Performance Improvement and Performance Dysfunction: An Empirical Examination of Distortionary Impacts of the Emergency Room Wait-Time Target in the English National Health Service

Abstract

The literature on the use of performance measurement in government has focused much attention on hypothesized unintended dysfunctional consequences that such measurement may produce.We conceptualize these dysfunctional consequences as involving either effort substitution (reducing effort on nonmeasured performance dimensions) or gaming (making performance on the measured performance dimension appear better, when in fact it is not).In this paper, we examine both performance impacts and dysfunctional consequences of the establishment in the English National Health Service of a performance target that no patient presenting in a hospital accident and emergency department (emergency room) wait more than 4 hours for treatment.Using data from all 155 hospital trusts in England, we find dramatic wait-time performance improvements between 2003 and 2006 and no evidence for any of the dysfunctional effects that have been hypothesized in connection with this target.We conclude by discussing when one would expect dysfunctional effects to appear and when not.During the past decades, there has been a significant increase in use of nonfinancial performance measurement in government as a tool to improve both democratic accountability and organizational performance (Cave, Kogan, and Smith 1990;Carter, Klein, and Day 1992;Hatry 1999; Heinrich 2003;Talbot 2005).Examples of such performance measures include anything from crime rates for the police to average wait time at a Division of Motor Vehicles office to the percentage of citizens calling a Social Security call center whoWe gratefully acknowledge the assistance of Stephen Morris, Lis Nixon, Liz Chart, Adrian Masters, Duncan Selbie, and Bill Alexander in helping us locate data used in this article and in answering a large number of questions from us, and of Paul Corrigan in arranging access to the UK Department of Health.