Stakeholders’ Expectations on Health Services: In Search of an Assessment Model of Performance

Introduction

Performance assessment in profit and not-for-profit organizations has been on the agenda for scholars and practitioners for the last thirty years or so. A consistent body of knowledge has been created that can help practitioners devise feasible and appropriate performance indicators for measuring and managing performance. Among these, are the Balanced Scorecard (Kaplan & Norton, 1996), the Business Excellence Model (McAdam, Reid, & Saulters, 2002), and the Performance Prism (Neely, Adams, & Kennerley, 2002). With the exception of the last one (regarded by Neely and colleagues as a second generation tool), these techniques were developed from the inside of an organization using Morgan’s metaphor of a machine searching for efficiency (Morgan, 2006). That means, performance indicators are means for improving processes and targets. There are few tools that look at the external constituencies (Connolly, Conlon, & Deutsch, 1980) that give resources and legitimacy to the organization, namely their stakeholders (Gomes, 2006; Gomes & Gomes, 2009).

In general, performance measures are developed looking at input, output, and outcomes, the so-called IOOs model (Boyne, 2002), or trying to explore the economy, efficiency, and effectiveness aspects of an organization’s operation, the so-called 3Es model (Boyne, 2002). In the first model, which we would describe as a functional perspective, an organization works like a machine that needs inputs in order to be able to produce outputs and outcomes. In the second model, there is a concern with the control of the several stages of the management process. Though these approaches have been endorsed by the literature on performance measurement, we contend that they are not the best way for devising measurement tools, because they do not address the perceptions of the key actors, those to whom they owe their survival (Pfeffer & Salancik, 2003): the constituencies.

To this end, this paper presents the results of a constructivist and interpretative investigation carried with local authorities, with the aim of identifying how stakeholders assess public service performance (the dimensions of performance they employ for doing so) and to devise more adequate and appropriate indicators that take into account stakeholder expectations.

In order to answer the research question of how stakeholder perceptions influence the development of performance indicators in public organizations, the investigation employed a phenomenological approach (Lee & Lings, 2008) to collect and analyze the data. In such an approach, “researchers begins with the direct, lived experience as a starting point, not just the ‘articulation’ of that experience” (Lee & Lings, 2008, p. 61). We interviewed several managers and stakeholders trying to find out how they assess the public services delivered by a number of local authorities.

This paper is structured as follows: it starts with a literature review which highlights the principal tenets of the organization-environment literature. In this investigation, the theoretical framework is drawn from resource dependence theory (Pfeffer & Salancik, 2003), institutional theory (Selznick, 1966), new institutional theory (DiMaggio & Powell, 1983), agency theory (Hill & Jones, 1992), and social network theory (Nohria, 1992; Rowley, 1997). The literature review is followed by the ontological and epistemological elements of the research, in order to clarify the principles of the investigation. Findings are presented and discussed in the following section. The paper concludes with theoretical and practical contributions made, as well as with some directions for further investigations.