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Waiting Time Targets Make Waiting Times Worse

Why Waiting Time Targets Make Waiting Times Worse

Targets are meaningless. Targets distort systems.

This month, Wellington Hospital began instituting a six-hour maximum wait in emergency. Patients waiting for beds are transferred to "transit lounges" in the wards. That hasn't solved the problem, it has simply moved the problem elsewhere.

The Emergency Departments of our hospitals are part of a larger health system, at first glimpse, the hospital itself

The current, ill-advised, introduction of the Toyota Production System to improve hospital performance is an attempt to fix these performance issues at the hospital level. But applying a manufacturing model and monitoring tools to patient care effectively turns a hospital into a factory. It will result in doing the wrong thing righter. It cannot begin to approach doing the right thing.

Waiting times may drop, but there is no guarantee - see the UK's NHS for myriad examples of the detrimental effects targets have on patient care. Hospital stay times may shorten but does this mean better care? Patient care may improve, but it will be an unintended consequence rather than a direct result of better performance. Why?

Managers are measuring the wrong thing

The true nature of the problem, of which ED waiting times are merely a symptom, is the relationship between primary and secondary healthcare. A national healthcare system extends from GP to Tertiary and on to Palliative Care. Tinkering with the bit in the middle, the hospital, will only create distortions somewhere else. It's the nature of systems.

Return to ED

Many of the people who present to ED should not be there in the first place. Their GP could deal with the problem, but they go to ED. Perhaps because they cannot get away from work to see their GP during working hours. Or they cannot afford the fees charged by the After Hours Primary Care Services. Or they simply cannot find a GP, as is the case in the Hutt Valley.

Does anyone know why people present to ED? Probably not, it's not the type of data that is likely to be collected. But to understand demand, it's crucial.

Every single person who presents, creates work for ED. Uses up capacity. Which means that the people within ED are stretched. Rather than setting targets, wouldn't it be better to reduce the load?

If Tony Ryall is determined to fix the problem, he needs to look at a different set of numbers. Sure, average waiting times based on Category Targets show an Emergency Department's performance. But that performance is determined by the system. Yes, the design of the entire healthcare system determines the performance of an Emergency Department. And the design of ED determines the performance of the people working within it.

It's pointless blaming the medical staff for poor performance when the system in which they are working is setting the constraints on that performance.

Tony Ryall is right, the problem won't be fixed overnight. But he's looking at the wrong numbers. So he'll keep shifting the problem until the system breaks completely. It's the nature of ministers and managers, past and present.

Before trying to fix the NZ Health System, those wishing to improve it need to understand just two things: the type and frequency of demand and the capacity of the system to respond to that demand. Then design the system against demand.

The numbers are available, they're just not being used in the right way. The numbers are being used to measure performance against targets. And targets distort systems.

Stephen Hay is Change Broker with People and Process, specialising in process improvement for service organisations. You can contact him through And you can tell your story of poor healthcare performance at

-- People and Process Limited Making Change Safe


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