Performance Improvement as a Foundational Component of the Clinical Model of Family Medicine: Rationale, Concerns, Ways Forward

• Family Medicine
• Family Physicians
• FMLC 2025
• Quality Improvement

Practice-based learning and improvement is one of the foundational elements of the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) Competencies.¹ PI, under various names, has been part of the ABMS and American Board of Family Medicine (ABFM) maintenance of certification (now continuous certification) process since its inception in 2003. While most family medicine graduate trainees now receive some training in principles of quality improvement (QI), many (especially later career) practicing physicians have not. PI is an attempt to capture the key concepts of a structured QI framework for improvement (ie, identify a problem, measure baseline performance, develop a goal and timeline for improvement, intervene, remeasure, reflect on what was learned during the intervention, and develop next steps), recognizing that QI is a discipline, the formal application of which may involve more expertise, resources, and support than available to many family physicians.

Among ABFM Diplomates, PI has been one of the more concerning aspects of Family Medicine Continuous Certification (FMCC). While the ABFM has been evolving its PI requirements, pockets of concern or confusion remain about administrative burden, required elements, and importance to day-to-day practice. PI’s role in the clinical model of family medicine was discussed during an August 2025 meeting of family medicine leaders and stakeholders.²

Viewpoint: Individual performance improvement in population quality metrics should not remain a priority in the Family Medicine Clinical Model

Because medical care accounts for only 20% of the modifiable contributors to population health outcomes, individual PI is not the key to better health outcomes.³ Current PI measures, most notably those embedded in the Merit-based Incentive Payment System (MIPS), fail to account for social drivers of health and the team-based nature of modern primary care.^4–6 Family physicians do not practice in isolation. Rather, outcomes are influenced by nurses, behavioral health specialists, oral health providers, community partners, communities, and patients themselves. Certification boards, payers, and regulators, however, lean heavily on physician-level metrics, tying them to professional advancement and financial incentives.

Holding individual physicians accountable for outcomes that depend on multiple, nuanced factors can particularly penalize physicians who care for under-resourced or medically complex populations with metrics that they cannot meaningfully influence.^5,6 Some have also noted that individual PI may inadvertently exacerbate health disparities for vulnerable populations.⁶ Vulnerable populations can face physical, financial, or geographical barriers to accessing health care. Individual PI metrics rarely include targets addressing access, which may contribute to systemic apathy in addressing these barriers.⁶ Many PI metrics lack relational measures, disincentivizing the patient-physician interactions that both improve health outcomes in vulnerable populations and remain the cornerstone of family medicine.

Additionally, PI can create unintended consequences and ethical dilemmas.⁷ The burden of reporting for PI metrics, for example, is substantial.^4,7 Physicians may spend hours documenting, reporting, and managing data for little demonstrable gain. This administrative load contributes to burnout and pulls time away from direct patient care. Patient autonomy may be compromised when physicians feel pressured to meet metrics rather than to honor individual preferences.^5,7 Physicians may deprioritize some aspects of care to focus instead on targeted outcomes.^5,7 Vulnerable populations may be further marginalized if their complex needs make it harder to meet standardized benchmarks.^4,5

Replacing individual PI with systems-level, value-based, and patient-centered measures offers a more holistic and accurate reflection of quality. The Person-Centered Primary Care Measure, recently incorporated into the MIPS clinical quality measures, is one such example of how to assess the effectiveness of a primary care practice within the setting of its community, rather than grading individual physicians on disease-oriented outcomes.⁸ Graduate medical education should embrace this shift by preparing physicians to lead and participate in teams that improve outcomes for diverse populations, rather than exclusive focus on individual metrics. Although physicians may remain engaged in PI, accountability for health outcomes must be contextualized. As Richard Brook noted in 2010, the era of PI as an individual pursuit is ending and the future lies in improving value across systems.⁹ Doing so will help restore joy in practice, reduce waste, and deliver better outcomes for patients, families, and communities.

Viewpoint: Individual performance improvement in population quality metrics should remain a priority in the Family Medicine Clinical Model

Involvement in PI signals to patients, the public, and peers that family physicians are dedicated to evaluating and attempting to improve their practice, whatever their roles or practice setting may be. Nonetheless, gestalt, high-level self-assessments of practice in the absence of data can be inaccurate.⁹ Improvement does not occur spontaneously—it takes planning and structure. In a sense, the process of performance improvement is similar to patient care. Imagine a patient with multiple comorbidities including type II diabetes mellitus, coronary artery disease, hypertension, mild renal insufficiency, back pain, and depression. Developing a plan of care for the patient, evaluating it, and tweaking it as necessary over time until desired outcomes are achieved is a familiar and comfortable process for family physicians. Family physicians care for panels and populations, not just individual patients one at a time. PI is, therefore, using our individual patient management skills on a larger scale.

Some have argued that physicians need not be involved in practice improvement, because the systems in which many of us work provide that function. Some physicians, however, are not surrounded by systems equipped to provide this service. Even for physicians who are, their system may provide the tools, but humans are needed to implement improvement strategies. Additionally, systems may focus on capturing relative value units (RVUs) and revenue or focus on specific individual diseases to earn “star ratings.” The latter may be important, but they fail to capture much of the important work of family physicians (patient multimorbidity, complexity, evaluation of undifferentiated complaints) or patient-oriented outcomes that matter. (Despite television advertisements, how many patients have thanked us for helping to lower their A1c?) Who within the healthcare system is better positioned to understand patients’ priorities and to advocate—directly or by supporting patients’ own advocacy—for meaningful improvements than the personal family physician? Yet tackling complicated and complex problems at scale is beyond the capabilities of any single physician. Addressing these issues, with their multiple process steps and the work of others, requires the involvement of the teams surrounding family physicians. Such involvement could also potentially help our team members with their career satisfaction.

Many improvement attempts will fail the first (or first few) times. Efforts may fail for reasons including lack of leadership support, complexity of the problem, the complex and often inconsistent nature of healthcare systems or local practice sites within a system, and inadequate adaptation of improvement efforts to local context (practice, patient characteristics). Reflecting on and learning from initial lack of success is important to adjust subsequent attempts, avoid giving up prematurely, and to avoid trying the same unsuccessful thing and expecting different results. Practice improvement is, or should be, as much about learning from lack of success as it is giving check marks for individual successes. Indeed, rather than punishing family physicians for initially failed efforts, we should acknowledge learnings from good-faith attempts to improve, and recognize efforts to undertake different or revised approaches to complex problems.

While PI is an important part of the family medicine clinical model, we should not and cannot be insensitive to the day-to-day challenges family physicians face. The ABFM experience over the last few years is that is most family physician disquietude about PI stems from not knowing what to do, or not knowing how to go about it. ABFM has been advising family physicians to focus on things they are already doing (because they are required by their health system) or focus on things they would want to address even in the absence of a PI requirement. Over time, ABFM has streamlined (and continues to streamline) templates to help family physicians structure and report their PI efforts. ABFM data shows that more than 30,000 Diplomates complete a PI each year. Over 90% report their PI activity is extremely or very relevant to their practice, and 85%–90% report they will make a practice change as a result of their PI efforts. While the PI efforts vary in size (number of patients involved), may Diplomates report substantial outcome changes upon remeasurement, including in nondisease focused areas such as health equity. Internal ABFM data also shows that 1 in 6 Diplomates report two or more PI activities for credit during their most recent certification cycle.

The question should not be, “Should family medicine continue with PI?” Rather, as a specialty we should be asking, “How do we evolve PI?” in such a way that we recognize family physicians for the good-faith improvement efforts they are already undertaking, and support them in trying to improve things they want to address or are struggling to address. Rather than focusing solely on single disease states, how can we focus on patient-oriented evidence and outcomes that matter? How can we focus on value (quality, cost, and patient centeredness)? Family medicine should help make meaningful PI easier to do, in a practical way that allows us to contribute to improvement and that is rewarding for family physicians, their teams, and their patients.

• Received for publication January 17, 2026.
• Accepted for publication April 8, 2026.