In our last post we talked about the importance of proper cleaning in Environmental Services and how many hospitals are unwittingly doing a poor job of it. In a presentation for the CDC on “The Role of Environmental Cleaning in Preventing HAIs”, Dr. Keith Woeltje of the Washington University School of Medicine cited studies that showed that though most hospital surfaces looked clean, their current cleaning program was not effectively removing pathogens. This negligence has serious implications on patient health, namely that it dramatically increases a patient’s likelihood of acquiring a Healthcare Associated Infection (HAI). The primary purpose of his talk, however, was not to point fingers but to provide solutions.

Dr. Woeltje outlined a programmatic approach that was tested in thirty-six hospitals. It started with collecting baseline data on current cleaning effectiveness and ultimately empowered ES staff to engage in an on-going self-auditing process.

Here’s what happened:

In Phase I, rooms that had been terminally cleaned were identified, marked and then evaluated after one or two patient cycles using a fluorescent gel system.

In Phase II, the data from the first phase was used to evaluate the overall effectiveness of the current cleaning program. This information was then used to educate Environmental Services staff about surfaces that were being neglected. It was important that these issues were presented to the ES staff in a supportive, “non-punitive” manner.

During Phase III, the same surfaces were tested again and compared with the baseline data from the first phase.

On average hospitals went from cleaning 45 to 80% of high-touch objects effectively. These are pretty remarkable results considering that they didn’t incur any additional costs in the process.

Staying Power

The only weakness of this type of educational approach was that results tended to be short-term. Though rooms were initially cleaned more rigorously, eventually there was an inevitable drop in results. Dr. Woeltje said that this downward slope could be reversed by continuing to track cleaning efficacy on an ongoing basis and getting Environmental Services staff to feel invested in the results.

One idea he tried was giving each area of the hospital a board dedicated to the specific issues important to that department (e.g. slip/fall prevention, infection rates, etc.). In the Environmental Services department, one issue on their board was cleaning efficacy. Efficacy measurements were regularly updated and posted and every day someone from senior leadership would come by to go over the board with ES staff. A frontline staff member, not the ES manager, would review their current cleaning efficacy rates with that person and describe what practical steps their department was taking to improve these results.

Dr. Woeltje identified the following factors as key ingredients to success in this type of approach:

– Support from upper management
– Buy-in from the ES staff
– On-going attention from managers
– Investment by ES staff in results
– Blameless benchmarking
– Cooperation about problems
– Recognition of success at all levels (i.e. within the ES department and by senior leadership)

One critical point Dr. Woeltje made in his presentation but didn’t elaborate much on was the centrality of process in the success of a cleaning program. He cited a study by Mark Rupp that showed that there is “. . . very little correlation between how much time the environmental services person spends in the room and how clean the room is. . . A lot of it has to do with workflow and efficiency, not that [ES staff] are busy cleaning stuff.” Developing an efficient process is key in sustainable cleaning efficacy. . . but it doesn’t stop there.

Process and People

Training ES staff to deal with other people in the hospital is an essential part of implementing the right process. As Matthew Stowe, OctoClean’s COO, says, “We don’t hire robots to clean buildings. We hire people to clean buildings. And these people have to deal with other people in the midst of trying to get their jobs done. Having a step-by-step, efficient checklist is important but what’s even more important is that you complete it regardless of the outside influencers. You can have the perfect process and all the right equipment and chemical but if you don’t apply them correctly, none of it matters. What makes ES staff deviate from their practices is other people. For example, distractions or resistance from patients, pressure from nursing to turn over rooms faster, and ES supervisors that are themselves responding to these outside pressures and in turn rushing their technicians. Staff need to feel supported by their managers and be trained on how to deal with the various types of feedback, personality types and cultures they may encounter as they go about their work.”

For example, ES need to be trained on how to deal with nursing or other medical staff who:
– think it is more important to get a patient in a room then take the time to clean that room properly
– think ES staff take 30 to 40 minutes to clean a room because they are lazy, not because they are following certain protocol

ES staff also need to be trained on how to deal with patients who may:
– be irritated that they are in their space
– think that they are not doing anything valuable
– want to chat for a long time
– dislike the smell of disinfectants
– have feedback for the ES staff about their work

Raising cleaning efficacy, then, requires a two-fold approach. First, ES managers and supervisors need to train staff on cleaning processes, help these staff become more comfortable and efficient in these processes, and, as Dr. Woeltje suggests, develop a programmatic approach that keeps them invested in their results. In addition, these same managers and supervisors need to protect their staff by training them on how to deal with input from people (patients and medical staff) that would tempt them to alter their processes.

In properly equipping ES staff to maintain cleaning efficacy standards, we are helping them to better fight for the preeminent goal of protecting patient safety.