MMHA 6900 Week 1 Quality Lineage Review Example

Three Lineages, One Decision: What Juran, Crosby and the Institute of Medicine Would Each Tell a Hospital About Its Heart Failure Readmissions

Student Name

Walden University

MMHA 6900: Healthcare Quality Management

Instructor Name

Month Day, Year

Three Lineages, One Decision: What Juran, Crosby and the Institute of Medicine Would Each Tell a Hospital About Its Heart Failure Readmissions

Purpose

Quality management in health care borrows from several traditions, and the one a leader follows shapes what they do first. This review compares three, the work of Joseph Juran, the work of Philip Crosby and the Institute of Medicine's framing of health care quality, by asking each the same question. Cobalt Ridge Medical Center, an invented 260-bed hospital used throughout this course, has learned from Medicare's public reporting site that too many of its heart failure patients come back within a month of discharge, enough to place it below the national benchmark. Its chief executive has asked the quality director what to do first. Each tradition gives a different first answer, and the differences reveal what each assumes about where quality comes from.

Juran: Plan, Control, Improve

Juran described quality management as three linked processes: quality planning, which designs a process to meet customer needs; quality control, which holds a process at its planned level; and quality improvement, which raises performance to a new level through project-by-project work (Juran, 1988). He insisted that most quality problems come from the system, not from individual workers, and that improvement happens through specific projects with clear owners and resources.

Juran's first answer to Cobalt Ridge would be to charter a project. A readmission rate worse than peers is chronic waste, in his terms, and chronic waste yields to a structured project: define the problem precisely, diagnose its causes with data, test remedies and then hold the gains through control. He would also ask whether the heart failure discharge process was ever planned at all, or simply grew, since a process that was never designed to prevent readmission cannot be controlled to do so.

Crosby: Conformance and Prevention

Crosby defined quality as conformance to requirements and argued that the cost of quality is the cost of doing things wrong, which management should measure and drive toward zero through prevention (Crosby, 1979). His approach emphasized management commitment, measurement of the cost of nonconformance and a culture expecting work done right the first time.

Crosby's first answer would be different. He would ask what the requirements for a heart failure discharge are, whether they are written down and how often they are met. If the hospital has a discharge standard, such as medication reconciliation, a follow-up appointment within seven days and teaching about daily weights, Crosby would measure conformance to each and count the cost of each readmission as a price of nonconformance. His answer leads to clear standards and a business case quickly, but it assumes the requirements themselves are right.

The Institute of Medicine: Six Aims and a System

In its quality chasm report, the Institute of Medicine set out six aims, asking that care avoid harm, rest on evidence, respond to each patient, arrive without harmful delay, waste nothing and serve every group equally well, and it argued that the gap between current care and these aims lies in the design of care systems, not in the effort of clinicians (Institute of Medicine, 2001). It called for redesign around patients' needs, the use of evidence, information technology and coordination across settings.

The Institute of Medicine's first answer would be to look across the transition. Heart failure readmissions often reflect what happens after discharge: whether the patient can get medications, understand them, see a clinician soon and reach help when symptoms return. The six aims would also prompt the question of equity, whether readmissions are concentrated among patients with fewer resources, which neither Juran nor Crosby would necessarily ask first.

The Three Answers Compared

Table 1

What Each Tradition Would Do First at Cobalt Ridge

The traditions are complementary. Juran supplies method, Crosby supplies standards and cost, the Institute of Medicine supplies the system view and the aims.

A Combined First Step

The review recommends a first step that draws on all three. Cobalt Ridge should charter a single project, as Juran would, with a named owner and resources. The project's first task should be to map the transition from discharge to the first weeks at home, following the Institute of Medicine's system view and checking whether readmissions concentrate in particular groups. As the map reveals what a good discharge requires, the project should write those requirements down and measure conformance, as Crosby would, so that improvement has a standard to hold.

This combination echoes the argument Berwick (1989) made that health care should move from inspecting for bad apples to continuously improving the processes that produce care, a view that drew on the industrial quality pioneers and helped bring their methods into hospitals.

Why the Lineage Matters for Leaders

A quality director's training often fixes which tradition they reach for first. Directors from engineering or manufacturing tend to start with projects and control charts; those from finance or compliance tend to start with standards and cost; those from clinical practice or public health tend to start with patients' journeys and disparities. None is wrong, but each has blind spots that the others fill. Knowing the lineages helps a leader notice which questions their own first instinct leaves out. At Cobalt Ridge, the quality director trained as a nurse and would naturally map the patient's journey; the review's value to her is the reminder to give that map a project owner and a written standard, so that what the map reveals is acted on and then held.

Conclusion

Asked what Cobalt Ridge should do first about its heart failure readmissions, Juran would start a project, Crosby would define and measure the standard and the Institute of Medicine would map the system across settings. Each answer is partial. Together they give the hospital a project with an owner, a system map that includes patients' lives after discharge and a standard to hold once improvement is achieved. The lineage matters because it shapes the first step, and the first step shapes everything after.

References

Berwick, D. M. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320(1), 53-56. https://doi.org/10.1056/NEJM198901053200110

Crosby, P. B. (1979). Quality is free: The art of making quality certain. McGraw-Hill.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027

Juran, J. M. (1988). Juran on planning for quality. Free Press.