How to make a silk purse from a sow's ear--a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians

Abstract

The introduction of performance league tables for UK surgeons and hospitals has forced them to learn how to present data in the best possible light. Though there is anurgent need for guidance, official guidelines on how to optimise performance data are lacking Surgeons' and hospitals' positions in league tables can make or break their reputations. They therefore need to learn how to present data in the best possible light. Although some may protest about “sexing up” poor performance data, “creative accounting” adds a positive spin. In contrast to the plethora of clinical guidelines, there is still no official advice on how to optimise performance data, and wide variations in practice persist. This review provides a timely, evidence based response to the urgent need for guidance. We searched Medline for empirical examples of creative accounting (using the search terms “gaming”, “mortality“, “league table$”, “upcoding”, “fraud$”, “quality“, and “quality indicators, health care/”) and identified 284 papers, of which we reviewed the most relevant for suitable examples. We also searched the web with Google using “examples hospital healthcare fiddling figures.” We included anecdotes from personal experience. In addition to fraudulent or biased research, which has been thoroughly reviewed elsewhere,1 we identified three broad categories of creative accounting: ### Manipulation of non-clinical performance targets This is particularly important for managers when meeting so called P-45 targets—an expression used by Tony Wright MP while examining Sir Nigel Crisp for the House of Commons Select Committee on Public Administration2 and meaning targets for which failure to meet can result in redundancy (in Britain the P-45 is the tax form people receive when leaving employment). A House of Commons investigation in 2002 uncovered strategies to bring waiting times and numbers of patients waiting for treatment within national targets.3 …