When their scores are used as a basis of reward and punishment, surgeons, as do others under such scrutiny, engage in creaming, that is, they avoid the riskier cases. When hospitals are penalized based on the percentage of patients who fail to survive for thirty days beyond surgery, patients are sometimes kept alive for thirty-one days, so that their mortality is not reflected in the hospital’s metrics. 2 In England, in an attempt to reduce wait times in emergency wards, the Department of Health adopted a policy that penalized hospitals with wait times longer than four hours. The program succeeded—at least on the surface. In fact, some hospitals responded by keeping incoming patients in queues of ambulances, beyond the doors of the hospital, until the staff was confident that the patient could be seen within the allotted four hours of being admitted.
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