From Strategy to Impact: Rethinking Performance Improvement Governance in Ambulatory Care and the Outpatient Setting
Performance improvement has become a strategic imperative in healthcare. Yet, particularly in ambulatory care settings, there's often a disconnect between the intentions set by leadership and the realities experienced by frontline teams. Goals are frequently mandated without clarity or resources, leaving teams scrambling to fulfill quotas instead of solving actual operational problems.
This isn't just ineffective—it's actively harmful. As quality improvement pioneer W. Edwards Deming famously warned:
“Eliminate slogans, exhortations, and targets for the workforce asking for zero defects or new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the workforce.”¹
In other words, setting arbitrary targets without addressing underlying systemic issues creates frustration, drives counterproductive behaviors, and erodes morale.
If we’re serious about performance improvement, governance structures must move away from compliance-based checklists and evolve into frameworks that genuinely align organizational strategy with frontline execution.
When Good Intentions Backfire
Many healthcare organizations unintentionally create perverse incentives through well-meaning but misguided governance structures. Consider mandates like setting arbitrary goals on staff participation in performance improvement initiatives. On the surface, this seems beneficial. But in reality, such requirements often lead managers and staff to label routine activities as "projects," diluting genuine improvement efforts and wasting precious time and resources.
This phenomenon aligns with Deming’s insight about the dangers of numeric goals:
“Eliminate management by objective. Eliminate management by numbers, numerical goals. Instead learn and institute leadership.”²
Deming argued that rigid numerical targets frequently lead to short-term thinking, manipulation, and superficial compliance rather than meaningful change. In healthcare, this often manifests as initiatives that exist more for the benefit of reporting than for patient outcomes or operational efficiency.
What Effective Governance Looks Like
Recent insights from Kaufman Hall, NEJM Catalyst, and McKinsey consistently highlight that effective governance is crucial to sustained performance improvement in healthcare.
1. Strategic Alignment Over Arbitrary Targets
Governance must ensure improvement initiatives align directly with strategic priorities. Rather than setting broad participation quotas, define clear, relevant operational problems—like patient flow, scheduling inefficiencies, or provider utilization—and guide teams toward those tangible issues.
Kaufman Hall’s 2023 report notes considerable variation in organizational effectiveness due largely to inconsistent governance approaches.³ Ambulatory care, with its unique operational pressures, needs a targeted, flexible governance model that supports real problems, not just participation numbers.
2. Structured but Agile Frameworks
Ambulatory settings require governance that provides consistency without bureaucracy. According to NEJM Catalyst, successful organizations promote clinician engagement, transparency, and accountability, rather than rigid hierarchical oversight.⁴
Effective governance doesn’t dictate every step; it clarifies direction, provides resources, and sets expectations—allowing frontline teams the freedom to innovate within clear boundaries.
3. Data-Driven—but Not Data-Dominated
Data analytics can be a powerful governance tool when used correctly. McKinsey’s studies underscore how predictive analytics and technology enhance operational efficiency, patient flow, and cost management.⁵,⁶ However, the value of data is in its application, not merely its availability. Leadership must use data to make informed decisions, not as a proxy for management itself.
Moving Past Common Pitfalls
Typical governance missteps include:
Unrealistic or vague targets disconnected from operational realities.
Fragmented projects that fail to align with organizational strategy.
Lack of real accountability, leading to broad involvement but limited meaningful results.
Short-term thinking spurred by overly numerical, quota-driven leadership.
Addressing these pitfalls means fundamentally rethinking the way we govern performance improvement, focusing on outcomes, engagement, and continuous learning, rather than just meeting numerical benchmarks.
Building a Better Governance Framework
Ambulatory care leaders have an opportunity—and obligation—to create governance structures that truly improve performance. Four practical steps can move organizations in this direction:
1. Prioritize Meaningful Improvement
Move away from vague participation quotas. Clearly articulate what specific problems your organization needs to solve, whether related to patient satisfaction, operational efficiency, or provider engagement.
2. Align Accountability and Ownership
Define clear roles and responsibilities. Instead of asking every team to invent a project, provide teams with strategic focus areas aligned with broader organizational objectives, and empower them with clear guidance and expectations.
3. Implement Flexible, Continuous Feedback Loops
Regularly revisit goals, reassess project effectiveness, and adapt accordingly. Ambulatory settings change rapidly, and governance must keep pace. Acknowledge setbacks openly, learn from them, and adjust strategies.
4. Invest in Capacity and Capability
Effective governance requires equipping teams with appropriate resources, training, and support—not just metrics and mandates. Improvement happens when teams have both the incentive and the capability to deliver.
Final Thoughts: From Mandates to Meaning
Ambulatory care governance can no longer rely on simplistic numerical goals or broad exhortations. Such approaches overlook the realities of daily operations and the complexity of the healthcare landscape.
Real improvement governance means embracing Deming’s wisdom: setting aside management by slogans and numerical quotas, and instead instituting genuine, thoughtful leadership. Only then can organizations close the gap between strategy and execution, moving beyond mere compliance to genuine impact.
Because improvement, when governed well, doesn't just meet goals—it transforms organizations.
References
Deming WE. Out of the Crisis. MIT Press; 1986.
Deming WE. The New Economics for Industry, Government, Education. MIT Press; 1994.
Kaufman Hall. The State of Healthcare Performance Improvement in 2023. Available at: https://www.kaufmanhall.com/. Accessed March 2025.
NEJM Catalyst. Improving Healthcare Operations Through Effective Governance. NEJM Catalyst Innovations in Care Delivery. 2023;4(2).
McKinsey & Company. The ‘big data’ revolution in US health care: Accelerating value and innovation. Available at: https://www.mckinsey.com/industries/healthcare/our-insights/the-big-data-revolution-in-us-health-care. Published April 2013. Accessed March 2025.
McKinsey & Company. Reimagining healthcare industry service operations in the age of AI. Available at: https://www.mckinsey.com/industries/healthcare/our-insights/reimagining-healthcare-industry-service-operations-in-the-age-of-ai. Published October 2021. Accessed March 2025.
About the Author
Isaac J. Moreno is the Founder and Principal Advisor at IM Healthcare Solutions, bringing more than two decades of experience in healthcare operations, technology, and consulting. A Lean Six Sigma Black Belt and U.S. Navy veteran, he has led large-scale initiatives within academic medical centers and outpatient care settings, always emphasizing that data must drive real action. By bridging strategic insights with tangible execution, he helps organizations achieve sustainable growth, operational excellence, and an elevated patient experience.