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
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. […] In circumstances like that, being pressured by distant leaders to hit an unrealistic target… I would GUARANTEE that there would be some level of cheating. And, more than 40 VA sites are under investigation by the Inspector General. This is systemic. It’s too simplistic to label people as “bad” and to then fire them. “Gaming the numbers” is very predictable human behavior (and it happens in other countries’ healthcare systems too). […]

  2. 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.


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