The Balanced Scorecard: A tool to measure performance and sell yourself

Scorecard is latest in AAOHN series of Success Tools

One of the ongoing challenges for occ-health professionals has been to demonstrate the economic value of their services to upper management. In a new development unveiled recently at the American Occupational Health Conference, it appears that the Atlanta-based American Association of Occupational Health Nurses (AAOHN) has come up with a tool that not only can provide a powerful vehicle for addressing this challenge, but also can give occupational health managers a more accurate picture of how well they are meeting their goals.

In recognizing one of the growing trends in all health care-related fields — a move toward the adoption of quality tools developed in other fields, particularly manufacturing, and the application of these tools to performance improvement initiatives — AAOHN enlisted an expert team to develop just such a tool for their membership. The third in a series of what AAOHN calls Success Tools is the Balanced Scorecard.

"The Balanced Scorecard represents management by measurement — a way of looking at what your customers expect of you and how well you meet those needs," explains Vickie Kamataris, RN, a quality leader with General Electric Corporate Healthcare in South Lancaster, MA, and one of the co-developers of the tool. "You not only show where opportunities [for improvement] are and how you are progressing toward your goals, but what your value is in the organization."

Kamataris, who is a Six Sigma Black Belt and has broad experience with such scorecards at GE, continues, "Say that one organizational goal for your corporation is a healthy work force — how are you contributing to that? It’s nice to say we have an occ-med function, but what specific objectives are we headed toward — e.g., risk avoidance? This can be a very valuable communication tool to upper management."

"From my perspective, the one big deficit [occ-med professionals] have is difficulty in demonstrating their value and measuring what they do for the organization," adds E. Sharon Blaney, RN, COHN[C], COHN-S/CM, who heads her own company, International Productivity Options, in Surrey, BC, Canada, and was Kamataris’ partner in developing the Balanced Scorecard. "When they do measure, they tend to do so in terms of more medical-related factors, and not things that are more understandable by the organization. So from my perspective, it’s designed in a way that’s understandable in the work place and that links financial performance as well as people performance."

This business-oriented approach is outlined in the scorecard’s four perspectives, which include both financial and nonfinancial metrics (bases of measurement), and ensure that both customer needs and business needs are met:

  • Financial perspective: What financial objectives must we accomplish?
  • Customer perspective: What customer needs will be met?
  • Internal perspective: How well are internal processes working?
  • Learning perspective: How must our team learn and innovate?

One of the roles of AAOHN is to provide information and resources for its members from the perspective of managing the workplace, Blaney explains. "Their series of Success Tools helps occ-health nurses look at business strategies, and this is another step in that process."

The idea of developing the Balanced Scorecard got its start when Blaney was chair of AAOHN’s professional practice committee. "One of the things mentioned was the balanced scorecard, because it was being used in lot of business," she recalls.

The team drew heavily on the work of Robert S. Kaplan of the Harvard Business School. "His seminal works were published in 1996,"1 says Kamataris. "He considered balanced’ to mean covering both financial and nonfinancial metrics. For me and GE, it was more than that; it means having a combination of structure, process and outcome metrics, and leading and lagging indicators. The type of metric you choose depends on the maturity of your processes and the needs of your customers."

How, why, and when would an occ-health professional use a balanced scorecard? "We approached it from two perspectives," says Blaney. "How a nurse would manage if there was already a process, and what to do if there wasn’t a measurement process in place. For example, let’s say the company is going to be adding a new process that might cause employees to have some exposure to hazardous substances. Do you have a process already in place to address this, or do you have to put in a new process in corporate health because you know this will be occurring? If the latter, you must link it up with the direction of the organization."

In other words, says Blaney, you must relate your plan to the corporate vision and mission statements. "You go through the process of strategic development — i.e., what are the strategic imperatives of the organization? You conduct a SWOT [strengths, weaknesses, opportunities, and threats] analysis — what strengths you have, the areas you need to improve," she says. "You do an assessment of the environment of culture you are in, and then you come up with a plan that really links to the strategic plan of the organization." (All of these steps are outlined in detail in AAOHN’s copyrighted document, "Creating a Balanced Scorecard," which also includes case studies, a section on metric development, and a scorecard graphic.)

The Balanced Scorecard approach will work for an occ-health operation of any size, says Kamataris, but your approach must be adjusted accordingly.

Take for example, the development of your metrics. The SMART (specific, measurable, actionable, relevant, and timely) approach, which has been used since the 1980s, is perfectly fine for what Kamataris calls a Scope A organization, which is a single clinic or a small set of clinics that are more alike than different.

However, she notes, "When the things you are measuring get bigger and bigger, you need to think in more complex levels."

If you are looking at a very new process — i.e., giving your clinics tools to prepare for a terror incident — "You start by thinking about how you would measure your progress along a continuum," says Kamataris. "The first step is structure; do they have an emergency plan? Does it include chemical, biological, and electrical components? The next thing you’d ask is, do they have a process in place? Eventually, the third level would be outcome: Of a given number of events, how many responded to them according to the guidelines? This is the most mature, highest level of metric."

To recognize the different levels of complexity, she added metrics for Scope B (corporations with manufacturing, service, and warehouse facilities with clinics in the United States) and Scope C (a global corporation with financial, manufacturing, and service businesses including aircraft engine, power generator, and medical equipment manufacturing and service, biotech research, security systems, light bulb, appliance, plastics, and electrical equipment manufacturing, equipment leasing, and customer call centers in the Americas, Europe, India, Asia, and China) organizations. For the Scope B organizations, SMARTER metrics are recommended, which add Equitable and Rigorous to the original five. For Scope C, the SMARTEST metrics are Simple and also are Transferable in terms of language, law, culture, and environment.

Thus, says Kamataris, any occ-health operation can benefit from the Balanced Scorecard. "Abso-lutely, even if you are a one-nurse operation in a business with only one clinic," she asserts. "You take your vision, your customers, define who they are, how you contribute to those needs, and you start measuring. It either shows you how great you are doing, or recognizes where the opportunities are so you can start moving toward being great. There’s no way this would be a wasted effort for anyone."

Chances are good you won’t get ideal scorecards the first time around. "Even if you do not get perfect ones, take the best you can and continuously improve," Kamataris advises. "The scorecard is not going to be perfect the first time; in fact, it will never be finished. As customers’ needs change and evolve, your approaches will change with them."

The scorecard takes a lot of work, she concedes. "Some docs have trouble with measuring, but once they see what happens they believe in it — and once they believe in it, anything is possible."

It’s important to remember, says Blaney, to customize your approach to your organization. "If you’re doing a program on heart health and you have a fit organization with an average age of 30, where people exercise and eat properly but have really high stress levels, it might be better to deal with stress issues than with cardiovascular issues," she notes. "Make sure what you do meets the needs of the organization."

"You don’t have to use our four quadrants," adds Kamataris. "Pick whatever fits your organization and best defines the needs of your customers."

When you direct your practice to the needs of the organization, says Blaney, "Then you talk the same language."

When properly applied, Kamataris concludes, the Balanced Scorecard "can help improve customer satisfaction, lead to self-improvement, and help you sell yourself to management."


1. Kaplan RS and Norton DP. Using the balanced scorecard as a strategic management system. Harvard Business Review January/February 1996; 74:75-85.

[For more information, contact:

Vickie Kamataris, RN, Quality Leader, General Electric Corporate Healthcare, South Lancaster, MA. Telephone: (978) 368-7919. E-mail:

E. Sharon Blaney, RN, COHN[C], COHN-S/CM, International Productivity Options, Surrey, BC, Canada. Telephone: (604) 669-8188, ext. 233. E-mail:]