Building upon some key discussion points in the Brown et al. paper, we explore the key elements driving performance measurement and quality improvement strategies in the Veterans Affairs healthcare system in the United States and the national primary-care trusts in England, both of which offer important insights into understanding the factors that affect rapid, large-scale change. In the context of these "extreme makeover" examples, our commentary discusses the currently evolving performance measurement culture in the Canadian primary healthcare reform setting. We specifically highlight the experiences in Saskatchewan, a province that has been acknowledged recently by CIHI as a leader in primary healthcare evaluation. Although Saskatchewan has attempted to overcome the methodological and conceptual challenges in evaluation that Brown et al. outline in their paper, a stable performance measurement culture has yet to emerge and systematically utilize performance measurement reports for purposes of facilitating change. Although there is a growing recognition that measures by themselves will not be able to spur improvement, it is yet to be seen to what extent these performance reports can speak compellingly to policymakers, primary healthcare providers and managers to serve as catalysts to a major leap forward in overall quality improvement.

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