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Cleveland Clinic: Quality of Improvement Journey

A recent report by Sollecito and Johnson (2013) revealed that about 48000 lives are lost yearly because of the infection of Methicillin-resistant Staphyloccus Aureus (MRSA) and Vancomycin-resistant Enterococci (VRE) bacteria. These two types of bacteria are known to resist some of the most effective antibacterial medicines which are currently in use. Majority of those who get colonized by these bacteria are hospitalized patients who fail to take care of their hygiene. It is necessary that a solution to this problem is found. For this reason, the researcher has selected a nursing indicator that would be able to address the problem in both public and private hospital in the country. The researcher chose Cleveland Clinic as the preferred institution where the identified procedures shall take place. The process chosen is a regular hand wash by the patients, nurses, and any other medical officers who handle various patients within this hospital. The research by Spath (2014) confirmed that the main mode of transmission of the two types of bacteria is through dirty hands which handle a colonized patient and proceeds to handle MRSA or VRE-free patients without cleaning.

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The research by Lighter (2011) at John Hopkins Hospital revealed that the rate of patient-patient bacterial infection reduced by 85% when the facility introduced a compulsory hand washing procedure for patents when leaving their beds or coming into their beds. The rate of nurse-patient bacterial infection was also reduced by 93% because of this new procedure at this facility. There researcher believes that if it was successful at John Hopkins, then it may work in this institution to help in addressing the problem of patient-patient or nurse-patient MRSA or VRE infection at this facility and many other healthcare institutions in the country.

A number of quality improvement models have been commonly used in the medical sector to help address various quality issues. Six-Sigma is one of the quality improvement models that have been used for a long period. Other common models include FADE and PDSA. Although these models may be applicable in addressing the issue that has been identified at this institution, they are too general to produce the impact needed at this stage. Moreover, they are more focused on issues to do with production, and this make them less appropriate for a project that involves hand washing. For these reasons, the researcher chose to use ISO 22000 Hygiene Certification. According to Lighter and Fair (2004), ISO 22000 Hygiene Certification has gained massive popularity when addressing the problem of hygiene. This quality model integrates principles of Hazard Analysis and Critical Control Point, which makes it the perfect model to address the problem of hygiene at any hospital (Lloyd, 2004). It is important to note that this is a continuous quality management process, as shown in the diagram below.

Continuous Quality Improvement Model

Continuous Quality Improvement Model

As shown in the above diagram the first step involves identification of the problem, which in this case is the spread of MRSA and VRE bacteria from one patient to another due to poor hygiene in the healthcare facility. The second step would be to identify carries. The research has been able to determine that nurses, patients, and other attendants are the carries of these two types of bacteria. The third stage is to determine the solution, which is specified as a regular hand-wash as specified in ISO 2200 Hygiene Certification. Finally, the outcome of the process shall be determined before starting all over again.

The primary measurement that will be used in this nursing indicator is the percentage reduction of cases of nurse-patient or patient-patient MRSA and VRE bacterial infection within Cleveland Clinic. The goal in this nursing indicator is to achieve a 99.99% reduction of patient-patient or nurse-patient MRSA and VRE infection within this facility. As mentioned before, this nursing indicator had achieved 85% reduction of patient-patient and 93% reduction of nurse-patient bacterial infection at John Hopkins. This success can be outsmarted at this facility if proper procedures are employed.

According to McLaughlin, Johnson and Sollecito (2012), some ethical dilemmas may arise when addressing sensitive issues within an organization. Most of the people who are expected to impellent these new processes are adults. When issues about hygiene are mentioned, others tend to develop a feeling that their level of hygiene is being questioned. It is necessary to address such dilemmas. Everyone who may be affected with this new policy should be informed about the importance of the procedure. They should be informed that although hands may be clean, any moment they come into contact with any object within the facility, they easily get contaminated. It is in such environments that MRSA and VRE thrive. The only way of fighting these deadly bacteria is to maintain a regular hand wash, especially after coming into contact with any object within the healthcare facility. This may help in addressing the dilemma.

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The Team

In order to realize success in this activity, it is necessary to embrace teamwork. There must be a concerted effort by the concerned stakeholders to find a lasting solution to this problem. The superintendent of nurses may assume the duty of the project leader, while all the nurses will be project members. Patients will be the target group that must be protected from any form of bacterial infection, especially the MRSA and VRE bacteria. The structure below shows a simplified leadership structure that will be used to implement the new strategy.

The Team

As shown in the above diagram, the project leader shall have a supervisory role over the project members. The project members will be expected to make regular reports about any cases of transmission of the bacteria from patient to patient or from nurse to patient.

The team members are expected to work on a rotational basis after every one week. Before taking over a given ward, the new group of nurses- with the help of the relevant doctors- will conduct a check up of the patients to determine those who are colonized by the two viruses, and those who are free from the viruses and make a documentation of this information. After a week, a new group shall take over control and determine if the previous team of nurses managed to prevent the transfer of MRSA and VRE bacteria from one patient to the other. This will be a continuous rotational process that is expected to last forever. The method can also be used to check the spread of many other infectious diseases within the wards. The decision to use this rotational strategy is based on the industry’s best practices that have been commonly applied by Mayo Clinics and John Hopkins with tremendous success. It is believed that it will also be a success at this institution.

The project leader in this project is expected to have some qualities that will help in making this process a success. The most important quality expected of such a leader would be transformational leadership traits. The nurse must be able to bring all the other nurses together, convince them that this procedure is necessary, and practically lead them into its application. The leader should also have proper communication skills. As mentioned before, some members of this organization may resist this new procedure that is to be implemented. It is the responsibility of the leader to convince them that this process is necessary and is not intended to intimidate anyone. This needs superior communication skills. Although it may be necessary to have a transactional leader to initiate and support change, success can best be achieved by a transformational leader because he or she has a higher capacity to motivate employees to accept change. In order to ensure that the staff embraces workplace changes, the senior leaders may need to have some specific managerial attributes. One such attribute would be the ability to listen to varying views and negotiate a common ground for all. It is expected that different people will have different views about what is supposed to be implemented and what is to be ignored. Success can only be achieved if these varying views are brought together.

It is the responsibility of the leader to ensure that these varying views are brought together to share a common course. Another important attribute is the ability to initiate or embrace change within an organization. Some leaders are known to oppose change. In order to achieve the desired success, the management must be ready to embrace and initiate change within the organization as may be necessary. They should lead others into adopting new practices. It is important to note that the role of the senior leader will evolve throughout the quality improvement journey. When initiating this project, he or she is expected to take lead in most of the activities. However, he will need to delegate the duties to junior officers as people get used to the new system. It is also predicted that that the leader may need to embrace emerging technologies in communication to enable him or her to monitor and control activities of the members without necessarily going to the wards. As the team grows, it is expected that the role of the senior leader may change towards managerial duties than leadership. This is so because he may not be present all the times at the units of the organization.

Evidence-Based Practices and Action Plan

According to the research conducted by Besterfield (2011), the number of people lost due to infection by MRSA and VRE is on the rise. The scholar observes that in the last five years, over 200,000 people have perished because of these antibiotic-resistance bacteria, and the statistics shows that the number is increasing. This grim statistics is confirmed by Oleske (2009) who says that many patients pass on because of the infection by MRSA and VRE which is very common in many hospitals in this country. Most of the healthcare institutions in this country have not been able to come up with proper measures which can enable them to fight these bacteria. The bacteria thrive in a dirty environment. Charantimath (2006) says that the main mode of transmission is through contact, and people at risk are the in-patients in these unhygienic hospitals. The most common mode of transmission is nurse-patient contact. This occurs when a nurse handles a colonized patient, and fails to wash the hand before handling a second patient who is not colonized. The second patient who is not colonized may be affected by the bacteria. The second mode of transmission is through patient-patient contact. This is a case where an MRSA and VRE-free patient comes into contact with a colonized patient and fails to wash his or her hands effectively. The bacteria collected from the colonized patient will find its way into the MRSA or VRE-free patient mostly through food intake (Hill, 2008).

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The primary causes of the problem are unhygienic practices in most of the healthcare institutions in this country. Morfaw (2009) says that it is okay to allow close interaction between patients within a given ward. However, this interaction has been one of the main reasons why some patients acquire diseases that they were not hospitalized for in the first place. When patients are allowed to share food freely without observing proper hygiene standards, chances of MRSA and VRE spreading to other patients becomes very high. Although the two are very deadly bacteria once they get into the human system, they can easily be fought by maintaining appropriate standards of hygiene within these healthcare institutions. As Hill (2008) says, hygiene is a simple but very important routine in hospitals that is always ignored by many stakeholders.

A cause and effect diagram would be appropriate in developing a comprehensive understanding of how these bacteria always find their way into the system of MRSA and VRE-free patients.

Fish Borne Diagram Showing the Cause and Effect in MRSA and VRE
Fish Borne Diagram Showing the Cause and Effect in MRSA and VRE.

As shown in the above fish borne diagram, all these factors which leads to infection by these bacteria is because of poor standards of hygiene. A further analysis can be conducted quantitatively using drill down analysis. This involves developing layers of data that can help in supporting the arguments of the analysis. It has been mentioned that within the last five years, close to 200,000 patients have succumbed to MRSA and VRE. The data also reveals that last year over 48,000 people were lost. This demonstrates that there is a rise in the rate of infection as shown in the diagram below.

The Rising Rate of MRSA and VRE Fatalities in Hospitals
The Rising Rate of MRSA and VRE Fatalities in Hospitals.

From the diagram above, there has been a consistent rise in the cases of MRSA and VRE fatalities in the hospitals from 2009. This means that the number of those who get infected with the bacteria is even higher. This is not the first time that this problem has been discussed in this country. It is worrying that instead of the rate of infection and fatalities going down, it has been steadily rising in most of the hospitals. According to the research by Lloyd (2004), the infection is more common in public hospitals where standards of cleanliness are poor, especially in the wards.

Action Plan

This research has confirmed that the main reason why the bacteria spread easily in the wards is because of poor hygiene in the wards, especially among the patients and some of the nurses. It is also confirmed that washing of hands is one of the perfect ways of fighting this infection among patients. The action that is most appropriate for this case would be a comprehensive plan on washing hands by all the stakeholders involved as per the requirements set by ISO 22000 Hygiene Certification. This will take place at different levels. The team chosen to participate in this project has to ensure that the policies at all these levels are closely followed to enhance effectiveness of the program.

Level 1: The patients

In this first level, the nurses will introduce a policy among the patients where they will have to wash their hands when they leave their beds and when they come back, irrespective of whether or not they have handled anything. In order to achieve success at this level, the administration will have to increase the number of sinks within the wards. Each patient should have his or her own sink where he or she can wash hands without sharing the soaps or the taps with other patients. This is one of the ways of controlling the spread of the two bacteria. This means that when colonized patients leave their beds, they will have to wash their hands before handling anything or coming into contact with anyone. The bacteria will be washed away, decontaminating their hands. It would be safe for others to come into contact with their hands. For a patient who is not colonized by the bacteria, they will have to wash their hands when they leave their beds, a process that is expected to destroy any bacteria that they could have carried from the objects or people they handled. The nurses participating in this project is expected to monitor this process.

Level 2: The nurses

The nurses must also ensure that they actively participate in the hand washing project because they also contribute to the spread of the bacteria. All the nurses will be expected to wash their hands immediately after handling any patient within the wards. This will not only protect them from contracting the bacteria, but also prevent the possibility of spreading it to other patients or other people. The nurses will also be expected to wash their hands before handling their patients. This would help in protecting the patients in case the nurse had touched any contaminated object.

Level 3: Other attendants

There are other attendants who are responsible for cleaning the wards or distributing foods to the patients. They will also be expected to take part in the hand washing project. Before handling any food material, they will have to wash their hands thoroughly. They are also not expected to have a direct body contact with any patient when they are serving the food. Cleaners must ensure that they avoid bodily contact with the patients.

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Level 4: Visitors

All the visitors to the wards may be prime agents for the spread of the bacteria. A clear policy should be developed that requires all the visitors to wash their hands before coming into contact with their patients. They must also avoid any attempt to have bodily contact with other patients within the ward besides the one they have come to visit. They must wash their hands as they leave the facility to ensure that they are not infected with the bacteria, just in case their patient is colonized.

Effectiveness of the initiative in mitigating the risks and improving health

This initiative is very effective in minimizing the rate at which MRSA and VRE bacteria is spread from one patient to the other within the wards. It is confirmed that the bacteria is majorly spread when the hand comes into contact with bacteria by handling an infected person. It is easily introduced into the body through ingestion when a person with such contaminated hands eats something without washing the hand. For this reason, the best way of eliminating the risk of infection is to introduce a policy that will encourage washing of hands as frequently as possible. This may help in reducing the possibility of the bacteria spreading from one person to another. Even in cases where someone comes into contact with a contaminated object, the policy of washing the hands before getting to bed and before eating may lower chances of infection.

Cost effectiveness of the initiative

This initiative is highly cost effective to the health institutions that decide to implement it. The workforces that will be used in the initiative are the nurses working at the facility. This means that there is no extra labor cost to be incurred in case it is implemented. The items that are needed to effectively implement the strategy are also cheaply available. The facility may need to buy hand washing liquid soap for every patient in case the patients may not be able to buy them. This can be factored into the bill for the patients, which means that the cost can be easily transferred to the patient. The liquid soap is cheap and cannot strain the hospital financially. The third item needed is tap water, which should be available in any standard health institution. The last item that is needed is time for the nurses who are expected to participate in this project. At least one nurse will be needed in a ward at a time to ensure that the policies set are adequately observed. The management of the hospital is expected to set some finances to buy the liquid soap. They should also be willing to reschedule the nurses as per the request by the team leader so that at least one nurse will be present in each of the wards.

Summary of the Impact of the Team Process on the Nurse Sensitive Indicator

It is expected that the impact of the team process on the nurse sensitive indicator will help minimize the rate of MRSA and VRE bacterial infection within Cleveland Clinic. The analysis of the impact of the hand washing project will be done quantitatively, on a monthly basis. After every one month, an analysis will be conducted to determine the improvements that have been achieved in terms of reduction of rates of infection of these bacteria per month. The figure below shows the expected reduction rate of the infection from what is the case currently, to what we expect to achieve after nine months.

Reduction in Rate of Infection.
Reduction in Rate of Infection.

It is expected that with the right implementation of this project which is in line with ISO 22000 Hygiene Certification, there will be a reduction of the rate of infection from the current 534 patients per month to less than five patients per month within the last nine months. This massive reduction in the rate of infection is the main objective of this project. It is also expected that within the next nine months, there will be a zero rate of infection with these bacteria within Cleveland Clinic. The patients will no longer be at risk of infection of MRSA and VRE bacteria when they are hospitalized at this facility.

The quality improvement model chosen for this study is the ISO 22000 Hygiene Certification, and the timeline below will define the expected changes in terms of percentage as per the given duration.

Timeline of the Milestones.

Timeline/ Milestone
(% Reduction)
June July Aug Sept Oct Nov Dec Jan Feb
June The Start
July 12%
August 23%
Sept 37%
Oct 49%
Nov 62%
Dec 75%
Jan 89%
Feb 98%

As shown in the timeline above, it is expected that by the end of the ninth month, there will be a 98% reduction in the rates of infection. The diagram above shows the expected trend of the changes that will be expected when this project is implemented effectively. The guiding principles will be those of ISO 22000 Hygiene Certification.

Summary of the Positive Attributes of the Team Process in Creating Improvement

According to Mohanty (2008), achieving success in a group can be a big challenge because different individuals think differently when it comes to approaching some tasks. It is important to find a way of creating uniformity within the group in order to forge ahead with a common goal and a common strategy. In order to create improvement that is intended in this project, there must be some positive attributes that should be observed by the team members including the senior leader. The following are the desirable attributes that should be observed by the team members.

Motivation to improve morale

It is necessary to ensure that all team members are constantly motivated to ensure that they remain dedicated to their work. Motivation of the members is a responsibility of every member of the organization. The leaders are expected to respect their juniors when directing them to various duties. Members should not be overworked because this may lower their motivation. Fellow team members should encourage one another and avoid any statements that may demean the work of other team members.

Conflict resolution strategies

The leadership of the team should develop appropriate conflict resolution strategies among the team members. Negotiation between the conflicting parties should be encouraged. In case this fails to yield fruits, the last option should be arbitration by the team leader. All conflicts must be resolved internally. Chances of resolving conflicts through channels outside those that are defined within the project should be highly discouraged.


Negotiation should be highly encouraged whenever the team members have conflicting opinions about a task that should be handled or any other personal issues. In order to achieve success through negotiation, all members of the team must appreciate the diversity that exists in the group, and the fact that solution can only be achieved internally.

Role of the senior leader in securing resources for the team

The senior leader has the responsibility of ensuring that the needed resources are made available to the team members. He is the direct link between the team members and the top management of the hospital. The resources specified in the sections above must be available before the project is initiated.

Team dynamics

There are some changes that may be experienced in the process of implementing the project. According to Morfaw (2009), it is always difficult to introduce some changes within an established system. However, this team will need to find a way of embracing the changes that may occur in the process of implementing the project. The team members should remain dynamic in order to ensure that they deliver superior services in every task that is assigned to them.


Cleveland Clinic is one of the best healthcare facilities in the United States. However, the frequent infection of the inpatients by MRSA and VRE bacteria is raising concerns among stakeholders. The main cause of this infection has been determined to be poor hygienic standards by the nurses and patients. In order to combat this problem, a team of nurses will need to introduce a regular hand washing campaign among all the people who visit the wards, including the nurses and patients. Using ISO 22000 Hygiene Certification principles, the team members must appreciate the fact that quality improvement is a journey.


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