Perceptions of Performance Measurement Systems among Clinical Managers: Implications for Waiting Time reduction

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Data may be preliminary. 24 September 2025 V1 Latest version Share on Perceptions of Performance Measurement Systems among Clinical Managers: Implications for Waiting Time reduction Authors : Maria Beatriz Gonzalez-Sanchez 0000-0001-9247-178X [email protected] , Cristina Gutiérrez-López 0000-0003-2080-6047 , and Francisco Santías 0000-0002-7928-6050 Authors Info & Affiliations https://doi.org/10.22541/au.175870637.70838113/v1 188 views 112 downloads Contents Abstract Introduction Research design 4. Discussion and conclusions References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract This paper investigates whether clinical unit managers’ perceptions of performance measurement systems (PMS) influence service outcomes, specifically patient waiting time (WT) in specialized medical care. Reducing WT is a major challenge, as delays can compromise health outcomes and impact patient satisfaction. Drawing on theories of planned behaviour and organizational commitment, we hypothesize that when managers perceive PMS tools as indispensable, they are more likely to engage with them, leading to improved unit performance. Based on survey data from 67 clinical units in public hospitals in Galicia (Spain) and official WT records, we analyse the association between PMS perception and service performance using contingency tables. The results indicate that perceiving performance measurement systems as essential by clinical unit managers is significantly associated with reduced patient waiting times The article’s innovative contributions lie in its focus on PMS at the middle-management —specifically clinical unit managers—rather than at the broader and more commonly studied health system level. Furthermore, it examines the effectiveness of PMS when used by physician-managers, rather than by general administrative leadership. Our findings underscore the importance of managerial perception in the successful implementation of PMS and provide practical implications for policymakers and hospital administrators. Specifically, they suggest that improving managerial training can enhance efficiency and patient outcomes. Perceptions of Performance Measurement Systems among Clinical Managers: Implications for Waiting Time reduction Maria Beatriz Gonzalez-Sanchez 1 ECOBAS, Universidade de Vigo, Spain 2 Biocost Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur). SERGAS-UVIGO https://orcid.org/0000-0001-9247-178X Cristina Gutiérrez-López Universidad de León, Spain https://orcid.org/0000-0003-2080-6047 Francisco Reyes-Santiás Universidade de Vigo, Spain https://orcid.org/0000-0002-7928-6050 Abstract This paper investigates whether clinical unit managers’ perceptions of performance measurement systems (PMS) influence service outcomes, specifically patient waiting time (WT) in specialized medical care. Reducing WT is a major challenge, as delays can compromise health outcomes and impact patient satisfaction. Drawing on theories of planned behaviour and organizational commitment, we hypothesize that when managers perceive PMS tools as indispensable, they are more likely to engage with them, leading to improved unit performance. Based on survey data from 67 clinical units in public hospitals in Galicia (Spain) and official WT records, we analyse the association between PMS perception and service performance using contingency tables. The results indicate that perceiving performance measurement systems as essential by clinical unit managers is significantly associated with reduced patient waiting times The article’s innovative contributions lie in its focus on PMS at the middle-management —specifically clinical unit managers—rather than at the broader and more commonly studied health system level. Furthermore, it examines the effectiveness of PMS when used by physician-managers, rather than by general administrative leadership. Our findings underscore the importance of managerial perception in the successful implementation of PMS and provide practical implications for policymakers and hospital administrators. Specifically, they suggest that improving managerial training can enhance efficiency and patient outcomes. Keywords: Clinical unit manager; Performance measurement systems; Waiting time Highlights • Positive PMS perception by clinical managers reduces patient waiting times • Strengthening managerial skills of clinical leaders enhances efficiency • Insights contribute to international debate on PMS in healthcare middle management • Findings advance understanding of PMS effectiveness in reducing waiting times Introduction After decades of rising healthcare expenditures [1], health remains a strategic priority in developed countries, representing a major budget item and a driver of related industries and employment. Hospitals -structured around medical units or services- function as central hubs for essential care, specialized treatments, and emergency services, making them a vital component of healthcare systems. Apart from the management teams, each clinical unit within a hospital is led by a manager responsible of the corresponding medical services. Although these managers are practitioners, their organizational responsibilities extend beyond their primary clinical focus. For this reason, they have a variety of tools designed for managerial purposes with alternative objectives and scopes. These tools, known as performance measurement systems (PMS), aim to influence individual behaviour and decision-making in ways that help achieve organizational goals [2–4]. However, most of these PMS come from private industrial sectors [5] mostly in Anglo‐Saxon contexts [6], and they must be adapted to the specific circumstances of their use, particularly when implemented in public healthcare settings [7]. Therefore, both profit and non-profit healthcare organizations employ PMS tools like key performance indicators, cost accounting, balanced scorecards, and reward systems at a service level. Although PMS are widely implemented in hospitals, few empirical studies have assessed their effectiveness when used by physicians. Existing research primarily focuses on CEOs, CFOs, or other administrative roles, despite evidence that the use of PMS varies depending on the professional background of hospital leadership [8]. This paper aims to fill this gap by surveying clinical unit managers about the tools they use and examining whether their perception about utility is associated with better performance in their units. To identify these tools, we conducted an in-depth literature review to compile a diverse selection for consideration by the clinical unit manager. While not exhaustive, this list includes tools that are commonly used in previous research [9–11] and presumably also used by practitioners (See Appendix I). Hospitals are large and complex organizations that often face long patient waiting times for necessary care, which increases pressure on resources, reduces patient satisfaction, and may compromise timely access to critical treatments. Consequently, managing waiting time for specialized medical care is a key challenge in healthcare. In this context, PMS can help clinical unit managers reduce patients waiting time (hereinafter, WT) by shaping individual behaviour towards organizational goals [12–15]. This paper uses the WT per medical service as a proxy for performance, assuming that the shorter WT indicates better outcomes whereas longer WT suggest poorer performance. The reasons are twofold. First, it provides a valid measure for all the services considered and enable comparison across them. Second, all services follow the same registration rules, ensuring homogeneity in data calculation. In the public health system, individuals must access services based on the priority assigned to their condition, so that patients with the same pathology and severity who have been waiting longer are attended to first [16]. In the context of healthcare services, some theoretical frameworks support the notion that when clinical managers perceive management tools as essential, the quality and effectiveness of their services tend to improve. According to the Theory of Planned Behavior [17] a widely used model of human behaviour, positive attitudes toward a given tool increase the likelihood of its consistent and effective use. When managers perceive a tool as beneficial, they are more likely to be committed to implementing organizational or managerial measures. This relationship has been supported by various studies in health-related contexts [18–20]. Similarly, organizational commitment theory emphasizes that when managers are engaged and recognize a tool’s importance, they are more likely to foster sustained improvements in care delivery [21,22]. Together, these frameworks suggest that managerial perception plays a critical role in translating management tools into improved service quality and effectiveness. The study is developed for a Spanish case, whose National Health System (NHS) is defined as a structure of 17 regional health services. Private healthcare plays a complementary role in the NHS. Servizo Galego de Saúde (hereafter SERGAS) is the Galician Regional Healthcare Service responsible for 7 public hospitals comprising 196 medical units to provide care to a total population of 2,699,499 inhabitants, 25.18% of which is over the age of 64 [23]. Thus, the contextual setting of our investigation is the medical service with in-patient activity at Galician public hospitals (Spain) throughout 2015 and 2016. The objective of this study is to examine the impact of clinical unit managers perception of PMS on WT, a widely accepted outcome measure in healthcare. Prolonged delays can negatively affect patient outcomes and quality of life, whereas shorter WTs are linked to greater satisfaction and trust. Furthermore, international organizations consider WT a standard benchmark for assessing health system performance [24]. The contribution of the paper is twofold. First, it contributes to current management accounting and healthcare literature by providing empirical evidence that the use of PMS can enhance clinical performance through the reduction of WT for patients requiring specialized medical care. Second, it offers a novel perspective by focusing on mid-level management (clinical unit manager) rather than top executives (CEOs, CFOs, etc.). The results support that PMS improve WT outcomes, benefiting both patient satisfaction and hospital performance. The remainder of the paper is structured as follows: first, we outline the research methodology and present the empirical findings. Subsequently, we discuss these results in light of the theoretical framework, and finally, we draw conclusions and reflect on their implications for research and practice. Research design Data The data sources included, on the one hand, information provided by the clinical unit manager through a survey, and on the other, data from the Galician Regional Healthcare Service (SERGAS). The data provided by SERGAS refers to the WT for the 67 clinical services that completed the questionnaire, thereby reflecting the performance of each clinical unit. Regarding the questionnaires, once the necessary contact data and the approval of the general director of the hospital had been obtained, we followed the five steps proposed by Dillman [25], starting with sending an e-mail to the clinical unit manager [26] that included a link to the web survey as well as a brief description of the study’s purpose and a guarantee of confidentiality. Although we contacted all 196 services in population, we finally received 70 fully completed valid questionnaires (see Appendix II). However, three of them were excluded due to missing data, resulting in 67 usable responses, representing a response rate of 34.18%. Although the number of responses is slightly low, the response rate is higher than those found in other accepted papers in the field [27,28]. The questionnaire consisted of 14 items addressing PMSs within each clinical unit. Responses were categorized using the Net Promoter Scores (NPS) resulting in three levels: detractors (scores from 0 to 2), passives (3 and 4) and promoters (score of 5). Only responses in the highest category were considered for analysis, since they reflect individuals who perceived the use of PMS as indispensable. In some cases, participants indicated that certain tools did not exist in their unit or left the item unanswered. This was particularly notable for five of the fourteen PMS tools— employee satisfaction measures (NO. 12), reward systems (NO. 14), and the three items related to cost accounting (NOs. 3, 4, and 5)—which showed a high rate of reported non-existence. This suggests that clinical unit managers often lack information about these specific tools. Other tools such as balance scorecard (NO2); teaching and research meetings (NO7); management agreements (NO8); key process indicators (e.g., average stage or occupancy rate, NO10) and key outcome indicators (e.g., mortality rate or infection rate, NO11) were considered essential by many respondents. Nevertheless, tools such as strategic plan (NO1); clinical sessions (NO6); key structural indicators (buildings and workers) (NO9); and benchmarking (NO13) were also considered. The percentage response per tool is shown in Table 1. Table 1. Descriptive statistics of survey responses (N=67) Detractors Passives Promoters Not available 0 Not used 1 Barely Used 2 Some Use 3 Moderate Use 4 High Use 5 Essential Use NO1 Strategic plan 21 13 6 27 18 6 9 NO2 Balanced Scorecard 6 4,5 0 9 22,5 24 34 NO3 Cost accounting: cost per service 36 19 6 15 13,5 4,5 6 NO4 Cost accounting: cost per process 33 24 16 15 9 1,5 1,5 NO5 Cost accounting: cost per patient 31 27 15 15 10,5 0 1 NO6 Clinical sessions 3 1,5 6 16,25 16,25 24 33 NO7 Teaching and research meetings 1,5 1,5 3 15 18 22 39 NO8 Management Agreements 11This tool refers to ADX, the acronym of Acordos de Xestión, and represents management agreements established between hospital general manager and the clinical unit manager. 3 6 3 4,5 12 22,5 49 NO9 Key structural indicators 16,5 9 10,5 16 13,5 22 12 NO10 Key process indicators 1,5 0 4,5 3 13,5 31,5 46 NO11 Key outcome indicators 3 1,5 4,25 4,25 15 33 39 NO12 Employee satisfaction measures 42 16 15 4,5 7,5 9 6 NO13 Benchmarking 15 9 19,5 10,5 16,5 22 7,5 NO14 Incentive and reward system 25 16,5 6 27 12 9 4,5 N/A indicates that the participant either reported that the specific tool does not exist or left the answer blank (few cases). Methodology The methodology is based on contingency tables (also known as cross-tabulations or double-entry tables) which organise categorical data into a structured format. These tables display the frequency of individuals classified into two or more discrete categories. Cross-tabulation is widely used in medical research because it is a simple yet powerful tool for analysing relationships between categorical variables, such as gender; patient outcome; complaint type; treatment received or hospital type. It reveals the distribution of individuals across combination of categories, facilitating the identification of associations and patterns [29,30]. Additionally, contingency tables are applied in binary diagnostic testing [31] and are valued for their ease of interpretation. Specifically, the rows and columns representing the variables define cells that display the frequencies of each variable combination. This structure allows for the examination of potential associations between dependent and independent variables and may suggest patterns that indicate the presence or absence of a relationship between them. Our aim is to examine how the acknowledgment of PMS by clinical unit managers influences WT. This approach enables us to explore the relationship between specific PMS tools (independent variable) and WT (dependent variable), thereby contributing to the identification of potential drivers of health care inefficiencies, specifically excessively long WT, reported as the most frequently mentioned problem in the Spanish healthcare system. The frequencies included in contingency tables have traditionally been used to describe the characteristics of the number, annual increase rate and proportion of patients´ complains [32]. In our study, frequency is used to describe the number of medical units with a short or long WT whose managers acknowledge the relevance of each PMS tool. This methodological approach is justified because the initial analysis of the relationship between WT and PMS tools in the sample of 67 Galician clinical manager who responded the questionnaire did not yield a statistically significant result (p = 0.192). The validity of this Pearson’s Chi-square test is compromised, given that 66.7% of the cells have an expected count of less than 5— a severe violation of the test’s core assumptions that may lead to unreliable results [33–35]. Since we contacted the complete population, expanding the sample is not a viable option to overcome this limitation in statistical power [36]. To address this issue and obtain a more robust estimate of the association, a sample weighting procedure was applied using tenure of the manager as the weighting variable. This statistical technique is used to correct imbalances and adjust case weights so that the sample better reflects, in this case, the accumulated level of experience within the healthcare system [37,38]. The aim is to assign weights to observations that more accurately reflect the population structure in a key variable—assuming that experience (tenure) influences the relationship between PMS and WT outcomes. After applying this weighting, the Chi-square analysis on the adjusted sample (N = 1246) reveals a significant association (p < 0.001), suggesting the existence of dependency between the variables that was masked in the unweighted analysis due to statistical limitations stemming from the small population size and the violation of test assumptions. 3. Results For the list of PMSs presented to managers, Tables 2 and 3 display the results of contingency analyses, categorized as short (<32 days) and long (≥32 days) WT. Each analysis cross-tabulates whether the clinical unit manager considers the PMS tool to be indispensable. For each tool, tables present both the observed and expected counts of services. Table 2 shows that the number of services with short WT is generally lower than expected when the manager acknowledges the specific tool. For example, for managers who consider the use of the strategic plan (NO1) to be indispensable, the number or services with short WL (4) is more than the expected value (2.8). In sum, the observed number of services when WT is shorter than 32 days -indicating good performance-, shows only 2 tools below the expected recount balance scorecard (NO2) and teaching and research meetings (NO7). For the remaining 12 tools, the observed counts exceed expectations. The results suggest that actual performance exceeds expectations for 12 out of 14 tools when the clinical unit manager considers their use indispensable. Table 2. Contingency table results for PMS tools use with short WT (<32 Days) NO1.Strategic plan 4 2.8 NO2.Balance scorecard 3 < 10.6 NO3.Cost accounting (1 st level development) 2 1.9 NO4.Cost accounting (2 nd level development) 1 0.5 NO5.Cost accounting (3 rd level development) 1 0.5 NO6.Clinical sessions 11 10.2 NO7.Teaching and research meetings 11 < 12 NO8.Management agreements 17 15.3 NO9.Key structural indicators 4 3.7 NO10.Key process indicators 16 14.3 NO 11.Key outcome indicators 14 12.5 NO 12.Employee satisfaction measures 3 1.9 NO 13.Benchmarking 3 2.3 NO 14.Incentives and rewards systems 2 1.4 Table 3 shows that the actual number of services with long WT is lower than expected when the manager considers the PMS to be fundamental. For example, when analysing the importance of the strategic plan (NO1), only two services have a long WT compared with to an expected value of 3.2. Table 3. Contingency Table Results for PMS tools use with Long WT (>32 Days) NO1.Strategic plan 2 3.2 NO2.Balance scorecard 10 12.4 NO3.Cost accounting (1 st level development) 2 2.1 NO4.Cost accounting (2 nd level development) 0 0.5 NO5.Cost accounting (3 rd level development) 0 0.5 NO6.Clinical sessions 11 11.8 NO7.Teaching and research meetings 15 > 14 NO8.Management agreements 16 17.7 NO9.Key structural indicators 4 4.3 NO10.Key process indicators 15 16.7 NO11.Key outcome indicators 13 14.5 NO12.Employee satisfaction measures 1 2.1 NO13.Benchmarking 2 2.7 NO14.Incentives and rewards systems 1 1.6 Therefore, perceiving the strategic plan (NO1) as indispensable by the clinical unit manager seems to lead to better outcomes in the provisions of healthcare services, with more cases of short WT and fewer cases of long WT. It is only for teaching and research meetings (NO7) when services do not improve their effectiveness since more than expected face a long WT. In situations where WT exceeds 32 days—indicating reduced performance—the pattern reverses. As shown in Table 2, 13 tools present observed counts lower than expected. Teaching and research meetings (NO7), however, show a slightly higher observed count than predicted, presenting a different pattern from the rest of the managerial tools considered. The findings indicate that the number of services with more than 32 days of WT is worse than expected. The results of this study generally support the idea that recognizing the importance of PMS tools enhances the effectiveness of medical services by reducing WT. Specifically, the actual number of units with short-term WT is higher than expected, while the number of units with long-term delays is lower. This pattern holds across most tools, with one notable exception: teaching and research meetings (NO7). This tool does not follow the general pattern, likely due to its medical-specific nature rather than managerial focus. It involves physicians discussing diagnoses, treatments, and clinical decision-making, as well as analysing clinical guidelines, new treatments, or case studies—activities that are inherently less aligned with managerial efficiency. Among the PMS tools, the balanced scorecard (NO2) stands out as particularly impactful. This strategic tool, which incorporates financial and non-financial data [39], aligns organizational objectives with key outcomes, making it especially suitable for medical services [39]. The findings confirm previous research highlighting its contribution to performance [41]. However, the most effective approach in this context involves combining the balanced scorecard with other tools, such as management agreements (NO8), which establish specific objectives; key performance indicators (NO9, NO10, NO11), which monitor structural, process, and outcome dimensions; and benchmarking (NO13). Together, these tools create a comprehensive framework for improving medical service performance. On the contrary, the PMS tools with a smaller impact on unit performance include employee satisfaction measures (NO12) and the rewards system (NO14). Some managers may perceive employee satisfaction measures as less effective, as low satisfaction levels often do not significantly influence managerial decisions. Similarly, the rewards system shows limited variability among public institution workers, particularly in public hospitals where respondents are on stable, risk-free career tracks and compensation is not directly tied to outcomes. This is further compounded by the public sector’s tendency to prioritize equity over individual competence, as managers may not fully recognize the utility of these PMS tools in their decision-making processes. These findings suggest a need for greater alignment between PMS tools and managerial priorities in public sector organizations. 4. Discussion and conclusions In the context of New Public Management (NPM), private sector practices were introduced into the public sector to enhance efficiency, accountability, and performance. In hospital management, NPM has promoted decentralization, managerial autonomy, and the use of PMS. These systems are applied not only at the hospital level but at the level of individual departments or clinical services, such as surgery, radiology, or emergency care. Within this framework, the clinical unit manager plays a key role, acting as the link between clinical practice and organizational objectives. Their engagement in using PMS is critical for implementing performance-based strategies, assessing outcome and motivating staff. However, to our knowledge, this perspective has been poor studied. This paper examined how clinical unit managers perceive PMS tools and how such perceptions are associated with service performance. While previous research typically acknowledges the technical effectiveness of these tools and assumes their positive impact on performance [9,6], it often overlooks a central factor: the role of the clinical unit manager in recognizing and valuing these tools. Our findings highlight the critical role of managerial awareness and acceptance in determining PMS effectiveness. Consistent with theories of planned behaviour [17] and organizational commitment [21,22], a positive managerial attitude and perceived usefulness of PMS are linked to improved service-level outcomes. Importantly, effectiveness depends not only on technical design but also on the engagement of those responsible for their use. Empirically, the results support the idea that recognizing the importance of PMS contributes reducing WT in healthcare services. Specifically, the actual number of units with short-term waiting times is higher than expected, while those with long-term delays are fewer. This pattern applies to most tools, with one notable exception: teaching and research meetings (NO7). This tool does not follow the general pattern, likely due to its medical-specific nature rather than managerial. Unlike other PMS tools, this practice is more clinically than managerially oriented, focusing on diagnostic and therapeutic discussions rather than organizational performance. The study also highlights the importance of adopting the managerial level of analysis. Prior research has generally examined PMS at the hospital or system level, often focusing on administrative executives. By contrast, this study directs attention to clinical unit managers, who operate at the interface between professional practice and organizational strategy. These physician-managers face unique challenges in balancing clinical and managerial responsibilities, and our evidence suggests that their perception of PMS can be decisive in achieving service efficiency. This contributes to a more nuanced understanding of PMS effectiveness across hierarchical levels in healthcare organizations. Another important insight is the heterogeneity across PMS tools. While strategic plan (NO1), management agreements (NO8), key process indicators (NO10), and key outcome indicators (NO14) were strongly associated with reduced WT, others, such as teaching and research meetings (NO7), did not align with performance improvements. This suggests that not all PMS tools directly contribute to service efficiency, and their value depends on the degree of alignment with performance goals such as WT reduction. This finding underscores the need for context-sensitive adaptation of PMS, especially since many originate in industrial or private-sector settings and may require tailoring to the priorities of public healthcare. This work presents a few limitations that also provide ample opportunities for future research. Firstly, future studies should expand the sample to other regional health services, enabling a more comprehensive comparison across diverse geographical contexts and healthcare systems. This could help identify whether the observed patterns are consistent or specific to the region studied. Secondly, adding different types of uses could enhance the present findings about PMS. The importance lies not only in the implementation and formal recognition of each tool by managers, but also in how it is effectively utilized, i.e., enabling vs. coercive and diagnostic vs. interactive. Finally, the interest of a comparative study between the public and private sectors is unquestionable and would shed light on how collaboration or competition between them influences efficiency, quality, and access to healthcare, particularly in mixed systems. This is particularly relevant in a country like Spain, where the establishment of agreements between public and private healthcare is a matter of public interest, as it is often understood as a step toward the privatization of the public health system. In terms of practical implications, the findings show that it is crucial for clinical unit managers to recognise the importance of PMS tools to improve service outcomes by reducing WT. Clinical managers achieve better unit outcomes when they perceive PMS as supportive of their work, which may only be possible through appropriate management training. Consequently, developing managerial competencies is essential for the effective leadership of clinical units. Ethic statement Not applicable Acknowledgements We sincerely thank the managers of Galician public hospitals for granting access to their clinical unit managers to participate in the survey. Appendix I: Survey questionnaire used in the study Demographics Age Year of Birth Gender Male/Female Tenure Year started working at SERGAS To what extent do the clinical unit manager use the following management tools ( 1: Not at all, 5: Is indispensable) … Strategic plan implemented and communicated throughout the organization … Balanced scorecard: monitoring of strategic objectives and indicators related to 1) patients, 2) processes, 3) training, and 4) financials … Cost accounting: cost per service (e.g., Cardiology) … Cost accounting: cost per process (e.g., Appendectomy) … Cost accounting: cost per patient (e.g., Mr./Ms. X’s appendicitis) … Clinical sessions … Teaching and research meetings … Management Agreements … Key structural indicators (e.g., material and human resources) … Key process indicators (e.g., waiting list, average length of stay, occupancy rate) … Key outcome indicators (e.g., discharges, mortality rate) … Employee satisfaction measures … Benchmarking: comparison of departmental results with those of other departments or institutions … Incentive and reward systems based on results achieved Appendix II: Galician Public hospitals, beds and medical services per hospital H1 Complexo Hospitalario Universitario de Santiago de Compostela - CHUS A Coruña 1,395 33 H2 Complexo Hospitalario Universitario de A Coruña - CHUAC A Coruña 1,336 34 H3 Complexo Hospitalario Universitario de Vigo - CHUVI Pontevedra 1,273 32 H4 Complexo Hospitalario Universitario de Ourense - CHUO Ourense 855 25 H5 Hospital Universitario Lucus Augusti (Lugo) - HULA Lugo 844 26 H6 Complexo Hospitalario Universitario de Pontevedra - CHUP Pontevedra 606 23 H7 Complexo Hospitalario Universitario de Ferrol - CHFERROL A Coruña 435 23 7 hospitals 4 provinces 6,744 beds 196 services References 1. 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Rev , 2009;18(1): 93-122. https://doi.org/10.1080/09638180802481698 Crossref Google Scholar Information & Authors Information Version history V1 Version 1 24 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical unit manager performance measurement systems waiting time Authors Affiliations Maria Beatriz Gonzalez-Sanchez 0000-0001-9247-178X [email protected] Universidade de Vigo View all articles by this author Cristina Gutiérrez-López 0000-0003-2080-6047 Universidad de Leon View all articles by this author Francisco Santías 0000-0002-7928-6050 Universidade de Vigo View all articles by this author Metrics & Citations Metrics Article Usage 188 views 112 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Maria Beatriz Gonzalez-Sanchez, Cristina Gutiérrez-López, Francisco Santías. Perceptions of Performance Measurement Systems among Clinical Managers: Implications for Waiting Time reduction. 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