There are multiple reasons why performances measures fail. Sometimes the theory is good but the unintended consequences result in harm (four hour antibiotic rule for pneumonia). In other cases the individual recommendations are “evidence based” (performed well in clinical trials) but the shame game of public reporting negates their effectiveness (heart failure core measures, ventilator bundle). Still other measures were never evidence based at all. Such is the case for the adult pneumococcal vaccine. Although it will probably continue as a performance measure the latest meta-analysis serves as another nail in the coffin of evidence. According to the synthesis of high level clinical trials, for recurrent presumptive pneumococcal pneumonia, recurrent all cause pneumonia and death the vaccine doesn’t do squat, even in the high risk patients for whom it is commonly recommended.