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Performance Improvement in
Hospitals and Health Systems
Managing Analytics and Quality in Healthcare
2nd Edition

By
James R. Langabeer II, MBA, PhD
CRC Press
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Library of Congress Cataloging‑ in‑ Publication Data

Names: Langabeer, James R., 1969- editor.

Title: Performance improvement in hospitals and health systems : managing
analytics and quality in healthcare / [edited by] James Langabeer II.
Description: 2nd edition. | Boca Raton : Taylor & Francis, 2018. | Revised
edition of: Performance improvement in hospitals and health systems /
edited by James R. Langabeer II. Chicago, IL : HIMSS, c2009. | “A CRC
title, part of the Taylor & Francis imprint, a member of the Taylor &
Francis Group, the academic division of T&F Informa plc.” | Includes
bibliographical references and index.
Identifiers: LCCN 2017044404| ISBN 9781138296404 (paperback : alk. paper) |
ISBN 9781138296411 (hardback : alk. paper) | ISBN 9781315100050 (ebook)
Subjects: LCSH: Health services administration. | Medical care--Quality
control. | Hospital care--Quality control. | Medical care--Evaluation.
Classification: LCC RA971 .P465 2018 | DDC 362.11--dc23
LC record available at https://lccn.loc.gov/2017044404

Visit the Taylor & Francis Web site at

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Leadership is the capacity to translate vision into reality.

Dr. Warren Bennis, Management Scholar

Contents

Acknowledgments���������������������������������������������������������������������������� ix
About the Editor........................................................................................xi
About the Contributors.......................................................................... xiii
Introduction................................................................................... xvii

Section I  QUALITY AND PERFORMANCE IN HEALTH

1 Quality and Quality Management������������������������������������������������3
JAMES LANGABEER
2 Strategy and Performance Management������������������������������������19
JAMES LANGABEER AND OSAMA MIKHAIL

Section II  PERFORMANCE IMPROVEMENT METHODS

3 Performance Management Methods and Tools��������������������������43
JAMES LANGABEER
4 Developing New Quality Teams�������������������������������������������������63
JAMES LANGABEER
5 Project Management������������������������������������������������������������������75
JAMES LANGABEER AND RIGOBERTO DELGADO
6 Process Redesign��������������������������������������������������������������������� 101
KIM BRANT-LUCICH

Section III  DATA ANALYTICS AND POPULATION HEALTH

7 Big Data, Predictive Modeling, and Collaboration������������������123
JAMES LANGABEER
8 Analytics in Healthcare Organizations������������������������������������ 141
JEFFREY R. HELTON

vii
viii ◾ Contents

9 Population Health Management����������������������������������������������169

BOBBIE KITE
10 Future of Quality Improvement�����������������������������������������������201
TIFFANY CHAMPAGNE-LANGABEER
AND RIGOBERTO DELGADO
Glossary of Key Terms�������������������������������������������������������������������213
Index����������������������������������������������������������������������������������������������225
Acknowledgments

The healthcare industry is dynamic, so individuals and organizations must

change as well. We grow and improve by reading, by continuous learning,
by leading, and by serving our profession. That’ s why I appreciate the sup-
port from the Healthcare Information and Management Systems Society in
this second edition. I also appreciate the always rapid responses to my ques-
tions from Taylor & Francis senior editor Kristine Mednansky.
Also, as with the first edition, this book would not be possible without
the contributed expertise from a few of my colleagues. Their perspectives
help provide balance and offer insights and creative perspectives. I appreci-
ate their contributions. Lastly, I wish to acknowledge all the great innova-
tors, researchers, and practitioners who have helped form new theories and
pathways for driving quality and change in this industry. There are a lot of
health organizations doing some wonderful things, and we are all learning
from their successes and failures. I hope that the ideas we present here will
spark ideas and actions in those who read this book.
I also really appreciate my wife, Tiffany, for all her love and support.

ix
About the Editor

James Langabeer is professor of biomedical informatics and healthcare

management at the University of Texas Health Science Center at Houston.
His primary expertise is in strategic and operations management for hos-
pitals and healthcare organizations. Dr. Langabeer has led performance
improvement, strategic planning, and business affairs at several large aca-
demic medical centers. He was also the founding CEO of a regional health
information exchange organization and has consulted for dozens of organi-
zations on quality improvement and strategy.
Jim’ s research has been funded by multiple national agencies, includ-
ing the American Heart Association and the Centers for Disease Control
and Prevention. Dr. Langabeer has a PhD in management science from the
University of Lancaster in England and an MBA from Baylor University,
Waco, Texas, and has received advanced training in decision making and
negotiation from Harvard Law School, Cambridge, Massachusetts. He is a fel-
low of the American College of Healthcare Executives, and was designated
a fellow of the Healthcare Information and Management Systems Society in
2007.
Jim is the author of multiple books, including Health Care Operations
Management: A Systems Perspective , 2nd Edition (Jones and Bartlett, 2016).
His research has been published in more than 75 journals, including Health
Care Management Review , Journal of Healthcare Management , Health Care
Management Science , and Quality Management in Healthcare .

xi
About the Contributors

Bobbie Kite is the academic director and associate professor of the

Healthcare Leadership Program at the University of Denver, University
College, Colorado. In addition to working at the University of Denver, she
is an adjunct professor at The Ohio State University Wexner Medical Center,
Columbus, in the Department of Biomedical Informatics. Dr. Kite’ s research
centers on population health, health data analytics and informatics, and
education within these fields. She earned a PhD in healthcare management
at the University of Texas School of Public Health, Houston, and completed
a postdoctoral fellowship in the clinical and translational research informat-
ics program through the National Library of Medicine at The Ohio State
University, Columbus.

Jeffrey R. Helton is an associate professor of healthcare management at

Metropolitan State University of Denver, Colorado, teaching health econom-
ics, healthcare finance, and health informatics. He is a Certified Management
Accountant, a Certified Fraud Examiner, and a fellow of the Healthcare
Financial Management Association. He has worked as chief financial officer
in the industry, bringing 28 years of experience leading the finance func-
tion for hospitals, health plans, and integrated health systems across the
United States. Jeff earned a PhD in healthcare management at the University
of Texas School of Public Health, Houston; a master of health administra-
tion from the University of Alabama at Birmingham; and a BBA from Eastern
Kentucky University, Richmond. Dr. Helton is also a coauthor of the text-
book Health Care Operations Management: A Systems Perspective (Jones and
Bartlett, 2016).

Kim Brant-Lucich is the information services (IS) site director for Little
Company of Mary Medical Center in Southbay, California, Providence Health

xiii
xiv ◾ About the Contributors

and Services. She is responsible for overseeing hospital IS operations,

including infrastructure, desktop support, and strategic alignment of busi-
ness and information technology (IT) initiatives. Prior to joining Providence,
Kim served in a variety of executive IS and process redesign roles for Zynx
Health and St. Joseph Health in Orange, California. In her prior roles, she
developed a comprehensive, web-enabled, reusable methodology for pro-
cess redesign and change management for system implementation proj-
ects. She also worked with IT and business executives to develop their
IT strategic road maps and value propositions for IT initiatives. In addi-
tion to her current responsibilities, Kim is an adjunct faculty and lecturer
of Advanced Healthcare Information Technology at Cal State University,
Long Beach. Kim is past national chair of the Healthcare Information
and Management Systems Society (HIMSS) Management Engineering-
Performance Improvement Community and has also served on the national
HIMSS health information exchange committee. Kim has an MBA from the
University of Southern California, Los Angeles, and a bachelor of arts degree
from the University of California at Davis. She holds a Project Management
Professional (PMP) certification and is a volunteer instructor for the Project
Management Institute’ s PMP prep course.

Osama Mikhail currently serves as senior vice president of strategic plan-

ning at the University of Texas Health Science Center, Houston. He is also
a professor of management and policy sciences at the University of Texas,
School of Public Health. At the school, Dr. Mikhail teaches courses in health-
care finance, planning, and management, and advises students in both the
master and doctoral programs. Previously, Dr. Mikhail was an executive for
multiple health systems. At St. Luke’ s Episcopal Health System in Houston,
he served as chief planning and chief strategic officer. Dr. Mikhail received a
BS in math and physics from the American University of Beirut in Lebanon;
an MBA in finance from the University of Pennsylvania’ s Wharton School,
Philadelphia; and an MS in industrial administration and a PhD in systems
sciences from the Graduate School of Industrial Administration at Carnegie
Mellon University in Pittsburgh, Pennsylvania. Dr. Mikhail is a coauthor of
Integrating Quality and Strategy in Health Care Organizations (Jones and
Bartlett, 2012).

Rigoberto (Rigo) Delgado is a health economist and associate profes-

sor of healthcare management and economics at the University of Texas
at El Paso. Dr. Delgado also holds a joint appointment at the University of
 About the Contributors ◾ xv

Texas School of Public Health, Houston. He has worked as an economist,

management consultant, and executive for several organizations. His pri-
mary expertise is in cost-effectiveness methods, health services research,
healthcare finance, and population health analytics. Rigoberto has a PhD
in health economics and management from the University of Texas School
of Public Health and an MBA from the University of California at Berkeley.
Dr. Delgado is fluent in Spanish and has worked in the United States, Latin
America, Middle East, and England. Rigo also serves on several boards of
charity health clinics in Texas. In 2005, the U.S. secretary of agriculture
appointed Rigoberto to serve on the National Organic Standards Board, and
he served as the chair of the board in 2008.

Tiffany Champagne-Langabeer is an assistant professor at the University

of Texas Health Science Center, School of Biomedical Informatics, Houston.
Dr. Champagne-Langabeer’ s expertise is in health information exchange,
health policy, and technology. She was the vice president of a large regional
health information exchange, where she was one of the initial founding
members of the management team. She is a registered dietitian and has an
undergraduate degree in nutrition from the University of Texas; an MBA
from the University of St. Thomas, Saint Paul, Minnesota; and a PhD in
health management and policy from the University of Texas School of Public
Health, Houston. Tiffany’ s research has been published in multiple aca-
demic journals, including the Journal of the American Heart Association and
Quality Management in Healthcare .
Introduction

Intelligence is the ability to adapt to change.

Dr. Stephen Hawking
Theoretical Physicist
In the few years since the first edition was published, much has changed in
the world. Presidential politics have continued to make healthcare financ-
ing and delivery a topic of great debate. Lack of certainty around the health
insurance marketplace and other provisions of the Affordable Care Act have
created some ambiguity and turmoil. Reimbursement policies from payers
are also constantly shifting. Organizations have responded in many ways.
We have seen much greater emphasis on data analytics to identify gaps
and drive down costs in the system. There is much more use of telehealth,
remote monitoring, ambulatory care, and other alternative delivery mecha-
nisms. There is also a heightened focus on the health of “populations” and
not just “individuals.” This has led to a growth in population health manage-
ment. Stimulating technology investments (through electronic health records
and health information exchanges) have received less attention and funding
in the past few years, however.
To keep up with these changes, there needs to be significantly greater
emphasis on analyses and analytics, everything from predictive modeling
of admissions, to data mining of “profitable” payers and patients, to linear
modeling of readmissions. Performance and quality improvement profession-
als will continue to incorporate data and analytics into their tool kits. In this
edition, we address these topics covering population health, quality manage-
ment, and business analytics.
This second edition seeks to address many of the challenges that health
systems are having with regards to using technology and analyses to drive

xvii
xviii ◾ Introduction

changes in results. We have significantly expanded on the coverage of all

these topics. The themes of this book are summarized in Figure 0.1.
For nearly two decades, I have been researching and practicing health-
care management. In my view, management is essentially about guiding
others to achieve better results, but this is not the exclusive domain of a
manager—it is an inherent component of every individual’s job description
within an organization, from the bottom to the top. We get better when
clinical units strive for lower infection rates, when housekeepers aim to turn
beds and rooms faster, and when patients have less idle time in a waiting
room. This book is written for those of you who take your role seriously
and wish to raise the level of performance in your own organization.
In this second edition, we commonly use the terms performance
improvement and quality management synonymously. There are technical
distinctions between them, as we will describe in the first chapter, but they
essentially refer to the same set of practices and concepts. These concepts
need to be understood by managers and executives, but they will be used
daily by some of you—those of you who struggle daily to combat the sta-
tus quo, using a combination of methods to change systems and processes.
Some organizations call these people industrial or management engineers,
but most go by many other names—quality coordinator, operations analyst,
process consultant, project manager, black belt, Six Sigma consultant, busi-
ness process analyst, process improvement analyst, management analyst,
and quality manager are some of the more common titles. Small differences
aside, these are key positions that help to lead change and improve per-
formance. You will notice that we use these terms interchangeably in this
book. But more importantly, every administrator and executive that devotes

Figure 0.1 Trends in healthcare.

 Indroduction ◾ xix

the majority of his or her time to making things better, not just maintaining
the status quo, is really a performance improvement professional.
Since the field of quality management and performance improvement is
expanding rapidly, it is difficult (or impossible) to find any one expert in the
area who understands the theory and practice of all the methods used by
leading health systems. So, I turned to several colleagues and recognized
experts in this area for help. In this book, we have assembled multiple indi-
viduals who have extensive practical and scholarly knowledge around these
topics. These experts share their methods, results, and best practices. All of
them have spent multiple years in a hospital or health organization leading
change, as well as in providing scholarly research in an academic setting.
Each of these authors brings his or her own unique experience and perspec-
tive to these topics, and the book is much more comprehensive as a result.
I asked the authors to write on the topics they are most interested in or pas-
sionate about.
This book should be useful in classrooms, but it is not intended to
be theoretical in nature. I hope it is applied, practical, and actionable.
Healthcare organizations have a long way to go to master their process
workflows, information and management systems, and overall performance.
It is my expectation that this book will significantly advance this discussion
by providing valuable insights into what practitioners are doing to control
and improve their environments.
This book is written for all those in health systems who are charged with
not just maintaining the status quo, but delivering results. Executives, admin-
istrators, managers, analysts, physicians, nurses, and pharmacists all will
benefit from better understanding process and performance improvement.
I think this is a timely and relevant book, as hospitals, clinics, and systems
begin or continue their improvement journey. I hope the chapters in this
book contribute to that outcome.
QUALITY AND I
PERFORMANCE IN
HEALTH

In the first two chapters, we explore the theories and concepts underly-
ing performance improvement. Chapter 1 provides a very in-depth discus-
sion of quality and quality management. Quality pioneers and theories are
described, along with the various perspectives on quality in healthcare.
Chapter 2 describes the link between strategy and operational effective-
ness, and provides a framework for performance management. It is impor-
tant to note that the term performance means different things to different
people, depending on your perspective and the setting. In the retail indus-
try, a customer might consider performance to be the quality of the product
she is buying, while the retail executives might view it as return on assets
or same-store year-over-year sales growth. In healthcare, performance is a
broad and complicated topic. A provider might look at safety or process of
care measures, while administrators and the board of trustees might define
performance in financial terms. Analysts should know that quality and per-
formance management is multidimensional, and is defined by clinical, qual-
ity, financial, and strategic dimensions. Before we try to improve, we need to
know which area we are focusing on.
Chapter 1

Quality and Quality

Management
James Langabeer

Contents
Introduction.........................................................................................................4
Quality.................................................................................................................4
Quality Management...........................................................................................7
Core Components of Quality Management.......................................................9
Planning, Improvement, and Control...............................................................11
Need for Healthcare Improvement...................................................................12
Performance Improvement...............................................................................13
Summary............................................................................................................16
Key Terms..........................................................................................................16
Discussion Questions........................................................................................16
References..........................................................................................................16

An organization’s ability to learn, and translate that learning into

action rapidly, is the ultimate competitive advantage.
Jack Welch
Former CEO of General Electric