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Gaming the System: E.R. Targets

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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. 

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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 is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. 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 book is an anthology 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
  1. […] lead to cutting corners, much as British hospitals cut corners and gaming the system to hit 4-hour A&E targets and 8-minute ambulance targets. Targets and fear-based management will lead to errors… but […]

  2. […] 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). […]

  3. […] also having a METHOD for improvement can lead to all sorts of problems. See the examples of the NHS emergency departments and the VA waiting time scandals for examples of people “fudging the numbers” or […]

  4. […] leaders might think they are “holding people accountable.” Look at situations like the 4-hour A&E waiting targets in the British NHS. People get blamed and punished, so they end up gaming the numbers and distorting the system (by […]

  5. 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.

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