Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?

Document Type : Original Article


1 Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand

2 Auckland District Health Board Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

3 Auckland District Health Board, Auckland, New Zealand

4 School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand


Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations.
We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n = 68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data.
Our research established that gaming behaviour – in the form of ‘clock-stopping’ and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches – was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff.
Gaming of New Zealand’s ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game.


 Commentaries Published on this Paper


  • Beyond Targets: Measuring Better and Rebuilding Trust; Comment on “Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?”

         Abstract | PDF


  • Improve the Design and Implementation of Metrics From the Perspective of Complexity Science; Comment on “Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?”

         Abstract | PDF


  •  Games People Play: Lessons on Performance Measure Gaming from New Zealand; Comment on “Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?”

         Abstract | PDF


Authors' Response to the Commentaries


  •  If Gaming is the Problem, Is “Complexity Thinking” the Answer? A Response to the Recent Commentaries

          Abstract | PDF


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Volume 9, Issue 4
April 2020
Pages 152-162
  • Receive Date: 21 February 2019
  • Revise Date: 18 October 2019
  • Accept Date: 18 October 2019
  • First Publish Date: 01 April 2020