The Effect of Strategic Management on the Organizational Performance Using the Balance Scorecards Approach to Measure Performance: A Case Study in the Nursing Department at Al-Khalidi Hospital and Medical Center

Organizations nowadays are increasingly impracing in using strategic management to improve their performance, this study has mainly focused on the impact of the strategic management on the performance of Al Khalidi Hospital and Medical Center (KHMC), based on the using of the Balanced Scorecard as a measuring tool, regression analysis results Indicates the existence of a strong positive impact of strategic management on performance. The main findings in this study that the internal process perspective is the most affected perspective in the strategic management, and that the strategic management have a positive impact on the performance in (KHMC). The four perspective of the balanced score card is an effective tool to measure the performance by objective achievement.


Introduction
Strategic Management became the most important basic features in the success of any organization, projects or business, and it help to build a base essential to develop and measure performance, Strategic Management is a System of integrated processes related to strategic analysis and emanating from the organization's vision, mission until reach to the organization goals in growth and continuity and get a competitive advantage (Al-haj Mohammad, 2011).
Strategic Management outlines the concept of transmission of the institution from the administrative practices based on the mood of the individual, the random, routine, obviousness, intuition and tradition to the administrative practices that depend on participate (The team) and the planned change and innovation, initiative and invested in new technology and using renewable information in addition to the adoption of scientific research and experimentation as a stepping stones that essential for the development, and that is from the perspective that the management is a science that has its theories and principles and be exercised only by those who have prepared a special setting and received a professional license to practice. (Al-Khatib, 2001, p. 169).
"As a final step for the application of strategic management, is to work on the validation of the progress of the strategic management by evaluating the performance of the strategy through a review of internal and external factors that have adopted the strategy and measure performance and take corrective action.
In measuring institutional performance, we can use the concept of the Balanced Scorecard. "The value of the "balance scorecard" in recognizing how the interests of a variety of stakeholders can be interrelated" (Dessetal., 2012, p. 147) financial and non-financial. The advantages of the Balanced Scorecard are the approaches that seek to translate the mission and strategy into operational objectives, with the Balanced Scorecard, business unit performance measurement is not only expressed in financial measures but towards further elaboration into measures to encourage business units to create value for the company that is now and in the future. In addition to improving the internal capabilities such as the effectiveness of investment in human resources, systems and procedures are needed to obtain better performance in the future". (Fattah &Syaripudin, 2016).The balanced scorecard supplemented traditional financial measures with criteria that measured performance from three additional perspectives-those of customers, internal business processes, and learning and growth, which they applied to measure performance in Al Khalidi Hospital and Medical Center (KHMC).

1.1Study Problem
Problem of the study arose through the need to determine the impact of strategic management on the performance of the organizations and the extent to which managers involved in strategic planning are affected by the results of the planning and how they find the effect on the performance of the organization.
Recently, many organization start using the balanced score card in strategic management and to evaluate the performance of their strategic plans to determine where they are and how they will be, and therefore we can formulate the problem of the study by the following questions: -Does the using of strategic management improve the organizational performance?
-How can the Balanced Score Card define the level of performance from its four perspective and how it will be reflected on the top management whom involved in the strategic planning?

Importance of the Study
This study is focusing on the linking between the performance measurements and the desirable results of strategic planning through applying the balanced score card system that measure the performance from four perspectives, financial, learning and growth, internalprocesses, and customer and stakeholders.
Most of studies are evaluate the performance according to the financial perspective; the researcher used the BSC as a more comprehensive tool to measure the entire performance according to how much the firm can achieve its goals.
Kaplan & Norton proposed a general framework to enhance performance management system and to govern the consistency and quality of processes within organizations. The start point was to answer the following questions related to the four perspectives: 1. To achieve vision how must the organization learn and improve? 2. To satisfy customers, at which processes must organization excel?
3. To achieve vision how must the organization looks to its customers? 4. If we Succeed, How will the organization looks to its shareholders?

Objective of the Study
The aim of this study is to identity the effect of applying strategic management using the balanced score card which measure and evaluate the organization performance that it use Balanced Scorecard (BSC) as a valid and well-focused approach to measure the effectiveness of all the used procedures and activities. It is an Integrated Management System that consists of three components: 1) Strategic Management System.

3) Performance Measurement System.
This study is aim to examine the effectiveness of the third component according to the perspectives of: -Financial perspective -Learning and growth perspective -Internal processes perspective -Customer and stakeholders' perspective.

The Study Model
This study is to investigate the improving impact of the strategic management on the organization performance ijbm.ccsen using the independ

Hypot
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Main
Ho: The S  Vol. 13, No. 4;2018 scaled back so that employees can be more motivated to work. In addition, indicators of skills and employability (competency) of employees as well as the involvement and active participation of employees and career development within the company have been considered relatively.

Vesty an Balanced
SaadandDaraghma (2016) study entitled: "Using of the Balanced Scorecard for Performance Evaluation: Empirical Evidence from the Listed Corporations in the Palestine Exchange (PEX)". This paper is aiming at testing the extent to which the listed Palestinian corporations in the Palestine Exchange (PEX) are using the four perspectives of the Balanced Scorecard (BSC) in evaluating the performance.
The findings of this paper state the following points: (1) The financial managers rely on the financial and customer perspectives for evaluating the performance of the listed corporations in the PEX.
(2) The Palestinian listed corporations do not rely on the learning and growth indicators for measuring the performance. (3) The Palestinian listed corporations do not rely on the business process indicators for measuring the performance. (4) This paper concludes that the listed corporations in Palestine do not rely on the BSC indicators for measuring the performance in a correct and complete way.

What distengwesh this study
What distengwesh this study is that it measure the performance of all procuresses and activities depending on the measuring tool (BSC) using the four perspectives of them, and the progress for five years.

The Methodology of the Study
In order to achieve the objectives of the study and testing of hypotheses we select the descriptive analytical method, by reference to the following sources of data: 1-Secondary sources: include survey of the previous theoretical studies relevant to the subject of the study.
2-Primary sources: included the design and distribution of the questionnaire on the study sample in order to gather data about the views category covered.
Statistical analysis software (SPSS) used for the purposes of statistical analysis of the data collected.

The Study Population
The study conducted within Al Khalidi Medical Center and the population was focused on the nursing department, the sample we choose to study consists of the top and middle level of management.
The case sample number is 32 from the total population that is 35.* * (Reaserch Method for Business, UMA SEKARAN & ROGER BOUGIE,2010).

Literature Review
Strategic Management consist of the analysis, decisions and actions an organization Undertakes in order to create and sustain competitive advantages over a lengthy period of time, that mean focusing on two fundamental questions: -How should we compete in order to create competitive advantages in the market place?
-How can we create competitive advantages in the market place that are unique, valuable, and difficult for rivals to copy or substitute?
The process of obtaining the competitive advantage is related to an organized steps of management that strategically start with the vision and mission until achieving goals, according to the definition of (David, 2011) of strategic management that "it is an art & science of formulating, implementing, and evaluating, cross-functional decisions that enable an organization to achieve its objectives" (David, 2011, 6), this definition lead us to the main three stages of the strategic management steps: Strategy formulation, Strategy implementation, Strategy evaluation.
Strategy formulation include developing a vision and mission, performing SWOT analysis (strength, weaknesses, opportunity, and threats), establishing long-term objectives, choose the best from alternative strategies.
"Pearce11 & Robinson (2011) suggest the risks of strategic management, that managers must be trained to guard against three types of unintended negative consequences of involvement in strategy formulation: 1-The time that managers spend on the strategic management process may have a negative impact by scheduling their duties to allow the necessary time for strategic activities.
2-If the formulators of strategy are not intimately involved in it's implementation, they may shirk their individual responsibility for the decisions reached. Thus, strategic managers must be trained to limit their promises to ijbm.ccsenet.org International Journal of Business and Management Vol. 13, No. 4;2018 performance that the decision makers and their subordinates can deliver.
3-Strategic managers must be trained to anticipate and respond to the disappointment of participating subordinates over unattained expectations. Subordinates may expect their involvement in even minor phases of total strategy formulation to result in both acceptance of their proposals and an increase in their rewards, or they may expect a solicitation of their input on selected issues to extend to their areas of decision-making.
Sensitizing managers to these possible negative consequences and preparing them with effective means of minimizing such consequences will greatly the potential of strategic planning". ( Pearce11 & Robinson, 2011,11).
Strategy implementation include Developing a strategy-supportive culture, Creating an effective organizational structure, Redirecting marketing efforts, Preparing budgets, Developing and utilizing information systems, and Linking employee compensation to organizational performance.
Strategy evaluation is the final stage, Managers desperately need to know when particular strategies are not working well; strategy evaluation is the primary means for obtaining this information. All strategies are subject to future modification because external and internal factors are constantly changing. Three fundamental strategy-evaluation activities are (1) reviewing external and internal factors that are the bases for current strategies, (2) Measuring performance, and (3) taking corrective actions. Strategy evaluation is needed because success today is no guarantee of success tomorrow! Success always creates new and different problems; complacent organizations experience demise.
"Pearce11 & Robinson (2011) suggest the benefits of Strategic Management, whenusing the strategic management approach, managers at all levels of the firm interact in planning and implementing. As a result, the behavioral consequences of strategic management are similar to those of participative decision-making. Therefore, an accurate assessment of the impact of strategy formulation on organizational performance requires not only financial evaluation criteria but also nonfinancial evaluation criteria-measures of behavior-based effort. Several behavioral effects of strategic management improve the firm's welfare: 1-Strategy formulation activities enhance the firm's ability to prevent problems. Managers who encourage subordinates' attention to planning are aided in their monitoring and forecasting responsibilities by subordinate who are aware of the needs of strategic planning.
2-Group-based strategic decisions are likely to be drawn to be from the best available alternative. The strategic management process results in better decisions because group interaction generate a greater variety of strategies of group members improve the screening of options.
3-The involvement of employees in strategy formulation improves their understanding of the productivityreward relationship in every strategic plan and, thus, heightens their motivation.
4-Gaps and overlaps in activities among individuals and groups are reduced as participation in strategy formulation clarifies differences in roles.
5-Resistance to change is reduced. Though the participants in strategy formulation may be no more pleased with their own decisions than they would be with authoritarian decisions, their greater awareness of the parameters that limit the available options makes them more likely to accept those decisions". ( Pearce11 & Robinson, 2011, 9-11).
In this study we will focus on the third stage to measure the effective impact of the strategic management on the performance of the organization.
In order to measure the performance of the organization we will use the Balanced Score Card (BSC) as a strategic tool for applying the strategic plan and measuring the performance. "The balance scorecard is not only a management system, it enables companies to clarify their strategies, translate them into action, and provide meaningful feedback around both the internal business processes and external outcomes in order to continuously improve strategic performance and results". (Pearce11 & Robinson, 2011, 363).
In January 1992 Robert S. Kaplan and David P, Norton introduce the Balanced Score Card in a paper entitled "the Balanced Score Card: measures that drive performance" in Harvard Business Review.
The traditional financial accounting measures (return on investment and earnings-per-share) was giving an unobvious perspective to measure the organizational performance and doesn't give a comprehensive measure for performance. So the BSC concept become as a solution for this dilemma because it balances between more comprehensive perspectives of performance.
The Balance Scorecard balances and link between:  Vol. 13, No. 4;2018 are the ICCU unit and the highly-specialized Intensive Stroke Unit, considered as the largest in the private sector in Jordan. Furthermore, KHMC boasts seven new operating theaters, which have recently been modernized and re-equipped with the very latest equipment and cutting-edge operating room systems in addition to a 24-hour pharmacy and emergency wards fully equipped for minor surgeries, cardio-pulmonary resuscitation and minor orthopedic surgery rooms alongside an observation area offering the best possible emergency services. Complementary to our emergency services is KHMC's highly trained and specialized paramedic team and ambulance cars available and operating 24 hours a day.
From this perspective KHMC focus on the strategic planning to improve it's medical service as a competitive advantage around the region, and KHMC implement all the requirements of strategic planning starting with vision mission and SWOT analysis (Strengths, Weaknesses, Opportunities & Threats), in addition to the strategic plan until reaching to the final stage of evaluating the performance.

KHMC Strategic Analysis
In order to identify KHMC's directions for improvement, development, setting priorities, defining quantified objectives & setting action plans, KHMC has delivered a comprehensive SWOT analysis of its business situation. Results of the SWOT Analysis are provided hereafter:

Strengths Weaknesses
Distinguished reputation of the history of service quality. Institutional stability that leads to resistance to Promotion & media coverage.
Opportunities Threats New regional & international markets potential. Competing medical centers are achieving international recognition.
Franchising. Shortage of qualified human resources in the local market.
Attracting insurance companies. Large health care centers with higher capacities.
Developing KHMC insurance system. Increasing costs.
Develop coalitions with external/foreign parties. Insurance companies policies.
International recognition of the level of health care service in Jordan.
Access to the center (heavy traffic).
Performance improvement through partnerships with local community.
Protective regulations against patient's financial default.
Compliance (recognition) with international standards. Relatively high turnover.
Another new big health care centers opening. Develop local community service programs.

KMC's Strategic Plan
International Journal of Business and Management Vol. 13, No. 4;2018