CONTEXT: Strategy development and implementation in acute care settings is often restricted by competing challenges, the pace of policy reform and the existence of parallel hierarchies. OBJECTIVE: To describe a generic approach to strategy development, illustrate the use of the Balanced Scorecard as a tool to facilitate strategy implementation and demonstrate how to break down strategic goals into measurable elements. DESIGN: Multi-method approach using three different conceptual models: Health Promoting Hospitals Standards and Strategies, the European Foundation for Quality Management (EFQM) Model and the Balanced Scorecard. A bundle of qualitative and quantitative methods were used including in-depth interviews, standardized organization-wide surveys on organizational values, staff satisfaction and patient experience. SETTING: Three acute care hospitals in four different locations belonging to a German holding group. PARTICIPANTS: Chief executive officer, senior medical officers, working group leaders and hospital staff. INTERVENTION(S): Development and implementation of the Balanced Scorecard. MAIN OUTCOME MEASURE(S): Twenty strategic objectives with corresponding Balanced Scorecard measures. RESULTS: A stepped approach from strategy development to implementation is presented to identify key themes for strategy development, drafting a strategy map and developing strategic objectives and measures. CONCLUSIONS: The Balanced Scorecard, in combination with the EFQM model, is a useful tool to guide strategy development and implementation in health care organizations. As for other quality improvement and management tools not specifically developed for health care organizations, some adaptations are required to improve acceptability among professionals. The step-wise approach of strategy development and implementation presented here may support similar processes in comparable organizations.