Health-care organizations are operating in a complex environment. Financial pressures from government, the need to arrange integrated care and improve performance for multiple stakeholders, as well escalating costs are driving administrators to search for effective management tools. In addition, all aspects of the sector are being asked to account for their performance and to demonstrate efficiency and effectiveness in providing services to their clients.
Financial measures alone are not sufficient to measure performance. Other factors missing from traditional financial reporting such as competence, customer focus, operational efficiency, innovation and knowledge must be carefully considered. Adopting Balanced Scorecard (BSC) in healthcare organization permits us to develop a more comprehensive set of performance indicators. The BSC is a management tool, originally applied to private sector, developed by Kaplan and Norton in 1992 . Their framework broadened the traditional performance assessment approach by integrating financial measures with other key performance indicators linked to additional areas: customer preferences, internal business processes, organization growth, learning and development. Performance measures belonging to all four features are included in BSC .
About ten years after Kaplan and Norton developed BSC, a number of health-care organizations started to adapt and implement this framework in various settings from North America to Asia [3–5] and also in Europe [6, 7] with the remarkable experience of NHS Performance Assessment Framework  in United Kingdom. In the past few years a growing number of Italian health-care institutions adopted BSC with the aim of measuring overall performance and to improve clinical and financial goals .
When applied to the health-care sector, the four traditional perspectives should be slightly modified to better display the functioning of public funded hospitals. The Financial Perspective should contain indicators of efficiency and asset utilization, including cost containment. Community Perspective should include measures of quality patient-centred care. Internal Processes Perspective should report indicators of continuous quality improvement and integrated service design. Growth and Learning Perspective should cover measures of human capital and strategic competencies. In each of the perspective significant success activities, indicated as Key Performance Areas (KPAs), are defined. Afterwards critical success factors, known as Key Performance Indicators (KPIs), are identified as well as measurement methods and standards. They balance between long term and short term in addition to internal and external factors contributing to business strategy that is translated into operational terms. Design of a strategic map, communicating outcomes to achieve by means of strategic initiatives for all Perspectives and their relationships, represents an essential component of BSC.
Traditionally financial metrics obtain increased importance than other parameters like quality of care, patient satisfaction, innovation, physicians and staff fulfillment.
In consequence of Laboratory Analysis management and staff requests for being evaluated, not only for financial outcomes, but also for relationships with community, internal procedures improvement, competence and knowledge, a first application of BSC was carried out with satisfactory results  in the past. In continuity with previous experience, the model was again applied, only with slight modifications to better depict Laboratory Analysis current activity. The objective of this paper is to confirm feasibility and value of using BSC to measure, over time, performance in Laboratory Analysis Operative Unit (OU) of St. Anna University Hospital, in particular the capacity to highlight outcome differences and explain their occurrence and relationships.