Finding a Balance
Using Leading Health Metrics
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Traditionally, occupational and environmental health and safety professionals collect data on conditions relevant to health and safety only after a problem has been identified, sometimes after it has been occurring for a long time. For example, they might measure injury or illness rates or disease risk or prevalence in their client or employer’s workplace. These lagging metrics, also referred to as retrospective indicators, are a commonly used tool to identify health concerns and hazards and control exposures and risks. Unfortunately, by the time a risk or exposure has been detected using lagging indicators, worker health has already been negatively affected. Moreover, due to the time interval between exposure and the appearance of illness or injury, relying on lagging metrics may provide an incomplete assessment: the absence of documented illness or disease does not mean that no hazardous exposures are occurring in the work environment.
An alternative approach involves the use of leading metrics, also called leading indicators, to better predict and influence lagging health metrics or outcomes. Leading metrics measure exposures, risks, factors, programs, actions, or controls that exist in the work environment before worker health is negatively impacted. They can address acute or chronic health conditions and positive in addition to negative outcomes—such as the percentage reduction in employee air quality complaints. Examples of leading metrics can include the percentage of identified risks that have been controlled or the percentage of employee health screenings that have been performed. The commonality is that these measurements are taken before the occurrence of illness or injury. Leading metrics are indirect indicators of a potential problem, not the health effects that result from the problem.
Nor does this approach require lagging metrics to be discarded. The Best Practices Guide for Leading Health Metrics in Occupational Health and Safety Programs, published in 2020 by AIHA and the Center for Safety and Health Sustainability (CSHS), advises OEHS professionals on how multiple leading health metrics can be combined in a balanced set with at least one lagging metric to support a productive, proactive approach to occupational health. Balanced sets of metrics that measure occupational health data can be used not only to predict and prevent unwanted outcomes and comply with regulations but also to improve the effectiveness of organizational health and safety programs.
APPLYING BUSINESS CONCEPTS IN OEHS Paul Esposito, CIH, CSP, a member of the AIHA/CSHS task force that produced the 2020 guidance document, has been interested in better health and safety metrics since the 1980s. As the head of a consulting firm, he learned the value of using metrics in business to measure the performance of employees and organizational departments. As a consulting industrial hygienist to Fortune 500 companies, he was exposed to Six Sigma, a set of statistical analytical techniques and tools that aim to improve quality in manufacturing and business processes. Esposito observed the way that methods of statistical analysis could be used to improve business performance and began to consider how the concepts could be applied to OEHS.
Alan Leibowitz, CIH, CSP, FAIHA, has also been involved with efforts to develop health and safety metrics for many years. By 2018, he had become bothered that the existing guidance for using metrics in the OEHS field had not been updated in acknowledgement of recent advances in technology, data collection, and methodologies, including the advent of Big Data and the use of biometrics sensors in the OEHS field.
OEHS professionals “hadn’t looked to see what options and what new information had been put out there and whether some of the more current approaches to scientific investigation might be applied to leading metrics,” Leibowitz said, and added that he had found it surprising that leading metrics did not seem to have been discussed for many years. He approached the AIHA Board of Directors on the need to revise AIHA’s literature on metrics and subsequently chaired the task force, established by the Board, that created the Best Practices Guide.
Before and during the document’s development, both Leibowitz and Esposito were concerned by the lack of what they referred to as a “silver bullet” in leading health metrics: the failure for any single metric to meaningfully convey the state of worker health and safety in all organizations. In other words, there is no “one-size-fits-all” metric. Instead, Leibowitz said that the task force identified many approaches to using leading metrics in the OEHS field and incorporated some new information, including a new application of the balanced scorecard concept specific to health and safety.
Originally used in business strategy, the balanced scorecard uses a specific set of four metric quadrants to provide a concise but comprehensive view of an organization’s performance. Applied to occupational health, the balanced scorecard concept was simplified to a balanced set of leading and lagging health metrics. The balanced set comprises several leading metrics that have meaningful relationships with each other, along with a single lagging metric, which measures an employee health impact that the organization intends to avoid or even a positive health effect that the organization actually encourages. The addition of the balanced set approach is one of the most significant differences between the updated guidance document and previous literature on leading metrics.
Esposito compared the balanced set approach to the way that businesses collect data from different areas of their operations to measure their success toward various goals. “You don’t run a business by just looking at how much you spend on overtime or how much you spend on [merchandise], how much your stock is worth, or what your inventory backlog is,” said Esposito. “You look at many different factors. There is no one metric that tells you how your business is doing, so why would you try to put safety and health people in a box and tell us to do that?”
The balanced set comprises several leading metrics that have meaningful relationships with each other, along with a single lagging metric.
DESIGNING A BALANCED SET OF METRICS When running a business, you establish targets and then collect data to ensure you are on track to achieve these targets. Using the balanced set of metrics, employee safety and health programs can be conducted in a similar way. According to Esposito, the intent of the task force that created the 2020 guidance document was to “get health and safety to be an integral part of the business,” and, as with running a business, for OEHS professionals to know and measure what their strategies are, what their targets are, and how to achieve them.
Employee health outcomes, such as avoiding illness or injury, can be thought of as analogous to business targets. In the process of achieving these outcomes, OEHS professionals can collect data on hazards, exposures, actions, and conditions of work to determine whether their organization is able to meet its safety and health targets. “You need to know how to establish reasonable targets and then keep track of whether or not they’re being achieved,” Esposito said. “As with any business, we cannot wait for an illness or injury to occur and then start to manage our program. So, if you don’t have good leading metrics, indicators, objectives, and targets, you’re really not going to be able to manage anything. You’ll have a bunch of programs, but you won’t know if they’re actually serving an effective purpose.”
The ability to measure the effectiveness of health and safety interventions is a strength of the balanced set approach, particularly its inclusion of a lagging metric—that is, a particular health outcome of interest. “If you don’t balance a set of leading metrics with a lagging metric,” said Esposito, “you won’t be able to influence or measure the effectiveness of any of your strategies or programs.”
Stephen Hemperly, CIH, CSP, CLSO, FAIHA, another member of the guidance document task force, recommended developing a balanced set of metrics by “working backwards” from the identified health outcome. “And based upon that,” said Hemperly, “what evaluation and control measures might I put in place to minimize the potential that adverse health outcome will occur?”
In his own career, Hemperly has drawn on his decades of OEHS experience to identify possible health metrics to use in facilities operated by organizations he works for. “Based upon the industry in which that facility is operating—what kind of products that they are trying to put out or what kind of service they’re trying to provide,” he said, “there are going to be some recognized exposures, the potential for having excessive exposure to various chemical, physical, and perhaps ergonomic agents.” From that basis, Hemperly encouraged OEHS professionals to evaluate the extent to which these exposures would result in employees experiencing the health outcome in question and follow the hierarchy of controls to reduce the likelihood of worker health being affected.
The Best Practices Guide also suggests the following questions for consideration: what information is available with respect to the risk, controls, and health outcome? Can the health outcome be influenced or predicted? How is the exposure or prevalence of illness best influenced? What is the population exposed or overexposed? Are there unknowns that need to be further evaluated? What other data is needed? For what purposes will the data be used, and who will have access to it? What are the costs of acquiring the metrics?
In many cases, various parts of an organization are already collecting data that OEHS professionals can use to create leading metrics. The ways that organizations evaluate their success as a business may reveal information about worker health. “Every organization has some way of measuring the performance of their operations,” said Leibowitz. “What are the things that you look for in business metrics, and how can you make the things you’re measuring for health and safety look like those metrics? And are there things that are being collected by other parts of the organization that you could use in your health and safety metrics? Things like attendance [records] and things that you might get out of medical claims are quite often very useful for health metrics.”
Often, however, new metrics and collective mechanisms will have to be created to provide enough data to make an analysis. Leibowitz stressed that good metrics are measurable; meaningful, in that they can be acted upon; transparent, in that they can be communicated to both internal and external audiences; and standardized so they can be compared to metrics collected by other organizations.
The metrics in a set must also be meaningfully related to each other. Leibowitz, Esposito, and Hemperly all described this as one of the most significant challenges with designing a set of leading metrics, and Leibowitz further pointed out that correlation does not mean causation. Because almost every health outcome is influenced by multiple factors, many interrelated variables may contribute over time to its appearance. Ensuring a meaningful relationship between metrics depends on the specific metrics in question, and is beyond the scope of this article, but AIHA’s guidance document provides a suggested starting point. The guidance document also further discusses the needs and uses of leading metrics, provides many examples of leading health metrics, and includes a list of resources created by other organizations.
“The more leading metrics you have that are related,” said Esposito, “a check-and-balance system is almost built in. Because if one number doesn’t react the way it’s projected to react by your other numbers, that says you have a problem.”
PROACTIVE APPLICATIONS OF THE BALANCED SET OF METRICS Many chronic illnesses and health outcomes develop slowly over time: for example, hearing loss and injuries from repetitive trauma. Exposures to various chemical and physical agents often result in health outcomes that do not surface for years. However, applying the balanced set approach can help OEHS professionals prevent illnesses and injuries before they arise by collecting data that enables good organizational housekeeping and effective health and safety controls. According to Leibowitz, measurements within a balanced set of metrics provide OEHS professionals with the tools or the information to make proactive decisions. “They at least guide you to things that might make a difference in protecting employees,” he said.
Hemperly offered an example from his own career of a facility in California where air quality was often affected by wildfires. To prevent negative health outcomes caused by poor air quality in the facility, Hemperly had to maintain the heating, ventilation, and air conditioning system. The leading metrics he used toward this goal included sampling for airborne particulate matter, measuring indoor carbon dioxide levels to evaluate building ventilation, and installing air filters with appropriate MERV ratings. “We’re developing these programs to try and address, hopefully proactively—although there are reactive programs as well—these various stressors that can result in adverse health outcomes,” Hemperly said, describing the maintenance of the HVAC system as well as his organization’s other protective programs, which also controlled noise, ergonomic injury, and nonionizing radiation hazards. Although the health impacts of these programs may not become clear for years, Hemperly can ensure that his organizations are on the right track.
It may even become possible to implement programs that actually improve worker health and maintain them using the balanced set framework. Just as the health outcome may be a negative impact that the organization wishes to avoid, the OEHS professional may also choose to focus on a positive outcome—Hemperly cited the example of smoking cessation—and formulate programs that encourage it. “You build these programs, and they may be initially a reaction to an adverse outcome,” he said, “but they’re really directed toward trying to make sure that we’re taking proactive measures to make sure we don’t have problems in the first place.”
This approach elevates OEHS beyond preventing illness and injury and complying to regulations, and it supports OEHS professionals in taking protective roles in worker health. Total Worker Health, the holistic framework developed by NIOSH to account for the variety of factors influencing worker health and the role OEHS professionals can play in sending employees home in better health than they came to work, relies on use of the balanced set of metrics. Furthermore, as the COVID-19 pandemic continues and the role organizations can play in promoting health becomes clearer, it is incumbent on them to develop effective worker health programs, supported by better health metrics.
ABBY ROBERTS is editorial assistant for The Synergist.
The Synergist thanks Alan Leibowitz, Paul Esposito, and Stephen Hemperly for their input during the writing of this article.
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AIHA: Best Practices Guide for Leading Health Metrics in Occupational Health and Safety Programs (PDF, 2020).
The Campbell Institute: An Implementation Guide to Leading Indicators (PDF, 2019).
OSHA: “Using Leading Indicators to Improve Health and Safety Outcomes” (2019).