Learning Goals May Prevent “Goals Gone Wild”

The recent special issue describes complex problems challenging the Veterans Health Administration.^1,2 Complex problems require thoughtful, realistic solutions, but such solutions may be difficult to develop in environments that value short-term, goal-focused performance. Currently, the Veterans Health Administration faces accusations of inappropriate scheduling practices that delayed or prevented care. Unrealistic performance standards are one potential cause.³ Health care leaders should consider the potential unintended impact of performance incentives on risk taking and unethical behavior, colloquially known as “goals gone wild.”⁴ Learning goals may be one solution.

Goal setting is a well-researched, effective intervention.⁵ Goals are powerful motivators that may be strengthened by incentives.⁶ Experimental studies demonstrate that specific, difficult goals improve task performance.^7,8 Specific goals focus attention and difficult goals motivate effort. Effects are strongest for simple tasks, in part because solutions to complex tasks require more than just increased effort.⁹ We propose a focus on learning goals instead of performance goals as a solution to complex problems, such as suicidal ideation, homelessness, and population health identified in the special issue.

The distinction between performance and learning goals reflects the difference between means and ends. Performance goals are appropriate when strategies for achieving a goal (i.e., the means) are well known but there is a need to increase either motivation or attention toward achieving the goal (i.e., the ends). For example, performance goals are appropriate for increasing motivation and attention toward providing aspirin for possible acute myocardial infarction. Implementing performance goals for complex public health challenges may result in undesirable side effects, such as increased risk taking and unethical behavior because performance goals overly focus attention on personally relevant rewards and punishments.¹⁰ This may limit individuals’ ability to consider broader implications of goal-focused behavior, such as effective and ethical solutions to complex problems.

Learning goals focus attention on developing new means to achieve the ends.^4,10 In practice, facilities that demonstrate progress in developing strategies that are innovative for difficult, complex problems such as access, suicide, homelessness, and population health could be rewarded regardless of whether the strategies are initially effective. For example, a facility could be rewarded based on the degree to which it developed and tested a thoughtful strategy for increasing access. The reward would be based on the degree of incremental learning resulting from the program. Such a learning strategy would take pressure off leaders to be perceived as successful and focus effort where it belongs—improving care.