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Measuring quality: how to empower staff to take control

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The balanced score card can be used to involve nurses in developing and acting on quality indicators; it also shows at a glance how well standards are being met


In this article…

  • What a balanced scorecard is and how it works
  • Why using balanced scorecards can improve the quality of patient care
  • How to develop a balanced scorecard system
  • Why staff should be involved in developing indicators



Lisa Grant is deputy director of nursing and governance, The Walton Centre Foundation Trust, Fazakerley, Liverpool; Tony Proctor is professor, Chester Business School, University of Chester.


Grant L, Proctor T (2011) Measuring quality: how to empower staff to take control. Nursing Times; 107: 7, early on-line publication

A vast amount of information relating to standards of patient care is collated from hospital wards, yet there is not always evidence that this information is discussed or acted upon by ward staff.

Involving ward staff in setting up systems to monitor performance and deciding how to address shortcomings uses their insights into care provision and gives them ownership over standards of care.

The balanced scorecard is an effective tool for monitoring quality that can be applied to healthcare. This article discusses how to use it to develop and implement system of measuring the quality of nursing care. 

Keywords: Quality, Balanced scorecard, Metrics

  • This article has been double-blind peer reviewed


5 key points

Performance monitoring is essential to ensure patients receive a high-quality service

Indicators must have an impact on the delivery of patient care

If performance monitoring is to be effective staff need to feel actively involved

The balanced scorecard assists in measuring performance and helps to identify shortcomings

The system allows staff to see easily where improvements are needed


Quality is the focus of much activity in the NHS. In the pursuit of providing excellent service quality, the NHS next stage review, undertaken by Lord Darzi, set the basis for a health service that would empower staff and give patients choice. One of the aims of the review was to ensure healthcare would be personalised and fair (Department of Health, 2008).  In an interim report, Darzi described the development of a quality framework supported by metrics - ways of measuring outcomes of care - that would be collated from a range of staff groups (DH, 2007).

The standards now in place focus on patient outcomes, and make the provision of high quality services a priority for the NHS. These standards describe the level of quality that healthcare providers are expected to meet in terms of safety, clinical and cost effectiveness, governance, care that meets individual patient need, joined up care and quality of care (Care Quality Commission, 2010). Failure to achieve these standards can result in financial penalty, loss of reputation and ultimately closure. It is therefore vital that the quality of care delivered is regularly benchmarked, monitored and improved to reassure both patients and providers that care meets the highest standards.

Griffiths et al (2008) suggested it was important to identify metrics that would have an impact on the delivery of patient care.  Since the idea of quality in healthcare is multifaceted, there are many opinions on what actually constitutes quality. In particular, these opinions concern:

  • What quality means to patients and their families;
  • How it should be evaluated by doctors;
  • What role it plays in patients’ overall satisfaction;
  • How it should be addressed by healthcare managers (Chilgren, 2008).

Many academics have argued about the nature of quality in healthcare.  Descriptions of quality of care vary depending on the perspective and role of the observer, who may be a patient, a clinician, a purchaser, or a manager. Descriptions also depend on the clinical setting, patients’ expectations, and the severity of illness. Struder (2003) argued that excellence is determined by patients’ perceptions that they should receive extraordinary service and quality. However, Heinemann (1996) suggested that as well as patient satisfaction, specific indicators should be measured to give an insight into how care is being delivered, such as patient falls, medication errors and infection rates. These metrics also need to be presented in a meaningful way to identify areas for improvement.

Metric indicators enable us to understand how procedures are progressing and how they can be improved.  They can provide a way of making care providers accountable for the quality of their services. Accountability for nursing quality exists at many levels, starting from the point of care, for example where individual nurses are accountable to clinical managers and patients.

To ensure patients receive a high quality service we need a system of target setting and performance monitoring of nursing care.

An existing problem

A great deal of data and information on the quality of patient care is regularly collected in hospital wards. However, it is not always clear whether staff have been given the opportunity to discuss this information or taken action where necessary in response to any problems or shortcomings it identifies. This suggests nursing staff at ward level do not fully accept the need to monitor and improve the quality of nursing care provided. However, it may indicate that nurses do not feel a sense of ownership of the information collected.

One way to approach this problem is to use a planning system called the balanced scorecard as a performance tool to monitor care (Kaplan and Norton, 1992). This offers a way of displaying nursing indicators in a way that makes it easy to see quickly any indicators where agreed standards are not being met (Box 1).

Box 1. What is the balanced scorecard?

The balanced scorecard is a tool is used extensively in business and industry, government, and non-profit organisations worldwide to monitor organisation performance.   It provides a framework that not only assists in measuring performance, but helps planners identify what should be done and measured and enables people to put their plans into action. The balanced scorecard suggests we view organisations from four perspectives, and develop metrics, collect data and analyse them relative to each of these:

  • The learning and growth perspective:

This includes the provision of employee training, along with the use of mentors and tutors within the organisation. It also focuses on the ease of communication among workers that enables them to get help with a problem when it is needed.

  • The business process perspective:

This refers to internal processes. Metrics used here give managers information on how well their unit is running, and whether its products and services conform to customer requirements.

  • The customer perspective:

This involves developing metrics for measuring and evaluating customer satisfaction.

  • The financial perspective:

Metrics need to be established to monitor income and expenditure streams or efficiency.

In practice, the headings chosen will vary with the nature of the organisation and the precise task the scorecard is implemented to perform. However, in principle these four perspectives usually appear in one form or another as components of the factors being assessed in the scorecard.

Effective use of the balanced score card involves setting targets and tolerances to measure performance regularly, and requiring staff to develop action plans to address unsatisfactory work. However, the tool also enables staff to recognise positive outcomes. Further evidence in the form of ward meetings can then be instigated to show how nursing staff are engaged with, and encouraged to be part of the action setting and improvement process.  Such performance measurements also help to show how nurses are driving and highlighting their improvement priorities. Fig 1. is an example of a balanced scorecard designed to monitor the quality of nursing care on a hospital ward.

Developing a monitoring system

To develop an effective monitoring system it is essential to ask nurses what metrics they believe would be meaningful when examining ward and nursing performance. These views can be collected via a questionnaire. In order to gain a real insight into nurses’ opinions of what indicates the quality of patient care it is advisable not to refer on the questionnaire to any data already collected.

Questionnaires can be structured around the three sub-headings set out in The NHS Next Stage Review (Darzi, 2008) and by the NHS Information Centre, namely: safe, effective and personal care. Nurses should be asked to list under each of these headings three nursing indicators they think are important, and which can be audited regularly to show the quality of care patients receive. This information may then be used in conjunction with the routine data collected and collated to enable the desired nursing metrics to be identified. 

The next stage is to construct a balanced scorecard using the chosen metrics; the scorecard is usually completed every month, presenting the previous two months of data. Monthly meetings can then be used as an opportunity for staff to discuss the information provided by the balanced scorecard, encouraging them to share ideas while reflecting on individual learning experiences and needs. These meetings can also be used to develop action plans to address any shortcomings identified.

Use of nursing indicators in the balanced scorecard

It is important that the public, managers and nurses recognise that each indicator chosen for the balanced scorecard is important and an indicator of nursing care (Lee, 2007). The indicators must be scientifically sound, useable and feasible, and to ensure meaningful indicators are chosen they must be measurable with available data at a reasonable cost. There must also be evidence that the quality or quantity of nursing substantially contributes to changes measured by the indicator. Measures should be chosen that minimise the risk that improved performance on specific indicators gives a false impression of an overall improvement. For example, measures focusing on the performance of care process, rather than on outcomes are most vulnerable to creating such a false impression (Griffiths et al, 2008).

Balanced scorecard action plans

The scorecard in Fig 1. has five headings:

  • Efficiency;
  • Patient safety;
  • Excellence in care metrics;
  • Delivering same-sex accommodation (DSSA) compliance;
  • Patient experience.

Under each heading a number of indicators are used to reflect aspects of nursing performance.  For example, under “patient experience” the percentage of patients reporting excellent, good/fair, poor and not applicable are recorded in columns 5 and 6 for the current and previous month.  Additional columns can be added to display data from earlier months if required.

The number of complaints about care, staff attitudes and the percentage of clinical incidents reported within 48 hours are recorded in a similar way. “Need for action” levels for all performance criteria are shown in columns 2, 3 and 4 under the “tolerances” heading.

The tolerances columns are colour-coded:

  • Green Acceptable/no specific action required;
  • Amber Take note, consider what action to take if necessary and proceed with caution;
  • Red Stop and consider action required immediately.

This colour coding reflects whether or not the situation is acceptable and the urgency with which any corrective action should be taken. Monthly statistics shown in columns 5 and 6 are coloured to match the relevant tolerance column. For example, the ward in Fig 1 received one complaint about staff attitude in the current month (column 5); this equated with the “tolerance” set in column 3 (amber), so the entry in column 5 is also coloured amber.

Entries for all the data in the scorecard are made using this approach. The colour coding helps staff to rapidly identify potential problem areas and to monitor trends at a glance.

Under the heading “efficiency” the balanced scorecard shows that in the current and previous month the ward was over-spending on staff pay, but under-spending on bank and agency use. This indicates a need for a review to ensure that safe staffing levels are maintained across the ward.

Results can be observed with respect to patient safety. In this particular case the number of patient falls may be unusually high because the ward helps to rehabilitate patients with head injuries, and it is useful to add such explanations to scorecards when reporting the results to senior management. However, the reasons for the falls should still be investigated since they were above the target levels set for both the current and previous month.

For the current month, there is an overall improvement across all the indicators relating to “excellence in care metrics”.  These are the risk assessments completed on admission, which were highlighted as under-performing in the previous month. Future action plans set by the ward to maintain this improvement include ward audits to ensure that risk assessments are completed in a timely manner.


The data collated under the headings of “effectiveness” and “patient experience” should mainly relate to national and internal targets. The data needs to be relevant to patients, clinician, purchaser or manager and the nurses (Klint and Long, 1989). This involves using indicators that monitor waiting times for appointments and surgery, which are important aspects of the overall patient experience. They should also include patients’ overall length of stay, which it is hoped will remain low to indicate that treatment and care was delivered in a timely and effective way.

Both Struder (2003) and Heinemann et al (1996) believed that excellence in relation to quality could be viewed from patients’ own experiences. However, Heinemann also suggested it was important to establish and monitor specific indicators alongside the patients experiences to improve quality of care. Such differences of opinion can reflect different professional perspectives within the NHS. A profession’s targets and aims relating to these professional perspectives can affect the way quality indicators are defined. For example, financial targets are important considerations when trying to ensure hospital trusts run effectively within the resources available to them. However, while nurses appreciate this is an important part of the provision of a quality service, they also consider other indicators relating to nursing performance to be an essential way of monitoring the quality of care delivery.

Indicators provide a means by which care providers can be made accountable for the quality of nursing services (Griffiths et al, 2008). However, there is an argumentthat nursing outcome indicators may not always be valid, and that reliable outcome measures can be difficult to identify within general healthcare (Marek, 1989). The balanced score card has been criticised for being used as a means to monitor performance. Wickes et al (2007) and Norrekilt (2003) considered it to be a top-down means of performance management founded on control-based management.  Chang (2007) argued that it has little impact on improving performance valued by local managers in the NHS.

However, the Department of Health (2009) recognised the use of the balanced scorecard as a quality control system that provides a framework for business planning, measuring organisational performance and local target setting. It also recognised that apart from financial monitoring, the balanced scorecard can also assist in monitoring customer satisfaction. In addition, the arguments that have been made against the balanced scorecard have not been reflected in our own experience of applying it to monitoring quality of care in an NHS ward environment. The tool has proved a useful mechanism for drawing attention to trends reflecting both good practice and also undesirable ones which merit urgent attention. This has in turn enabled staff to take appropriate action to maintain a high standard of care quality.

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