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The paper seeks to investigate decision‐making processes within hospital improvement activity, to understand how performance measurement systems influence decisions and potentially lead to unsuccessful or unsustainable process changes.

A longitudinal study over a 33‐month period investigates key events, decisions and outcomes at one medium‐sized hospital in the UK. Process improvement events are monitored using process control methods and by direct observation. The authors took a systems perspective of the health‐care processes, ensuring that the impacts of decisions across the health‐care supply chain were appropriately interpreted.

The research uncovers the ways in which measurement systems disguise failed decisions and encourage managers to take a low‐risk approach of “symptomatic relief” when trying to improve performance metrics. This prevents many managers from trying higher risk, sustainable process improvement changes. The behaviour of the health‐care system is not understood by many managers and this leads to poor analysis of problem situations.

Measurement using time‐series methodologies, such as statistical process control are vital for a better understanding of the systems impact of changes. Senior managers must also be aware of the behavioural influence of similar performance measurement systems that discourage sustainable improvement. There is a risk that such experiences will tarnish the reputation of performance management as a discipline.

Recommends process control measures as a way of creating an organization memory of how decisions affect performance – something that is currently lacking.