They note that while measurement of performance in the healthcare sector is essential for transparency and accountability, and to support improvement, performance measurement can have a range of unintended adverse consequences:
Tunnel vision: Focusing on aspects of clinical performance that are measured and neglecting unmeasured areas;
Adverse selection/inequity: Avoiding the most severely ill patients or excluding disadvantaged groups;
Bullying: Intimidating staff to achieve performance targets or to adjust data;
Erosion: Diminution of intrinsic professional motivation as a key driver of high quality healthcare;
Ceiling effect: Removing incentives for further improvement and potentially influencing top performers to reduce quality;
Gaming: Distorting the process of care in order to meet targets or manipulating data to misrepresent actual performance;
Distraction: Challenging, obfuscating or denying data which suggests underperformance instead of fixing performance problems.
They suggest countermeasures to help avoid these adverse consequences:
- Make data quality as important as hitting targets – By initiating a long term audit programme to tackle misreporting and incomplete or inaccurate data recording.
- Measure the context not just the indicator – Keeping performance measures under constant review, perhaps by multi-disciplinary specialist groups, including Royal Colleges and patient organisations.
- Avoid thresholds and consider the potential to incentivise ‘gaming’ in the design of metrics – Performance measures should be assessed according to the likelihood they will encourage abuse. Thresholds should be avoided wherever possible.
- Be more open – Making data underlying performance management widely available and promoting ongoing assessment of the degree to which metrics are being gamed.
- Apply measures fairly – In order to recognise legitimate mitigating factors such as resources and pressures outside the control of the organisation.