Action Implementation Model for Organisational Performance Measurement in Non-Acute Health Charities


 Background

Organisational performance measurement (OPM) is an evidence-based tool for planning business improvement and creating sustainable competitive advantage. Despite its value, non-acute health charities under-utilise OPM. The purpose of this paper is to provide the rationale and a detailed description of an OPM implementation model developed specifically for non-acute health charities. The aim of this new model is to encourage uptake of OPM in this sector.
Methods

The authors investigated the understanding and use of OPM in the non-acute health charity sector through a large mixed methods study. Multiple research activities, including PRISMA systematic reviews and two case study evaluations, identified factors and activities that are important for successful implementation of OPM in non-acute health charities. These were then integrated to form an implementation model.
Results

The resultant implementation model is a methodological tool designed to account for, and respond to, the specificities and strategic management needs of the non-acute health charity sector. It integrates five distinct yet interconnecting components – a theoretical framework; guiding principles; an implementation framework; measurement domains; and a monitoring and improvement tool.
Conclusions

The innovative OPM implementation model was designed as an evidence-informed approach to support the implementation of OPM in the non-acute health charity sector. It is titled the Non-Acute Health Charities Measurement Advantage Implementation Model (MAIM). Future studies should test the model in different organisational contexts and the impact of OPM on non-acute health charity performance.


Introduction
Organisations exist to provide social, health, economic and other value to individuals or groups of stakeholders (Griseri, 2013;Jones, 2013). People form organisations to coordinate their actions and create more value than working separately (Jones, 2013) and an organisation's success relies on its performance in creating and sustaining stakeholder value (Gomes & Romao, 2019;Sharma, 2009). The ability of Board members and executive managers to create more value from the resources at their disposal to outperform other organisations, otherwise known as competitive advantage (Jones, 2013), is their critical responsibility and signature of success. The ultimate aim of an organisation is sustainable competitive advantage whereby they maintain the factors that contribute to their performance and outperform their competitors over long-periods (Gomes & Romao, 2019;Sen & Vayvay, 2017;Jones, 2013).
Organisational performance measurement (OPM) is recognised as a contributor to effective organisational governance and sustainable competitive advantage (Nalwoga & van Dijk, 2016). It is seen as being "essential to the survival and success of the modern business" (Richard et al., 2009, p. 719) and over the past two decades has been recognised as a contributing factor in organisations, including those in healthcare, that demonstrate high performance (Carneiro-da-Cunha et al., 2016). OPM provides whole-of-organisation benchmarking intelligence and is distinguished from program evaluation, or the sum of multiple program evaluations, which offer singular dimension and point in time assessment (Nalwoga & van Dijk, 2016;Behn, 2003). OPM data can be used to assess an organisation's overall capability to ful l and sustain its purpose by promoting mission focus, resource allocation, process improvement, learning, evaluation and by managing consequences for poor performance (Nalwoga & van Dijk, 2016;Bititci, 2015;Behn, 2003;Kaplan, 2001). OPM is extensively used in for-pro t and government industry however its use within not-for-pro t (NFP) charitable industries has been slow by comparison. This is despite correlation between improved NFP organisational performance and NFPs that increase their level of accountability through performance measurement and disclosure (Bellante et al., 2017).
Non-acute health charities are both not-for-pro t organisations and health service providers. As described by , non-acute health charities form part of the broader global health industry and provide a range of non-hospital and maintenance care services across many health and wellbeing disciplines. They are known to be growing in relevance and importance as they relieve governments and for-pro t providers of workload and often complement other non-charity social services such as education, disability, mental health, aged care, rehabilitation, justice and welfare Soysa et al., 2016;Mueller, 2007). Such organisations are well-known in the United Kingdom, United States of America, Canada, and New Zealand and many other developed and developing countries (Soysa et al., 2016;Hardwick et al., 2015). In the Australian example, the sector has an estimated combined annual turnover in excess of $3 billion Cortis et al., 2015). Despite its diversity, the sector is treated somewhat homogeneously because these organisations share a number of common governance and service similarities . These similarities include: 1) they are governed independently, 2) have a broad range of stakeholder groups, 3) have common funding options through government contracts, fundraising / donations, fee-forservice and membership, 4) are intrinsically connected by their charitable reason-for-being, 5) do not have a pro t motive; and 6) bene t from unique governance legislation that allows them to function with not-for-pro t status eligible for donations or tax concessions Park & Peng, 2019;Hung & Hager, 2018;Hunter, 2017;Lecy et al., 2010).
Non-acute health charities are an example of the slow uptake of OPM in NFP industry. There is a dearth of peer-review literature relating to OPM and non-acute health charities and it appears such organisations under-value, under-utilise or under-report OPM Soysa et al., 2016;Laamanen et al., 2006). NFPs face escalating stakeholder concerns regarding organisational effectiveness, excellence and accountability (Seaman & Young, 2018;Clancey & Westcott, 2017;Hyndman & McConville, 2018;Lecy et al., 2010) and this sector's limited use of OPM and lack of public reporting requires consideration, especially as OPM enables organisational excellence (Bellante et al., 2017;Aboramadan & Borgonovi, 2016;Carneiro-da-Cunha et al., 2016) and in healthcare is known to enhance service e ciency and client outcomes (Mosadeghrad, 2015;Alharbi et la., 2016;Cacciatore et al., 2019;Grigoroudis et al., 2012).
Many authors have looked to understand what will be necessary to encourage NFPs to improve their approaches to accountability and performance (Hardwick et al., 2015;Boateng et al., 2015). In considering methodology for initiatives that bring about organisational change and development, evidence has veri ed the role of implementation models and frameworks in the development, and successful execution, of business strategies, program management and accountability processes (Damschroder, 2020;Li & Fu, 2019;Gervais, 2008). This is similar for OPM, as its implementation is known to bene t from structured frameworks and approaches such as Balanced Scorecard, the Business Excellence Model of the European Foundation for Quality Management (EFQM) and the Performance Prism (Bititci, 2015;Neely et al., 2017). The complex multidimensional nature of NFPs delivering healthcare services (Boateng et al., 2015;Grigoroudis et al., 2012) has led many researchers to consider the role of NFP business implementation models, particularly as OPM implementation requires adaptability and exibility to take into account the speci cities of individual sectors and organisations (Gomes & Romao, 2019;Bititci, 2015). Research has shown that replicating OPM measures or OPM implementation strategies does not guarantee success and at this point neither a generalisable OPM framework for NFPs, nor a speci c model for non-acute health charities, exists (Gomes & Romao, 2019;Soysa et al., 2016;Bisbe & Barrubes, 2012;. In the absence of an OPM implementation model for non-acute health charities the authors conducted a large mixed methods study to consider the factors for OPM success in such organisations. The ultimate aim of this paper is to encourage OPM uptake by non-acute health charities by providing rationale and a detailed description of an OPM implementation model developed speci cally for the sector. The method section summarises the study outcomes that informed the model and the results section describes the ndings and supporting evidence in relation to the OPM implementation model titled the Non-Acute Health Charities Measurement Advantage Implementation Model (MAIM). This is complemented by a discussion which considers the practice applications of MAIM, insights to support MAIM's use and opportunities for further research.

Methods
Between 2014 and 2020 the research team undertook a body of mixed methods research that included ve independent, yet interconnected, studies to develop the OPM model for non-acute health charities. The study's research plan received ethical approval from Deakin University, Australia (approval numbers HEAG-H 197_2014 and HEAG-H 89_2017). Table 1 outlines the research studies and resulting outputs. Firstly, a narrative literature review of the theoretical evidencebase for OPM and OPM implementation was completed. Secondly, a systematic review explored the extent of OPM in non-acute health charities and measures of organisational performance for such organisations . Thirdly, the recommended OPM measures were tested using the Delphi technique in an existing organisation involving 77 and 59 participants in pre and post surveys respectively (Colbran et al., 2017). Fourthly, a narrative literature review to identify the key factors for successful OPM implementation in non-acute health charities was conducted . This was followed by a qualitative and quantitative evaluation of the 12-month implementation of OPM in a case study organisation using the recommended implementation factors generated from the earlier ndings (Colbran et al., 2020;Colbran et al., 2021a).

Results
The Non-Acute Health Charities Measurement Advantage Implementation Model (MAIM) was created from the ndings of the ve studies. MAIM provides a comprehensive, easy-to-use, evidence-informed OPM implementation tool where none has previously existed. As illustrated in Fig. 1, MAIM integrates ve distinct yet interconnecting components: The rationale for bringing various elements together in a multi-layered implementation model as opposed to a single activity checklist is important. Implementation models are crucial in major change initiatives as they describe the phenomenon being activated, articulate the phases necessary to embed the phenomenon, and bring to life the relationship between theoretical reasoning and action (Ricciardi et al., 2019;Nilsen, 2015). They often require multi-layered components, such as the ve described in MAIM, to drive the whole-of-organisation experience, culture and learning processes necessary to develop systemic commitment, investment necessary, and renewal in knowledge and behaviour (Ricciardi et al., 2019;Bergeron et al., 2017;Nilsen, 2015;Argote, 2013;Jones, 2013). As described below, in the case of MAIM, the theoretical framework and guiding principle elements are included to in uence appropriate behaviours necessary for OPM success. They are followed by the implementation framework itself (NCPI Framework) and recommended organisational measures, and then a technique to monitor and adapt implementation. This multi-layered approach transitions implementation thinking from theory to a pragmatic way of implementing OPM in non-acute health charities.

Component 1: MAIM Theoretical Framework
MAIM is an implementation model founded on Organisational Learning Theory (OLT) and Action Implementation methodology. As OPM is a new phenomenon to the non-acute health charity sector, its introduction and successful implementation will require an acceptance of change in ways of working; understanding of the mechanisms and methodologies that enable change; and embracing skills and techniques to implement new organisational initiatives. From a theoretical perspective, OL generates cultures of psychological safety which support the adoption of creating, retaining and transferring knowledge that enables change and renewal in organisational systems, practises and tasks (Argote & Miron-Spektor, 2011). Such cultural development is often achieved by the development of comprehensive and multi-layered change plans, as seen within MAIM, which embrace task performance experience, organisational culture and organisational learning processes (Argote, 2013;Argote & Miron-Spektor, 2011). OL is known to enable the uptake of new ways of working and improving organisational performance through higher levels of employee engagement, ability-enhancing initiatives, decentralisation of authority and improving knowledge capabilities (Jyoti & Rani, 2017;Garcia-Morales et al., 2012). The inclusion of Component 2: Guiding Principles (Table 2) and Component 3: NCPI Framework (Table 3) are examples of OL in action within MAIM. Both include values and mechanisms which encourage planning, transparent communication, task experience and mistake appreciation.
Similar to OL, action implementation methodologies are used in change initiatives as they promote the use of implementation checklists and experiential learning as opposed to linear or sequential execution (Nilsen, 2015;Field et al., 2014;Greenhalgh et al., 2004;Rycroft-Malone, 2004). Examples such as the Knowledge to Action Framework (Graham et al., 2006) and the Promoting Action on Research Implementation in Health Services Framework (Kitson et al., 1998) are recognised for improving organisational performance and strengthening competitive advantage of non-pro t and healthcare organisations (Argote, 2013;Garcia-Morales et al., 2012;Prugsamatz, 2010;Murray, 2002). As seen in MAIM's ve components, such approaches embrace cycles of implementation which include scoping and de ning problems to be addresses, planning and preparing for implementation, initiating delivery and re ning implementation approaches, and sustaining new initiatives so they are embedded as business-as-usual activities that can be scaled-up (Nilsen, 2015;Greenhalgh et al., 2004).

Component 2: MAIM Guiding Principles
Guiding Principles within an implementation model are necessary to change and then maintain the transformational organisational and individual behaviours required to sustain program implementation (Nilsen, 2015;Metz & Bartley, 2012). The six MAIM Guiding Principles -clarity, adaptability, alignment, transparent communication, capability and accountability -were identi ed in a study that explored perceptions of staff from a non-acute health charity that successfully implemented OPM (Colbran et al., 2021a). They are explained in more detail in Table 2. Guiding principles are essential to support implementation approaches, such as OPM, that are di cult and require long-term commitment, as they provide the competency, cultural and leadership building blocks to support practice, organisational and systems change necessary for OPM implementation (Nilsen, 2015;Zimmerman, 2009). Component 3: Framework for Non-Acute Health Charity Performance Implementation (NCPI Framework) In line with the recommendations of Nilsen (2015) who identi ed the importance of using an OPM implementation checklist, the NCPI Framework  augments the OL and action implementation theories underpinning MAIM and is tailored to the nuances of the non-acute health charity sector. The NCPI Framework (See Table 3) features a multidimensional integrative design informed by Nilsen (2015) and Leug and Vu (2008). It recommends 30 operating elements grouped under ve implementation factors. It has been designed to encourage awareness and learning, to reduce the risk of misunderstanding and also overcome any capability de ciencies within organisations (Lueg & Vu, 2008;Buchanan et al., 2005). In response to ndings taken from a case study evaluation of the NCPI Framework, adaptations have been made to the model described previously . These adaptions include: stronger reference to the need to link OPM accountability in departmental and personal goals to staff performance appraisal processes (see Table 3, Element 4.5), strengthening reference to the value of OL culture within the adaptability MAIM guiding principle (see Table 2); strengthening reference to the importance of managers commitment to, and capability to implement, OPM within the capability MAIM guiding principle (see Table 2); calling out the need for review and improvement loops for products and services not just OPM implementation (see Table 3, Element 3.5).
Component 4: Performance Measurement Domains for Non-Acute Health Charities As described in Table 4, MAIM recommends six performance domains to measure internal and external success -quality of service; nance; stakeholder (customers and clients); people and culture; governance and management; and mission and purpose Colbran et al., 2017).
The MAIM measurement domains are important as measurement of performance is not possible without reference points to assess success (Boateng et al., 2016;Soysa et al., 2016;Colbran et al., 2017). Identi cation of organisational performance measures and indicators is therefore one of the major considerations necessary in OPM strategy (Zimmerman, 2009;Smith et al., 2008). Further, as no two sectors or organisations have identical objectives it is critical for OPM to be tailored through the creation of measures and indicators customised to represent all dimensions of an organisation's strategy and target outcomes (Boateng et al., 2016;Bisbe & Barrubes, 2012;Zimmerman, 2009;Schalm, 2008). Suggested strategies to develop organisational measures are offered in the NCPI Framework's Factor 5 (Table 3) and pro led in Colbran et al. (2017).
MAIM utilises Balanced Scorecard (BSC) methodology (Tarigan & Bachtiar, 2019;Sen & Vayvay, 2017;Kaplan & Norton, 1992) to construct organisational performance domains, measures and indicators. BSC is a leading OPM method and is used extensively in for-pro t, government, and non-pro t organisations (Tarigan & Bachtiar, 2019;Sen & Vayvay, 2017;Schalm, 2008;Paranjape et al., 2006). It can be adapted to suit industry types and speci c organisations (Kaplan, 2001) and is recognised for its ability to translate an organisation's mission, strategy and short and long-term objectives into a comprehensive set of performance measures and aligned initiatives (Inamdar & Kaplan, 2002). Those undertaking OPM implementation must be aware that their measures and indicators need to be meaningful and carefully developed as measurement overload is a critical risk factor for OPM implementation (Colbran et al., 2020/1).

Component 5: MAIM Monitoring and Improvement Evaluation Tool
The MAIM Monitoring and Improvement Evaluation Tool as described in Colbran et al. (2020) assesses what is working well in implementation using a 5-point Likert scale survey informed by the Gervais Program Evaluation Model (Gervais, 2008). Aligned to OL and action implementation methodology, the inclusion of an evaluation tool within MAIM encourages feedback loops to understand what is necessary to improve ongoing implementation (Field et al., 2014;Argote, 2013;Metz & Bartley, 2012). The tool describes internal stakeholder's perception of OPM usefulness (utility and usability) and the effectiveness of OPM infrastructure and systems established to support program design and implementation. The Monitoring and Improvement Evaluation Tool is presented in Table 5. It proved effective in monitoring OPM implementation within a case study non-acute health charity (Colbran et al., 2020).

Discussion
MAIM is the rst evidence-based OPM implementation model developed for non-acute health charities. It has addressed the dearth of extant literature through the integration of results from ve studies of a mixed method research program to offer a unique methodology designed to account for, and respond to, the speci cities of the sector. Through the use of OL and Action Implementation methodology which promote implementation checklists and experiential learning as opposed to linear or sequential execution, MAIM provides a way of measuring success in these complex multidimensional healthcare NFPs which often grapple with whole-of-organisational implementation and change (Boateng et al., 2015;Hardwick et al. (2015;Grigoroudis et al., 2012). This model provides an opportunity to further test these theories and to build an understanding of how central they are to OPM in non-acute health charities. It should promote greater attention to the importance of a sound theoretical approach to OPM.

Considerations for Boards and Executive Leaders
Organisational leaders are ultimately responsible for the success of their organisations (Odor, 2018;Guta, 2015) and OPM can enable sustainable competitive advantage (Carneiro-da-Cunha et al., 2016). The availability of MAIM makes a compelling case for Board members and executive leaders of non-acute health charities to undertake OPM. The activation and delivery of OPM invariably lies with organisational leaders and MAIM lls a void in existing evidence by offering those with the responsibility of non-acute heath charity stewardship an evidence-based OPM implementation approach tailored speci cally for their sector. One perspective will be that those that utilise MAIM to embrace OPM, and support its implementation, have an opportunity to address stakeholder calls for greater accountability, transparency and demonstration of effectiveness, position themselves as industry leaders and create an edge over competitors (Gomes & Romao, 2019;León & Bousquet, 2018;Sen & Vayvay, 2017;Aboramadan & Borgonovi, 2016). A stronger standpoint could be that with the availability of MAIM, and as bene ciaries of public, private and philanthropic funding, non-acute health charities are obliged to undertake OPM and can no longer standby idly without OPM action as other industries pursue enhanced accountability, transparency and performance.

The Need to Implement Well
The results of this broad study have demonstrated that OPM implementation is complex and does not occur through good intent alone. In utilising evidencebased implementation methodologies MAIM offers organisational leaders the opportunity to establish and enable the structure and processes necessary for successful OPM. This includes having organisational wide acceptance and resourcing, understanding by all members of the organisation, being embedded in everyone's work and being connected to every part of the business.
In regards to facilitation, it is clear the capacity of those tasked with the responsibility to facilitate OPM implementation is critical for success. Facilitators are critical as they are tasked to achieve the desired outcome by helping change participant attitudes, habits, skills and ways of working (NCCMT, 2020). Facilitation is a highly skilled task which requires appropriate knowledge, skills and personal attributes to operate across the facilitation continuum between actioning and doing things for others through to enabling and empowering others to act. So, while MAIM identi es the need to designate an OPM lead and facilitators -see NCPI Framework: Element 2.5 (Table 3), the organisation's willingness and readiness to hand over responsibility and support and develop facilitators is a key conceptual factor for OPM implementation.

Considerations for Stakeholders, Funders and Philanthropists
Most funders of non-acute health charities, such as government and philanthropists, take a project-based mindset to enable short term delivery outputs (Macmillan et al., 2014;Lowell et al., 2001). However now that an OPM implementation model such as MAIM is available to non-acute health charities, an alternative perspective may be to encourage OPM and OPM approaches. A re-alignment of investment decision-making towards OPM may enable more contemporary technical skills, resources, infrastructure and leadership development. Such approaches would be in line with calls on funders to support more systematic understanding of, and response to, the dynamics of capability and capacity building in non-pro t and voluntary sectors (Macmillan et al., 2014;Cairns et al., 2005;Lowell et al., 2001). MAIM could also be used to make a stronger case for third party investment in non-acute health charities through pursuit of increased accountability, effectiveness and e ciency.
Strengthening the Sector not Just Individual Organisations MAIM and OPM's potential to contribute to strengthening the sector's overall performance and reputation is also worth consideration. Evidence sourced though this body of work suggests the non-acute health charity sector faces growing expectations from stakeholders in terms of their performance (Gomes & Romao, 2019;León & Bousquet, 2018;Sen & Vayvay, 2017;Aboramadan & Borgonovi, 2016). This is coupled with increasing competition from for-pro t and government health providers (Schmitz, 2019;Archambault, 2017). The non-acute health charity sector may be threatened if it does not respond to such contemporary challenges. The World Bank's perspective is that industry groups, not just organisations, that fail to do business without continuous re ection, learning, course correction and application of modern solutions fall behind (Janus, 2016). In this vein, other researchers have explored sector-wide bene ts resulting from OPM (Duman et al., 2018;Beheshtinia & Omidi, 2017). As such, the non-acute health charity sector as a whole may bene t, and in turn strengthen opportunity for individual organisations, by pursuing a sector-wide approach to OPM development and implementation. MAIM could be used as the sector-wide OPM implementation tool and this opportunity is referenced in the further research section discussed shortly.
Potential for Broader Application MAIM may potentially also have relevance and application for the non-pro t industry more broadly. While this study has found the importance for sector and organisational tailoring when designing and implementing organisational performance measurement , it is also acknowledged that OPM is still in its infancy and being developed within non-pro t industry (Aboramadan & Borgonovi, 2016). As such, MAIM or particular components such as the NCPI Framework could be tested within NFP sectors and organisations outside the non-acute health charity sector.

Limitations And Further Study
MAIM is the rst attempt to develop an OPM implementation model for the non-acute health charity sector. The usefulness and utility of MAIM's elements has been demonstrated in two Australian case study organisations yet the Model in its entirety has not yet been tested in a live operating environment and this should be the aim of future studies. It is likely the Model is not a panacea for all challenges associated with demonstrating accountability and success in the sector.
Expanding evaluations to include multiple organisations will enable comparative analysis of results and learnings. Longitudinal studies to assess whether the introduction of OPM into non-acute health charities impacts on organisational performance should also be a goal for future study. Finally, as noted earlier, the potential of MAIM to support a sector-wide approach to OPM and enhancing the sector's reputation is also worth consideration.

Conclusion
OPM aids organisations to achieve sustainable competitive advantage yet it is under-valued, under-utilised or under-reported in the non-acute health charity sector . This paper describes an OPM implementation model (MAIM) developed speci cally for non-acute health charities. Its aim is to encourage uptake of OPM in this sector. MAIM utilises ve distinct yet interconnecting components and is informed by Organisational Learning Theory (OLT) and Action Implementation methodology.
While further testing in live case study environments is required, non-acute health charity leaders now have a sector-tailored tool which is comprised of evidence-informed components available to support OPM implementation in their organisations. The authors anticipate this step-by-step guide will encourage greater uptake and utilisation of OPM in the non-acute health charity sector. Adopters can now measure organisational performance and position themselves as industry leaders by demonstrating a willingness to be accountable and in pursuit of sustainable competitive advantage. Funders and other stakeholders may now also seek clari cation of non-acute healthy charity performance knowing that OPM is feasible for the sector. The study obtained ethics approval from the Human Research Ethics Committee of Deakin University, Australia (approval numbers HEAG-H 197_2014 and HEAG-H 89_2017) before commencement. Consent to participate in research activities were obtained in written format through direct weblink prior to participant access.

Consent for Publication
Not applicable.

Availability of Data and Material
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Competing Interests
The authors declare that they have no competing interests.

Funding
No funding was received for this study. The research reported in this paper is the sole responsibility of the authors and re ects the independent work of the authors.

Authors' Contributions
The study was designed by RC in collaboration with RR, KS, JT and GP. RC led data collection and analysis. RR, KS, JT and GP supported data analysis. RC drafted manuscript. All authors critically reviewed the manuscript, provided signi cant editing of the article and approved the nal manuscript.
FACTOR 1: Implementation Plan 1.1 Existence of a formal organisation strategy 1.2 Development and endorsement of a formal implementation plan which utilises evidence 1.3 Translate organisational vision and strategy into tangible objectives and measures 1.4 Articulation of organisational strategy and Implementation Plan in a Strategy Map 1.5 Go beyond short-term agendas and pay attention to medium and long-term objectives 1.6 Acknowledge and plan for deployment over extended time period 1.7 Ensure model is adapted to meet unique organisational realities and demands 1.8 Confirm who is responsible for which actions and activities 1.9 Undertake a test experience to improve the balanced scorecard measures and processes FACTOR 2: Commitment 2.1 Secure full organisational support for implementation 2.2 Demonstrated and continued Executive and Senior Management support 2.3 Organisational culture is appropriate and receptive to implementation 2.4 Creation of an Implementation Steering Committee -potentially with mixed representation across staff 2.5 Appointment of an Implementation Coordinator as a sole role or within existing role FACTOR 3: Organisation Understanding & Learning 3.1 Address any conceptual barriers within the organisation 3.2 Communicate organisational strategy, purpose, the Implementation Plan and its status and ensure staff are aware OPM IS for strategic management not just performance measurement 3.3 Participation of staff in design and revisions 3.4 Facilitate periodic and systematic review, adjustment and improvement 3.5 Provide feedback to learn about and improve organisational strategy and Implementation Plan 3.6 Identify and support champions across the organisation 3.7 Skills and tools in data analysis and management, and implementing feedback and learning systems in-place 3.8 Use team-based collaborative approaches among disciplines that done regularly work together

Clarity
Desire and capability to create a compass to guide organisational decision-making and focus effort.

Adaptability
Developing an Organisational Learning culture that accepts implementation is a journey, develops a sense of trust, understands implementation will not be a perfect process and that mistakes can be valued as learning experience.

Alignment
Willingness to connect and engage all levels of the organisation through performance measurement and capability to activate common measurement tools across the organisation.

Transparent Communication
Ensuring effective and regular measurement information and dialogue is shared to all levels of the organisation throughout the implementation process.

Capability
Development of a measurement culture and personnel capability in a supportive and safe environment. This includes dedicated investment to support learning and improvement in manager and staff competency and proficiency to enable implementation and its various elements in a responsive manner.

Accountability
Encouragement for increased organisational-wide willingness to be accountable against stated organisational objectives, evidence-based practice methodology and completion of implementation processes.   Colbran et al., 2017) Quality of Service Quality of Service strengthens attention to an organisation's core service Colbran et al., 2017) and spotlights capability to delivery evidence-based care for better health outcomes for service users and patients as they are "the focus of healthcare services" (Gurd & Gao, 2008, p. 17).

Stakeholders (Customers and Clients)
Stakeholder satisfaction and engagement is important for sustainable competitive advantage (Colbran et al., 2017) and the "overall performance of charities is best measured by a set of factors that reflect the multiple and diverse stakeholders associated with charities" (Boateng et al., 2016, p. 59). Health organisations and non-profit organisations can each have seven or more stakeholder or customer group types (Colbran et al., 2017) such as patients, citizens, clinicians, government, professionals, provider organisations, purchaser organisations, and philanthropists (Smith et al., 2008). However, the diversity of stakeholders can be difficult to manage as the expectations and needs of each stakeholder group vary and not just in relation to patient outcomes (Colbran et al., 2017). Potentially organisations may consider performance indicators for each group.

People and Culture
Many studies across healthcare and non-profit industry identify people, learning, capability development, culture, staff engagement and growth as important performance measures (Colbran et al., 2017). Organisational learning and growth are generated from people not just systems (Kaplan & Norton, 1992) and subsequently People and Culture has been identified as a stand-alone domain in the MAIM Model.

Governance and Management
Measures relating to systems and procedures in governance, strategic management, management practices and risk management enable more effective service and operations (Mueller, 2007). In traditional for-profit BSC models these are often referred to as the internal processes domain, however as a result of the need to highlight the importance of contemporary business practices in non-profit sectors the MAIN Model has tilted this domain 'Governance and Management'.

Mission and Purpose
The 'Mission and Purpose' domain has been created to reinforce attention on the effective and efficient achievement of an organisation's core focus areas and ultimate objective Colbran et al., 2017;Bisbe & Barrubes, 2012). 2.3 The adequacy of resources to provide personnel with information and training to support organisational performance measurement.
2.4 The degree of staff acceptability of resources available to support organisational performance measurement.
2.5 The degree of staff usage of resources available to support organisational performance measurement.
2.6 Clarity of roles and responsibilities of different personnel in relation to organisational performance measurement.

2.7
The level of flexibility and adaptability of organisational performance in order to solve a problem or barrier.
2.8 The adequacy of information and communication channels to organisational performance measurement.
Section 3: Gervais Operational Dimension 3.1 The degree of fairness of methods, activities and processes for organisational performance measurement.
3.2 The level of flexibility and quality of the methods, activities and processes of organisational performance measurement.
3.3 The feasibility of organisational performance measurement.
3.4 The level of conformity to existing norms and standards of organisational performance measurement.
3.5 The organisational performance measurement program's usefulness to support delivery of services and programs.
3.6 The ease of organisational performance measurement. (i.e. the fluidity of its processes and mechanisms of regulation).
3.7 The adequate use of program resources for organisational performance measurement.
3.8 The level to which personnel involved with organisational performance measurement are consistently available.
3.9 The level to which personnel are empowered to take a creative and constructive approach to organisational performance measurement.
3.10 The productivity of the personnel involved with organisational performance measurement.
3.11 The level of perceived satisfaction of the personnel involved with organisational performance measurement. 4.9 The degree to which resources to embed organisational performance are established.
4.10 The level that resources, means and methods for organisational performance measurement are optimised to attain objectives.

4.11
The level of conformity to the organisation's values and program principles established for organisational performance measurement.
4.12 The level of risk management for organisational performance measurement.

4.13
The level of change management processes utilised for organisational performance measurement.
4.14 The level of knowledge management processes utilised for organisational performance measurement.
Section 5: Gervais Systemic Dimension Page 15/16 5.1 The level of ability to build up resources for organisational performance measurement.
5.2 Availability of resources and services for organisational performance measurement.
5.3 Accessibility of resources and services for organisational performance measurement.

5.4
The complementary nature of activities to support organisational performance measurement.
5.5 The level of partnership or engagement with other programs to support organisational performance measurement.
5.6 The level of partnership or engagement with other organisations to support organisational performance measurement.

5.7
The level of satisfaction with partnership and exchanges that support organisational performance measurement.
5.8 The level to which each party undertakes their role and responsibilities in supporting for organisational performance measurement.

5.9
The level of clarity in relation to organisational performance measurement and how to engage with it.
5.10 The level of collaboration between sections to ensure coordination and transfer of information.
Section 6: Gervais Specific Dimension 6.1 The degree to which objectives for organisational performance have been attained.
6.2 The quality and quantity of products or services generated from organisational performance measurement.
6.3 The degree of information generated, and use of that information to inform practice, as a result of organisational performance measurement.
6.4 The level of satisfaction expressed by personnel with implementation of organisational performance measurement.
6.5 The level of perceived value and cost-effectiveness of organisational performance measurement. Figure 1