ORIGINAL ARTICLE

Integration of health management in schoolsusing the Balanced Scorecard as a strategic managementinstrument

S. Liersch & M. Sayed & I. Windel & T. Altgeld &

C. Krauth & U. Walter

Received: 15 July 2011 /Accepted: 3 November 2011 /Published online: 25 November 2011# Springer-Verlag 2011

AbstractAim Organizational development is crucial to healthpromotion in different settings. The Learn to Live Healthyintervention [German: Gesund Leben Lernen (GLL)] is a newschool health promotion strategy designed to develop schoolsinto healthy environments for all those who work and studythere. GLL focuses on strengthening available health resour-ces and reducing negative and excessive health stresses. TheBalanced Scorecard (BSC), a strategic management instru-ment designed to support change processes, is employed inthis BMBF-funded study. This research will assess thesuitability of the BSC as a management and evaluationinstrument for schools.Subjects and methods GLL assists schools in implementinghealth management programs with the aid of schoolcoaches. Besides setting up steering committees and healthcircles, goals and action measures are defined and oper-ationalized using a participatory quality development andevaluation approach. The intervention focuses on projectorganization instruments to implement organizationalchange processes in schools, develop these processes in agoal-oriented, systematic and sustainable manner, andimprove the quality of education in schools by means ofhealth interventions. It uses the BSC as a supportive

strategic management tool. The BSC provides the basisfor the definition and prioritization of goals at theparticipating schools and facilitates the measurement ofhealth promotion activities in schools. Structured telephoneinterviews were conducted for a post-workshop evaluationof methodology for the implementation process of the BSC.Results A preliminary evaluation of the implementationprocess revealed a fundamental need to integrate the LowerSaxon Policy Framework for School Quality. Therefore, theSchool-BSC no longer evaluates schools from four per-spectives, but rather from six, pursuant to the PolicyFramework. The health specialists expect the School-BSCto promote goal-oriented and structured work and transpar-ency within schools. Considering the participatory ap-proach, two health specialists were enlisted to optimizethe training concept.Conclusions Evaluation of the School-BSC in schoolsmakes it possible to assess its suitability as a managementand evaluation instrument in these organizations. Newlydeveloped school programs largely dispelled the initialreservations of the health specialists. The School-BSC isviewed as a useful tool for the creation of organizationalstructures and transparency and for the facilitation of work.This study provides information useful for enhancingmanagement-related interventions.

Keywords Health-promoting school . Occupational healthmanagement . Health . Management . Health promotion .

Balanced Scorecard

Introduction

Health promotion in schools has changed in recent decades.Through the inclusion of communities, it has evolved from

S. Liersch (*) :M. Sayed :C. Krauth :U. WalterInstitute for Epidemiology, Social Medicine and Health SystemResearch, Hannover Medical School,Carl-Neuberg-Str. 1,30625 Hanover, Germanye-mail: liersch.sebastian@mh-hannover.de

I. Windel : T. AltgeldAssociation for Health Promotion and Academy for SocialMedicine Lower Saxony,Fenskeweg 2,30165 Hanover, Germany

J Public Health (2012) 20:171–180DOI 10.1007/s10389-011-0465-8

mere health education and a health-related curriculum tocomprehensive school health promotion programs with thecurrently preferred organizational and structural strategies(Leurs et al. 2005).

Countries achieving top rankings in school comparisonstudies such as PISA and IGLU are characterized by a highlevel of independence of their schools and a feedbacksystem that focuses on effects and results. One of the mainreasons for the poor performance of most German states isthat the school system does not allow and encourage theschools, teachers and students to have a sufficient degree ofautonomy. Therefore, educational standards, increasedautonomy of schools, self-assessment, external evaluationof schools, school guidelines and other educational prem-ises are currently being discussed for the promotion ofschool development (Halder and Doering 2005). Until the1970s, measures for the regulation of school qualityfocused on the macro level, whereas the focus shifted ontothe individual school as the unit of organization and actionin the mid-1980s. In the latter approach, the school as awhole is given the responsibility for quality which, in termsof a learning organization, can be continuously improvedby systematic professionalization though increased freedomof discretion (Maag Merki 2005).

In 2006, Lower Saxony passed a law for the introductionof school autonomy based on which all public schools weregiven independent responsibility for planning, implement-ing and evaluating their own curricula, management,organization and administration starting in 2007. Eachschool decides for itself the extent to which it will fullyor partly exercise its discretionary power granted under thislaw or continue to use top-down directives. The goal is toimprove the quality of school work through extensiveautonomy. However, the schools always remain under statesupervision, and their work is subject to internal andexternal evaluations. The Policy Framework for SchoolQuality proposed by the Lower Saxon Ministry ofEducation (Niedersächsisches Kultusministerium 2006)serves as a model for school quality. Structural changes ineducation, like those in health care, can be described interms of quality, excellence, market and evaluation (Kuper2002). This implies a need to adopt appropriate manage-ment concepts and instruments such as those used in outputcontrol models.

Quality improvement and quality assurance are the mainareas where management methods and instruments areadopted in schools (and health promotion). All vocationalschools in Lower Saxony have been required to establishquality management systems based on the model of theEuropean Foundation for Quality Management (EFQM)since 2004 (Niedersächsisches Kultusministerium 2006).

In 2001, Lower Saxony became the first German state tointroduce a policy framework for the systematic develop-

ment and evaluation of school quality (revised in 2003).This framework is based on the following six quality areas:

1. Results and achievements,2. Learning and teaching,3. School culture,4. School management,5. Teacher professionalism and6. Goals and strategies for school development.

These quality areas are subdivided into 25 qualitycriteria, including the incorporation of health promotion inthe daily school routine. The schools have the discretionarypower to decide which priorities they will set and whichgoals they will pursue. Approximately every 4 years, eachschool is evaluated by the State School Inspectorate ofLower Saxony according to the Dutch model. Eachinspection includes a review of school records, interviewswith all stakeholder groups, lesson observation and a tourof the school. The results are summarized in an inspectionreport with the goal of highlighting areas for potentialimprovement (Niedersächsisches Kultusministerium 2006).

The Bertelsmann Foundation developed “Self Evaluationin Schools (SEIS)” as an instrument to evaluate andpromote the quality of schools in the scope of theInternational Network of Innovative School Systems. SEIShas been available in all German states since 2005 and wasrevised in 2007/2008. This evaluation instrument wasadapted to the state-specific policy frameworks for schoolquality commonly used in several parts of Germany. Therevised version defines six quality areas comprising 29quality criteria for “good schools.” In SEIS, the status of aschool is determined using school inspection questionnairesfor principals, teachers, staff, trainers, students and parents.These data provide a basis for defining future priorities forschool development. Although there is no specific focus onhealth, it is possible to include additional health-relatedquestions using the healthy school profile (Gattermann etal. 2010; Stern 2009).

Against this background, the promotion of health in theschool setting is an important field of action for theimplementation of Article 20 SGB V of the GermanNational Association of Statutory Health Insurance Funds.According to its revised guidelines, the implementation ofhealth promotion in schools should include behaviorchange and prevention strategies as well as activitiesoriented towards the specific needs and demands of theschools. Approval by the school general assembly and thusthe consent of all school stakeholders as well as theestablishment of a steering committee with decision-making authority are viewed as factors crucial to thesuccessful implementation of school health-promotionprograms (GKV-Spitzenverband) (GKV-Spitzenverband2010).

172 J Public Health (2012) 20:171–180

The Learn to Live Healthy (GLL) intervention

The Learn to Live Healthy (GLL) intervention is a modelproject that was jointly sponsored and conducted by theGerman National Association of Statutory Health InsuranceFunds (GKV-Spitzenverband) and the State Health Associ-ations of Lower Saxony, Saxony-Anhalt and Rhineland-Palatinate from 2003 to 2006. Saxony-Anhalt and LowerSaxony based their programs on organizational develop-ment and corporate health management concepts andexperiences. The strategy in Rhineland-Palatinate, on theother hand, was to train teachers as health promotionfacilitators. In a second step, these health promotionfacilitators trained network facilitators, who were giventhe task of implementing the health promotion andmanagement measures in their respective school environ-ments (Sachverständigenrat zur Begutachtung derEntwicklung im Gesundheitswesen 2007).

The overall goal of the intervention GLL is to transformschools into a healthy living environment for all stake-holders in terms of organizational development. Thisrequires the establishment of motivating working andlearning conditions that promote personality developmentand support and reinforce individual health and well-being.It is particularly important to make learning and teaching—the core areas of education—“healthier.” When decisionsare made in a school, their impact on the health and well-being of the different groups of persons they affect at theschool should always be considered. The GLL interventionfocuses on strengthening available health resources andreducing negative and excessive health stresses. Its maingoal was to raise the health status of all stakeholder groupsinvolved and to increase health knowledge and healthybehavior, particularly among the pupils. Teachers are keyactors in this plan, and the success of all action measuresimplemented to achieve the project goal is primarilydetermined by the teachers, e.g., by their motivation andenthusiasm. Consequently, equal emphasis is placed onimproving the health of students and teachers in LowerSaxony, particularly for the last ones in terms of psycho-social well-being.

Other important goals of the intervention are to establishsustainable structures in which health promotion can takeplace, to create health-oriented working and learningconditions that promote personality development, to in-crease individual well-being, to strengthen all schoolstakeholder groups' personal responsibility and capacity toact (empowerment), to increase the participation andcooperation in school change processes by all stakeholders,particularly students (participation-oriented approach), toincrease identification with the school, and to sustainablyincorporate health in the image of the school and schoollife. In accordance with the learning organization model,

schools are expected to develop health managementsystems according to a defined learning cycle (Fig. 1).

Based on experience gained in organizational settings,GLL was conceived based on the assumption of aconnection between work and health. The instruments,strategies and experiences derived from organizationalmanagement and project organization were used to initiatechange processes in schools according to the followingapproaches:

& Holistic approach,& Participatory approach,& Integrative approach and& Project management approach.

These strategies and instruments (including health steer-ing committees, questionnaires for data collection andanalysis, project plan and health circles) should be assessedfor their suitability in schools and revised and adapted tothe new setting as appropriate. The existing networks andservices of the cooperation partners should also be madeavailable to the schools or modified so that they are suitablefor use in schools.

This project views healthy school development as alearning process (Fig. 1). The first step is to raise awarenessof the subject of health. The next step is to set up a steeringcommittee consisting of members of all relevant stakehold-er groups (school management, teachers, students, parentsand school sponsor). The steering committee is responsiblefor planning action measures and guiding the implementa-tion process. The implementation process is a cycle. Thefirst step is to conduct an initial evaluation in order toidentify areas in need of improvement at the respectiveschool. Concrete measures are then developed by healthcircles. Once approved, the selected measures are imple-

Building awareness

Making healthan issue

Steering committee

Planning and guiding the implementation process

Initial evaluationIdentification of areas needing improvement

Cause analysis and development of measures inhealth circlesDecision to

implementmeasures

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Evaluation

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Fig. 1 Healthy school development as a learning process

J Public Health (2012) 20:171–180 173

mented and evaluated in terms of reaching the definedgoals. Schools attempting to establish a sustainable internalhealth management system are assisted and supervised bytheir respective Association for Health Promotion andAcademy for Social Medicine Lower Saxony (German:Landesvereinigung für Gesundheit und Akademie fürSozialmedizin Niedersachsen e.V. [LVG]) in activities suchas data gathering and problem analysis, the formulation of aproject plan and the establishment of health circles. Accordingto the principle of stakeholder participation, the schoolsautonomously define their own key issues and fields ofaction. If the schools need help in implementing individualmeasures, they may request assistance from their LVG, whichorganizes the support in collaboration with cooperationpartners. The LVG establishes contacts with various sportsassociations and other associations, foundations, universitiesand colleges, local authorities and at the various levels ofschool administration (state school boards and FederalMinistry of Education), creating a support network for theindividual schools.

Innovative school health promotion and disease preven-tion programs have been designed to reduce social inequal-ities in health in children and adolescents from sociallydisadvantaged backgrounds. For this reason, only elemen-tary schools, non-college preparatory schools (German:Hauptschule), and special schools in city boroughs andregions classified as socio-economically disadvantagedwere included in the pilot phase of the project in LowerSaxony. However, the long-term goal from the beginningwas to implement a health management system at allschools in Lower Saxony sometime in the future, providedthe project was continued.

Experiences of the GLL intervention

Our experiences in the pilot phase showed that projectmanagement and process-oriented work in the schoolsetting is a new and broad field of learning. To functionin a system of integrated health management, schools mustbe taught skills and knowledge they previously lacked, suchas the theories and methods of organizational developmentand occupational health management in the school setting.Consequently, school stakeholders require support fromexternal experts because they often see the new challengesas being incompatible with the school system. Withoutintensive counseling and follow-up guidance, these newlyacquired skills would be quickly lost (Windel 2005).

Kliche et al. (2007) conducted an impact assessment forevaluation of the GLL model project. The health-promotionstructures and projects in the intervention schools resultedin significant improvement (10 to 20%) compared tobaseline. Notably, the potentials of the project were more

intensively used by the successful schools. Because ofdifferences in progress at the different schools participatingin the GLL model project, only slight to moderateimprovement of teacher and student health and schoolstructure could be detected. Kliche et al. (2010) questionwhether the reliable and effective transfer of the procedureto other schools is possible. The effectiveness of theintervention depends on the underlying conditions at eachrespective school and the intensity of implementation. Nohealth improvement was achieved in schools with poorfacilities, high baseline stress levels and low levels of projectimplementation. Even at these schools, it was possible toestablish a basis for health-promoting school development bybuilding up management structures. Thus, GLL succeeded inproviding the impetus for the transformation of schools intohealth-promoting learning and working environments. Theeight model schools participated in over 90 sub-projects,although they originally told the project managers that theyonly wanted to take on two or three “problems.” Intensivesupervision was required, especially in the initial stages,because health promotion was not a self-evident topic at manyof the schools and was not considered to be a core mission ofthe schools. The schools cited three factors as being essentialfor their successful participation: continuous external advisorysupport, support from a number of different partners andsufficient time to proceed at their own pace (Windel 2011).

At the end of the pilot phase, all sponsors in LowerSaxony decided to continue the project at the state level.The State Association of Statutory Health Insurance Fundsthen took the place of the National Association. Theidentified success factors mentioned above were firmlyanchored in the project structure. Since June 2006, the LVGhas hired 46 specialists to ensure the continuation of theGLL intervention at the state level. These professionalswere trained in school health management in multi-dayseminars and prepared for their work at schools participat-ing in the project. The specialists are also continuouslysupervised by the LVG (semi-annual training courses,invitations to all events for the project schools, telephoneconsultation at any time). The cooperation partners releasedthese individuals from their normal duties so that they couldwork as school coaches in charge of supervising the schoolsparticipating in the GLL intervention. Twenty-five healthinsurance employees are currently participating in theproject. These health management specialists assist theschools in the definition and development of goals, actionplanning, the establishment of steering committees and theorganization of health circles. Moreover, they providesupervision, advice and moderation services as needed,help the schools find regional cooperation partners andsupport services, and organize specific workshops andtraining courses. The schools are closely supervised byexternal health management specialists for an initial period

174 J Public Health (2012) 20:171–180

of 2 years and are later expected to complete the healthmanagement duties on their own. The 2010/2011 school yearmarked the start of the sixth cycle of the GLL intervention. Atthat time, approximately 140 schools had completed or werecurrently participating in the project. Of the 15 new schoolsenrolled in GLL in 2010, two are elementary schools, three arevocational schools, four are comprehensive schools and sixare college-preparatory schools. The schools are selected bythe LVG after consultation with all cooperation partners.Schools with a majority of socially disadvantaged students arepreferentially chosen.

Integration of the Balanced Scorecard (BSC)as a management instrument

The Balanced Scorecard (Fig. 2) developed by Kaplan andNorton (1997) is a practice-oriented strategic managementinstrument. The BSC makes it possible to convert organi-zational goals into exact key performance indicators basedon cause-and-effect relationships. Variables causally influ-encing an organization's progress towards goal achievementare identified and used as performance indicators.

The Balanced Scorecard attempts to consider the overallplanning, management and control processes of an organi-zation, and thus goes above and beyond systems that onlyconsider the financial perspective (Boersch and Elschen RHrsg. 2007). The Balanced Scorecard considers not onlypast experience, but also future activities. All strategicobjectives must be linked to concrete measures, respon-sible parties and key performance indicators to yieldbinding early indicators. This is essential to ensure thatthe instrument can communicate clearly measurableinformation about an organization's progress toward goalachievement. The Balanced Scorecard also links theindicators to causes and effects (Niven 2009). Because itrequires the continuous adjustment of goals and measures,

the BSC can serve as a basis for organizational learning(Zurwehme 2000).

The Balanced Scorecard was originally used in differentparts of the private business sector, but is also suitable foruse in the public and non-profit sector (Kleine 2005).Today, this instrument is increasingly used by institutions inthe health and education sectors, such as hospitals (e.g.,Brinkmann et al. 2003), rehabilitation clinics (e.g., Kehl etal. 2005), schools (Seitz and Capaul 2007) and universities(e.g., Röbken 2003), including the University of HannoverMedical School (MHH Hanover) (Schweitzer et al. 2005).

In Germany, the Balanced Scorecard has found its wayinto vocational schools, but only through pilot projects. Aproject being conducted at vocational schools in Berlinfocuses on the development of a binding operational andstrategic instrument for self-management. This BSC-basedmanagement model has been subjected to scientific scrutiny(RKW Berlin GmbH 2008). To our knowledge, the BSChas not been systematically implemented and evaluated atany German elementary school, special school, collegepreparatory school or non-college preparatory high school(German: Hauptschule or Realschule) to date.

The BSC as a strategic instrument in the Learn to LiveHealthy intervention

The BSC will be used as a strategic instrument in the Learnto Live Healthy intervention in the scope of the projectsponsored by the German Federal Ministry of Educationand Research (BMBF). It forms the basis for the definitionand prioritization of the strategic objectives of the individ-ual schools participating in the intervention. Its originalfinancial, customer, process and potentials perspectiveswere adapted to the central questions encountered in theeducation sector. Communication of the strategies to allstakeholders ensures transparency, making it possible to

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Fig. 2 Balanced Scorecard(original illustration based onKaplan and Norton 1997)

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implement the innovations in a manner that is plausible toall parties involved (Conradt-Mach 2005). The BSCtherefore functions as a management instrument and acommunication tool. Sustained support to the schoolmanagement, the establishment of a steering committeeand the assignment of binding tasks are crucial to thesuccessful implementation of the intervention. The devel-opment of strategic objectives is a multi-stage process inwhich the prioritization and assessment of objectives leadto a reduction of complexity and place the focus on a fewachievable goals and measures, which can be consistentlypursued (Schweizer and Gloger 2006).

The BSC is an instrument designed to support changeprocesses. It also enables the measurement of health-promoting activities at schools. The joint establishment ofbinding goals and related measures for a defined period oftime, at the end of which the schools can determine forthemselves whether and to what extent they have achieved theset goals, is key to successful implementation of the BSC.

Poor communication of goals is often the reason whygoals are often planned but cannot be implemented inpractice. The Balanced Scorecard concept specificallyaddresses this deficit: the implementation and managementof school activities with the BSC are based on communicationand transparency. A unified understanding of all stakeholdersat a school is established by communicating the schoolstrategy and linking it with the strategic objectives of theschool. When all parties are cognizant of the goals of theschool and are aware of the measures needed to achieve thesegoals, then all initiatives can be geared in that direction. Thisallows all stakeholders to recognize that their actions alsocontribute to goal achievement.

The goal of the communication process is to ensure thatall stakeholders at the participating schools can follow theschool strategy. This makes implementation of the measuresplausible and transparent for all parties involved. The BSCcan be used as a management instrument and communicationtool for this purpose. The BSC provides schools a holisticview of their development and gives them the potential forholistic management. As the Balanced Scorecard was notconceived as an instrument for one-time use, the contents ofthe BSC must be regularly modified and updated.

The identification of suitable performance indicators andmetrics is central to the assessment of goals and goalachievement and, thus, to the measurement of changes andthe assurance of quality. The indicators and metricsindependently defined and evaluated by the schools mustbe easily comprehensible, determinable and evaluable.Indicators are quantitative benchmarks that reflect thestructure and processes of an organization. They serve toprovide a simple and easily understandable representationof important correlations that are not readily apparent in theraw data (Wagenhofer 2000). According to Paulus and

Witteriede (2007), the development of suitable indicators(and indicators systems) as the basis for standards is animportant task of research. An indicator is defined “as a signthat gives a fair and accurate representation of a part of theworking of a complex system and changes within it” (Young2005). According to the SMART criteria, the objectives ofindicators should be specific, measurable, achievable, realis-tic and timely. Furthermore, they should be culture-sensitive(Young 2006), gender-sensitive, simple, understandable andethically acceptable. Last but not least, indicators shouldmeet quality criteria for validity, reliability, sensitivity andspecificity (Walter and Schwartz 2003). A combination ofshort-, medium- and long-term outcome and process indica-tors is needed for the assessment of health-promotingschools. In 2000, the US Centers for Disease Control andPrevention (CDC) introduced the School Health Index (SHI)as a self-assessment and planning guide for future measuresat schools. An evaluation demonstrated the principal benefitof such an instrument for the assessment of need. At thesame time, it became clear that successful implementation ofthe instrument is dependent on the support of the staff andorganizational support (Pearlman et al. 2005).

Preliminary experience of the BSC as part of the GLLintervention

The Balanced Scorecard will be integrated in the GLLintervention in the scope of the study. The School-BSC willbe used as a supportive instrument for the promotion ofschool development in Lower Saxony. It provides the basisfor the definition and prioritization of the strategicobjectives of the individual schools participating in theintervention. The perspectives of the instrument wereadapted to the intervention for this purpose.

Prior to implementation of the Balanced Scorecard at theparticipating schools, 31 health specialists received inten-sive training in the background and use of the BSC. Thespecialists were continually supervised for the duration ofthe project. The specialists hold a package series ofsuccessive Balanced Scorecard workshops to introduce theBSC at the participating schools and support them in theimplementation of their health promotion strategies. Fol-lowing a participatory quality development approach,structured telephone interviews were conducted for a post-workshop evaluation of methodology. The main objectiveof the survey was to identify the potentials and problemsassociated with the implementation of the BalancedScorecard at the schools from the perspective of the healthspecialists. Another was to gather ideas on potentials forovercoming barriers. Of the 31 health specialists enlisted,22 (4 male, 18 female) were surveyed in these semi-standardized telephone interviews. Seven of the non-

176 J Public Health (2012) 20:171–180

surveyed health specialists could not be reached during thesurvey period (December 2009 to January 2010), and theremaining three had dropped out of the GLL intervention.The interviews were conducted using a semi-standardizedguideline. The data derived from the semi-standardizedinterviews were assessed by descriptive analysis. Openquestions were processed and analyzed by qualitativemethods. The analytical procedure corresponds to theprocedure for thematic coding and qualitative contentanalysis according to Mayring (2010).

The post-workshop evaluation of expectations revealedthat the health professionals regarded the BSC as astructured tool that helped schools set their goals and createtransparency. After the first workshops, the health special-ists rated the Balanced Scorecard as a useful instrument forthe measurement of progress at the very heterogeneousschools. Although the BSC procedure partly resembles thatnormally used by the health specialists, they expect that theBalanced Scorecard will have a supportive effect on thestructured implementation of the GLL intervention, result-ing in increased goal orientation. The Balanced Scorecardmakes it possible to document the progress towardsreaching the goals that were set and to make this progressvisible to all stakeholders, thus creating transparency.Furthermore, the Balanced Scorecard helps to improve theorganizational communication channels within the schoolsand to create binding commitment. Finally, the healthspecialists see the Balanced Scorecard as a practical toolthat facilitates their work.

The health professionals mainly expect problems related toputting the theory into practice. Besides the use of complexterminology, this includes the handling of measurementparameters, linking them to the perspectives and motivationto integrate the Balance Scorecard. They also expect to seebarriers to the documentation of results by the schools. There

is uncertainty regarding the use of the BSC at the differenttypes of schools, ranging from elementary schools (sometimesvery small organizational units) to college-preparatory schoolsand vocational schools (large organizational units). The healthprofessionals felt that the time allotted for training the schoolsto use the complex instrument was too short and that smalladditional training courses will be needed. To overcomebarriers, the terminology should be simplified and the use ofthe School-BSC should be simulated in case examples. Fourhealth specialists proposed linkage of the School-BSC withLower Saxony's Policy Framework for School Quality inorder to utilize potential synergy effects.

In view of the fundamental need to integrate the LowerSaxon Policy Framework for School Quality, the School-BSC no longer evaluates schools from four perspectives butrather from six pursuant to the Policy Framework (Fig. 3).The terms of the perspectives are identical to those of theLower Saxon Policy Framework for School Quality. Thisalso makes it easier to identify which goals belong to thedifferent perspectives. A key question was defined for eachperspective, which contributes to direct comprehension.The goals should be selected so that they reflect the schoolstrategy. The perspectives are not viewed as isolated entitiesbut are linked together in cause-and-effect chains wheneverpossible. Thus, the Balanced Scorecard not only serves asan instrument for the integration of health management inschools, but also facilitates the implementation of thePolicy Framework.

In view of the participatory approach, two healthspecialists were enlisted to optimize the training concept.The development of new school programs largely dispelledthe initial reservations of the health specialists. In theprocess, the development of a school-specific BSC wassimulated and potential problems with integration of theBSC into the organizational unit of the schools and

Learning and teaching

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Fig. 3 Learn to Live Healthy(GLL)/BSC project

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potential solutions were jointly discussed. The healthworkers have the opportunity to test the School-BSCprocedure in additional workshops based on the measuresby the schools (Fig. 4). The School-BSC is viewed as auseful tool for the creation of organizational structures andtransparency and for work facilitation.

Conclusions

The main problems associated with the existing outcomeevaluations include the short duration of the observedinterventions, sustainability problems, a small number ofsamples insufficient for differentiation, and the lack ofspecificity and sensitivity of some standardized instruments,particularly in view of the relatively good health status ofchildren and adolescents (Richter and Mielck 2006). Acombination of short-, medium- and long-term outcomeand process indicators is needed for the assessment of health-promoting schools. Health-related knowledge, quality man-agement and evaluation skills, and familiarity with theeducation system are crucial to the identification of suitableindicators for school health promotion (Barnekow et al.2006). The Balanced Scorecard is not primarily an evaluationinstrument, but rather a change initiative that integrates newmanagement processes. The school strategy is the central

factor that determines its transformation into a health-promotion school. The evaluation by health specialists duringthe implementation process showed that the introduction oforganizational management instruments in schools requiresdifferentiated adjustment of the instrument to the specificinternal and external framework conditions of the schools.The School-BSC is also regarded as having the potential tocreate structures that support the health-promoting orientationof schools and that improve the organizational communicationand transparency in schools. The use of a participatoryapproach to quality development proved to be necessaryfor the implementation of health management in schools.Participatory quality development is a useful method, espe-cially in setting approaches aimed at achieving the participa-tion of the target group in organizational developmentprocesses. Therefore, participatory quality development canbe viewed as a cross-cutting issue that should be integrated inall project stages whenever possible (Wright 2010).

Evaluation of the School-BSC in schools makes it possibleto assess its suitability as a management and evaluationinstrument in these organizations. The main objective is notonly to evaluate the schools in terms of their change processes,but also to determine the effectiveness of the overall GLLproject, including the project strategy and instruments(balanced scorecard, steering committees and health circles).If the School-BSC proves beneficial, it can serve as an

Perspective Goal KPI(key performance indicator) Target Current Time of goal

achievement Measures for change Who … ?Does What?

Reduce class cancellations No. of cancelled class hours 40 per

semester60 per semester

2nd semester 2011/2012

Prepare action plan for teacher absences

Improve ergonomics of workplaces (WP) in the school

No. of ergonomic WP for students 100% 60% 2nd semester

2011/2012Modification of WP for teachers and students

No. of ergonomic WP for teachers 100% 50%

Stress prevention for teachers

Number of stress-related illnesses

5 sick-leave days per semester

10 sick-leave days per semester

1st semester 2011/2012

Cooperation with providers of stress management courses

Sample Scorecard – School X

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school development

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Learning and teaching

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School management

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Fig. 4 Sample School-BSC scorecard

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evaluated management instrument for all schools. Thiswould allow schools to independently assess theefficacy of their activities and organizational changesin achieving their goals. The results of this study are submittedas policy advice regarding further development of the PolicyFramework for School Quality and the action measuresrecommended by the National Association of Statutory HealthInsurance Funds.

Acknowledgements The intervention is organized by the Associationfor Health Promotion and Academy for Social Medicine Lower Saxonyand has the following additional cooperation partners: the local statutoryhealth insurance fund Allgemeine Ortskrankenkasse (AOK), the LowerSaxony Ministry of Education, the Lower Saxony Ministry ofSocial Affairs, Women, Family and Health, the MunicipalAccident Insurance Association of Hanover and the State Accident Fundof Lower Saxony (GUVH/LUKN), the agricultural health insuranceLower Saxony-Bremen (LKK Niedersachsen-Bremen), the local statuto-ry health insurance fund Betriebskrankenkasse (BKK Niedersachsen-Bremen) and the Landesverband Niedersachsen der Ärztinnen und Ärztedes öffentlichen Gesundheitsdienstes e.V. The study is funded by theGerman Federal Ministry of Education and Research (BMBF: grant no.01EL0811).

Conflict of interest The authors declare that they have no conflict ofinterest.

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