Continuous Performance Improvement: There is No Comfort Zone

In the current shift toward value-based payments (VBP), everyone in healthcare is inconvenienced, anxious, or both. The healthcare system has enjoyed decades of quasi payment stability, so any change is measured as disruptive. Arriving at a comfort zone of permanent system stability in healthcare is now a mystical idea. On the other hand, to a large degree, healthcare has ignored the general industry standard of continuous performance improvement (CPI). The word “continuous” implies constant change. Yet we have seen that CPI monitoring of quality and process in industry leads to better products at lower prices. Industry seems to have adopted a triple aim much earlier than healthcare where the magic “Triple Aim” words were first introduced.  

George Halverson, in his book Health Care Will Not Reform Itself, succinctly noted, “Health care in America is badly organized, highly inconsistent, internally dysfunctional, sometimes brilliant, almost always compassionate, close to data free, amazingly unaccountable in key areas, too often wasteful, more often dangerous, and extremely expensive.”[i] His description of the healthcare system demonstrates a strong need for CPI with little chance of achieving a comfort zone any time soon. 

The airline industry’s introduction of CPI has shown reduced pilot errors and better safety. In recent years the hospital operating room has become a safer place as providers of all types have introduced time-out sessions to finally review all the relevant patient data before starting the surgical procedure. None of us would argue against W. Edwards Deming’s (1900-1993) idea that the word “rework” should be eliminated from the airlines or healthcare. Deming’s ideas have revolutionized industrial production, quality, and customer satisfaction beginning in the late 1940s thru today.[ii]  

As we explore this idea, it may be time to ask some penetrating questions about the Accountable Care Organizations’ (ACO) advancing role in community health. Is the ACO a real and important part of healthcare? Is it fair to apply the continuous performance improvement principles to these community-based organizations? Is it reasonable to expect that ACOs will ever achieve a new comfort zone as they apply value-based principles to the healthcare they provide? 

We have seen any number of three-letter-word organizations come and go across the healthcare spectrum–HMO, PPO, PHO MCO. On the other hand, the ACO is unique in that the responsibility for cost, quality, and patient satisfaction finally belong to the group that can deliver on the idea–physicians. We seem to be finally realizing that the CPI idea must become central to any successful and enduring healthcare program. One of the major complaints about the recent CMS redesigned ACO program, “Pathways to Success,” is that most ACOs were getting used to the shift to the Medicare Shared Savings Program (MSSP). In other words, providers had “finally” achieved a measure of a new “comfort zone” that is in the disruptive Medicare Shared Savings Program (MSSP) and now they must start all over again. It is suggested that a “comfort zone” in the airlines or healthcare may be a dangerous thing. 

The Salient ACO solution is designed to support Continuous Performance Improvement by guiding the user to the issues that CMS has specified as clinically and financially important. By comparing the individual provider or group against themselves month to month, quarter to quarter, the ACO can monitor and encourage CPI. There is no hiding in average or above-average performance without improvement. Anyone who is not fully engaged in the continuous improvement process is not helping the ACO or supporting the goals of the Triple Aim. Furthermore, in the context of this goal, physicians have a professional moral obligation to provide the best care to their patients. The new “comfort zone” can then be re-described as continuously better care at a lower cost along with improved patient satisfaction.  


[i] Halverson, George C., Health Care Will Not Reform Itself, CRJ Press, New York, 2009 pg. xv 

[ii] Deming, W. Edwards, The New Economics, 2nd edition, Cambridge, Massachusetts, Massachusetts, Institute of Technology, April 1994. 

Craigan Gray

About the Author

Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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