Gaming the System: E.R. Targets

The BBC morning news show had a story about what they call “Accident & Emergency” here in the U.K. There’s a lot of discussion, generally, in the news about improving true service quality instead of relying on targets.

One example given in the BBC story… there is a 4-hour target, where patients must be seen within four hours of arriving at A&E… and there are cases where, after 3 hours and 58 minutes, the patient is admitted to a ward. Problem solved, right? Well, except for the extra cost and risk involved in being admitted.

That’s an example of gaming the system — a fake improvement that suboptimizes one metric over the entire system.

This older BBC story, from 2006, talks about similar dynamics:

But they also said they had led to gaming, citing the four-hour A&E target which had meant extra staff were brought into casualty when performance was being measured, meaning operations elsewhere in the hospital had to be cancelled. 

Another gaming method involved patients having to wait in an ambulance outside A&E until staff were confident they could meet the target.

I’m not bashing the NHS employees… their behavior is perfectly rational behavior. Given targets, people are really creative about hitting them. That’s why we need real systemic process improvement, not more targets.

While I’m here, I’m hoping to meet John Seddon, the guru of moving away from targets and command-and-control management.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

7 Comments on "Gaming the System: E.R. Targets"

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  1. Dick Danjin says:

    John Seddon ,Vanguard. THis all goes back to Deming’s question “What is the purpose of your system ”

    Since the American Health Care System is still through Medical errors killing at least 240,000 patients a year .The facts tell us what it;s do no harm purpose is. Happy New Year.

  2. Dick Danjin says:

    WE have identified the enemy ,and the enemy is us !.

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