Increasing numbers of countries are using indicators to evaluate the quality of clinical care, with some linking payment to achievement.1 For performance frameworks to remain effective the indicators need to be regularly reviewed. The frameworks cannot cover all clinical areas, and achievement on chosen indicators will eventually reach a ceiling beyond which further improvement is not feasible.2 3 However, there has been little work on how to select indictors for replacement. The Department of Health decided in 2008 that it would regularly replace indicators in the national primary care pay for performance scheme, the Quality and Outcomes Framework,4 making a rigorous approach to removal a priority. We draw on our previous work on pay for performance5 6 and our current work advising the National Institute for Health and Clinical Excellence (NICE) on the Quality and Outcomes Framework to suggest what should be considered when planning to remove indicators from a clinical performance framework.