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?"

From the perspective of complexity science, this commentary addresses Tenbensel and colleagues' study, which reveals varied gaming behaviours to meet the New Zealand Emergency Department (ED) metric. Seven complexity-informed principles previously published in this Journal are applied to formulate recommendations to improve the design and implementation of metrics. (1) Acknowledge unpredictability. When designing a metric, policy-makers need to leave room for flexibility to account for unforeseen situations. When implementing a metric, they need to promote sense-making of relevant stakeholders. (2) Sense-making shall be encouraged because it is a social process to understand a metric, align values and develop a coherent strategy. Sense-making is important to (3) cope with self-organised gaming behaviours and to (4) facilitate interdependencies between ED and other departments as well as organisations. (5) We also need to attend to the relationship between senior management and frontline staff. Additionally, to address one of the methodological weaknesses in Tenbensel and colleagues' study, (6) adaptive research approach is needed to better answer emerging questions. (7) Conflict should be harnessed productively. I hope these recommendations could limit gaming in future metrics and encourage stakeholders to view inevitable gaming as an improvement opportunity.