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“Meeting the standards is the lowest level of quality that the community is willing to accept.” – Professor Grant Phelps.

In a recent AICG webinar, Kylie Scoullar, CEO of DonCare and Deputy Chair of TWEDL Child and Family Health Services, delivered a compelling presentation on the unintended consequences of performance measurement in healthcare. Drawing on her extensive experience across clinical, executive, and governance roles, Kylie explored how well-intentioned KPIs can sometimes undermine the very care they aim to improve.

KPIs Can Drive the Wrong Behaviour

Kylie recounted a personal experience that starkly illustrated how KPIs can distort priorities. As a manager, she raised a serious risk incident involving communication failures in mental health services. The system was not designed to support distressed individuals seeking urgent help, and the consequences were potentially fatal.

Instead of focusing on resolving the issue, Kylie was pressured to close the incident to meet the KPI deadline:

“Rather than a conversation about how to address the risk, resolve the risk, problem solve it, and get a solution, what happened was that I was pressured to close the risk incident.”

This example highlights a critical flaw: when compliance becomes the goal, care can suffer. The KPI was met, but the risk remained unresolved, and the urgency to fix the problem dissipated.

Complex Systems Require Nuanced Measures

Healthcare is a web of interconnected systems, and KPIs often fail to capture this complexity. Kylie reminded attendees that metrics in one area can have ripple effects in other areas. For instance, emergency department wait times may be influenced by the availability of aged care beds—a factor outside the ED’s control.

“Solutions to an issue in one part of the system… might depend on another system entirely.”

This systems-thinking approach is essential. Without it, KPIs can inadvertently shift focus away from solving root problems and toward superficial compliance.

The Tyranny of Metrics

Kylie introduced the concept of “metric tyranny,” referencing Jerry Z. Muller’s book The Tyranny of Metrics. The book examines how metrics, although useful, can become counterproductive when misused or misinterpreted.

“Those who believe that what you cannot quantify does not exist also believe that what you can quantify does.”

This quote highlights the risk of overreliance on numbers. Not everything that matters in care can be measured, and not everything that is measured reflects what truly matters.

Unintended Consequences Are Predictable

Kylie drew parallels between healthcare and other industries, citing catastrophic failures at Dreamworld, Boeing, and Mid-Staffordshire NHS Trust. In each case, performance pressures overrode safety concerns, governance was weak, and warnings were disregarded.

“Targets and production throughput pressures eclipsed safety… warnings were ignored or minimized… there was a normalization of deviance.”

These examples serve as cautionary tales. When KPIs become high-stakes and disconnected from purpose, they can drive harmful behaviours and mask systemic issues.

Safeguards for Meaningful Measurement

Rather than abandoning KPIs, Kylie advocated for safeguards that ensure they support quality care. She outlined several strategies:

• Collaborate with practitioners: Involving frontline staff in the design and interpretation of KPIs ensures relevance and buy-in.
• Focus on workforce wellbeing: Engaged staff deliver better care. Kylie cited research indicating that employee engagement is correlated with improved patient outcomes and reduced adverse events.
• Elevate consumer voices: Kylie called for meaningful inclusion of lived experience in governance, not tokenism.
• Use data wisely: Benchmarking, trending, and triangulating data can reveal patterns that static metrics miss.
• Create informal channels: Kylie shared her initiative, “Coffee and Cake with the CEO,” as a way to foster open dialogue and surface issues that formal channels might miss.

Lead with Care, Not Compliance

Ultimately, Kylie urged leaders to keep care at the forefront. Whether you're a board member, clinician, or policy-maker, the message was clear: lead with compassion, especially when it’s hard.

“Leading with the care for the consumers… when it counts is what matters, not when it’s easy.”

She encouraged attendees to reflect on their own roles and consider what actions they could take to safeguard care. From elevating consumer feedback to integrating frameworks, every role has influence.

“Think about what we can do that would make a difference.”

The full webinar recording is available exclusively to AICG members. Become a member today to access the video and explore more resources on advancing clinical governance in diverse care settings.

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