Before I get into a rant along the lines of "you couldn't make this up", I want to firmly nail my colours to the mask.
I am a big believer in performance measures, key performance indicators (KPI) and performance targets.
Poor communication is at the heart of much bad management practice and key performance indicators very effectively say "this is important, pay attention to it."
Unfortunately ill conceived performance indicators encourage the wrong behaviour and can be "gamed" (deliberately manipulated) to make the person or department appear to have much better performance than is true.
You Couldn't Make This Up
In the UK we have a government obsessed with targets and key performance indicators (good) which appear to have been designed on a fragmented basis without checking for consistency with the overall goals on the systems and processes.
Accident & Emergency (A&E) departments in National Health Service (NHS) have been set a target:
All arrivals must be seen within four hours of being brought in.
It sounds reasonable on the surface. Anyone who has waited in an A&E department knows that they are not the most pleasant environments and you only go there if you have a problem.
Unfortunately basic queueing theory says that new arrivals will appear on a random basis - a bit like readers of my blog - no one for several hours and then a rush of 20 people in 10 minutes.
Add to that the Accident & Emergency department has another issue to consider.
Not all patient's needs are equal
Some people have trivial injuries while other patients appear in imminent life or death situations. No surprise because the varying needs are built into the name of the department - accidents and emergencies.
So why have a measure which doesn't differentiate on need?
Just as in battle hospitals, Accident & Emergency doctors have to operate a triage system. The important thing is to establish need and then treat based on that need.
Incidentally did you notice that the key performance measure says "seen" and not "treated" or discharged either to another hospital ward or back home.
The Carrot & The Stick
If you have performance measures, then what better way motivate action than to reward good performance and to punish the weakest.
You can see the logic but it may not be FAIR or APPROPRIATE.
Fairness is based on whether the performance is under the control of the person being assessed.
The NHS hospitals face punishments including restrictions on funding if they miss targets. That's right a bad hospital receives less cash when it is already struggling in terms of effectiveness and efficiency.
How does that work for the people in the local catchment area who pay their taxes and depend on that NHS hospital. Bad hospitals will become worse and that is not appropriate for the community.
Thanks to a poorly conceived KPI, the system has to be gamed.
The Unintended Consequence
So what would you do if you know that your target is based on the time lapse from admission to being seen.
Well you could try to speed up when doctors see patients (the intended result) but that depends on the priority of demands, the capacity of the department and the ability to flex that capacity with need.
Or you could delay admissions into the A&E department. That would keep performance within the target wouldn't it?
It is what is happening.
Seriously ill patients are being left in car parks and ambulances for hours to make sure the Government targets are met.
Let me think about this.
If there is a patient held waiting in an ambulance, doesn't that mean the ambulance can't be sent out to deal with other accidents and emergencies? So empty ambulances have to cover a larger territory and that means delays arriving on the scene to treat the need and give people the first medical response.
Official annual statistics show that 7 out of 11 of England's mainland ambulance trusts suffered long delays in turnaround time at A&E units.
There were more than 44,000 delays in handovers reported. This is the time taken between taking a patient to an A&E unit and being ready for the next 999 call. In London 322 delays were for more than two hours.
What About Your Key Performance Indicators
I believe you must have key performance indicators cascaded down from your business strategy into targets for individuals and departments so I am not calling for you to scrap your KPIs.
But have you checked that they are appropriate and encourage the behaviour and actions you want or can they be gamed?
Can individuals play the system so they look good while causing problems elsewhere?