Gaming in infection control: A qualitative study exploring the perceptions and experiences of health professionals in Mongolia Bat-Erdene Ider, MD, MScPH, a Jon Adams, PhD, a Anthony Morton, MD, MscAppl, b Michael Whitby, MD, MPH, b and Archie Clements, PhD a,c Brisbane, Queensland, Australia Background: This study aimed to gain insight into the extent to which gaming is responsible for the underreporting of hospital- acquired infections (HAIs) in Mongolian hospitals, to identify gaming strategies used by health professionals, and to determine how gaming might be prevented. Methods: Eighty-seven health professionals, including policy- and hospital-level managers, doctors, nurses, and infection control practitioners, were recruited for 55 interviews and 4 group discussions in Mongolia in 2008. Results: All study participants were aware of gaming, which could occur via the following mechanisms: (1) doctors or nurses con- cealing HAI by overprescribing antibiotics or discharging patients early; (2) infection control practitioners failing to report HAI cases to hospital directors; and (3) hospital directors preventing reporting of HAI cases to the Ministry of Health. Gaming was con- sistently perceived to be a response to punitive performance evaluation by the Ministry of Health and penalization of hospitals and staff by the State Inspection Agency when HAIs were detected. Participants held divergent views regarding the best approach to reduce gaming, including excluding the current single indicator (ie, HAI rate) from the performance indicator list, developing mul- tiple specific infection control indicators, improving the awareness of health managers regarding the causes of HAI, and increasing funding for infection control activities. Conclusion: Inclusion of the overall HAI rate in the targeted performance indicator set and the strict control and penalization of hospitals with reported HAI cases are factors that have contributed to gaming, which has resulted in deliberate, extreme under- reporting of HAIs in Mongolian hospitals. Key Words: Hospital-acquired infection; underreporting; performance evaluation. Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect Control 2011;39:587-94.) In the medical literature, gaming refers to the sub- mission of fraudulent reimbursement claims and the manipulation of clinical and nonclinical performance data. 1-4 Gaming of performance data mainly involves fraudulent administrative arrangements purposely made by clinical administrators to meet special perfor- mance targets and to avoid penalties. 4,5 A 2003 survey found that 85% of hospital trusts in the United King- dom achieved the national targets on accident and emergency department waiting times through various gaming strategies. 5 Since the late 1980s, performance indicators have been introduced in many countries as a tool for improving the quality of health care. 6-8 The impact of such initiatives on the veracity of hospital in- fection control data has been little investigated, how- ever. To date there has been only one published report on gaming in infection control, which warned of undesired consequences, including false coding of cases of hospital-acquired infection (HAI) in response to cutting reimbursements to US hospitals for the cost of treating certain HAIs. 9 In Mongolia, hospital performance indicators were introduced in the early 2000s, and the overall hospital HAI rate is included in the national indicator set. 10,11 Hospitals with high HAI rates are ranked lower in terms of quality of services provided, making administrators at these hospitals vulnerable to redundancy. When comparing the official HAI statistics to international re- ports, Mongolian Ministry of Health (MoH) officials strongly suspected that the reported HAI rates were From the University of Queensland, School of Population Health, Brisbane, Queensland, Australia a ; Infection Management Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia b ; and Australian Centre for International and Tropical Health, Queensland In- stitute of Medical Research, Brisbane, Queensland, Australia. c Address correspondence to Bat-Erdene Ider, MD, MScPH, Room 303, Edith Cavel Building, School of Population Health, University of Queens- land, Herston Road, Herston, QLD 4006, Australia. E-mail: Ibaterdene@ yahoo.com or baterdene.ider@uqconnect.edu.au. Conflict of interest: None to report. 0196-6553/$36.00 Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2010.10.033 587