I'm here in the UK for work, and the BBC morning news show had a story about what they call “Accident & Emergency” here in the UK. There's a lot of discussion, generally, in the news about improving true service quality instead of relying on targets.
The BBC reported years ago on the challenges the National Health Service (NHS) faced with emergency department (“A&E” in the U.K.) targets. On the surface, the four-hour requirement–that patients be seen within four hours of arrival–looked like a success.
Before the target, about 23% of patients waited longer than four hours. Within two years, that number dropped to just 5%. A clear improvement, right?
Not exactly.
The Problem: Gaming Instead of Improving
To meet the target, hospitals found creative ways to “comply” without necessarily helping patients. For example:
- Patients were admitted to a ward at the 3-hour-58-minute mark–whether or not admission was appropriate.
- Ambulances sometimes idled outside A&E so patients technically hadn't “arrived” until staff were ready to receive them.
- Extra staff were pulled into the emergency department during reporting periods, while surgeries elsewhere in the hospital were canceled.
These moves hit the target but created other risks, costs, and delays. In short: a system optimized for the metric, not the mission.
Rational Behavior, Broken System
I don't blame frontline staff for this. Their behavior was rational. When leaders impose arbitrary targets, people will do what's necessary to avoid punishment. It's predictable human behavior.
The real problem is the system. As Deming reminded us, “A bad system will beat a good person every time.”
What Leaders Should Ask
The BBC story–and follow-up research from the London School of Economics–make an important point: targets can bring some benefit, but we have to ask if the benefits outweigh the costs. And if we see gaming, how do we redesign performance systems to discourage it?
That's a lesson for healthcare, but it applies in any industry. From sales quotas to customer-satisfaction scores, we've all seen examples where pressure to “hit the number” leads to distorted behaviors.
The Better Alternative
Instead of piling on more targets, leaders should:
- Focus on improving the underlying processes.
- Involve people at the front lines in diagnosing problems and testing solutions.
- Reduce fear and blame, so people don't feel forced to game the system.
- Measure progress by real outcomes for patients and customers, not just activity metrics.
Closing Thought
Metrics matter. But when hitting the target becomes more important than helping the patient (or customer), we've lost the plot. Real improvement requires redesigning systems, not just tightening the screws on people.
What metrics in your organization risk being “gamed”? And what would it take to shift from chasing numbers to improving systems?
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[…] 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 […]
[…] 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). […]
[…] 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 […]
[…] 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 […]
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.
WE have identified the enemy ,and the enemy is us !.
[…] Gaming the System: E.R. Targets […]
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