hospital level factors and standardized measure of patient satisfaction with a moderate adjusted effect size (p= <.0001, R2 adjusted= 0.184). Emergency department wait times post physician admit orders were most salient in predicting patient satisfaction scores (rs2= 0.434, β= -0.334, p= <.001). Recommendations to improve emergency department wait times include focusing on key decision points and implementation of electronic systems to support the movement of admitted patients out of the emergency department as quickly as possible.

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