By Kelly M. Pyrek

This article originally appeared in the January 2020 issue of Healthcare Hygiene magazine.

A division of labor in the hospital that is often fuzzy is that of cleaning and disinfection, particularly when it comes to electronic patient-care equipment and surfaces that are not subjected to a clear policy and procedure outlined by the healthcare institution in its environmental hygiene program.

As Dumigan (2008) reminds us, “All healthcare facilities have procedures for cleaning the patient care environment, but in the ‘real world’ experience there is often confusion about the division of labor when it comes to cleaning busy patient-care units and patient-care equipment. With the environment playing an ever-greater role in transmission of multidrug-resistant organisms and gastrointestinal illnesses, it is important to have clear lines of responsibilities for a variety of types of cleaning, along with consistent procedures, and a verification system to monitor effectiveness.”

As a consultant, Linda Lybert, founder and executive director of the Healthcare Surfaces Institute, has observed the confusion that exists as facilities grapple with ownership of cleaning and disinfection.

“It is important to recognize we are dependent on human behavior, which is something we don’t have complete control over,” Lybert says. “Assumptions are quickly made that someone else is responsible for, and critical areas are missed.”

“I have had many discussions with nursing professionals and EVS professionals that, when asked directly, they express confusion over who is responsible for what,” Lybert confirms. “When a problem arises, fingers point in many directions. Training programs for EVS workers provide training and instruction for efficient and effective cleaning and disinfection. Nursing professionals do not receive this training, yet they are often expected to turn over rooms in the emergency department (ED) or perhaps to clean areas of the patient room. It is crucial to note that nursing professionals have primary responsibility for patient care, and the last I checked, the curriculum for nursing school did not also include cleaning and disinfection of rooms, equipment, or furniture. Nurses will focus on patient care and will tell you that comes first, and often time any cleaning and disinfection requests are usually not done.”

Room turnover causes particular consternation, and Lybert recalls conversing with a clinician who confirmed that it is fraught with difficulties.

“I will never forget the conversation I had with an ED nurse who shared with me her frustration when the responsibility for room turnover between patients was their responsibility,” Lybert says. “This was a daunting and often impossible request, which I understood when she told me what she focuses on. When a patient arrives, there is a set amount of time for the patient to be seen, treated, admitted, or discharge. Penalties may apply if patients are not treated promptly. If the ED is busy such as during flu season or if there are several trauma patients at a time, there is no time for a nurse who is focused on patient care to efficiently and effectively clean and disinfect between patients.”

According to the ED clinician Lybert talked to, the ED is considered to be turned over by someone grabbing wipes and wiping down the railings on the gurneys, and then flipping the sheets over and moving the next patient in.
“In defense of the nurse, she was never trained to turn over the rooms,” Lybert says. “She wasn’t sure which wipe to use and used the one that is in the room. Her focus is on patient care.”

Lybert continues, “It is vital to note that EVS professionals came in once a day to do a terminal clean and disinfection, and while there are EVS professionals on staff, they are limited. If there is heavy contamination such as trauma, nursing staff may request help from EVS. In an occupied patient room, EVS professionals are reluctant to touch anything close to the patient. IV poles, medical equipment, monitors, walkers, bed rails, overbed tables, bedside tables, arms of the chairs next to the bed, are all often missed in daily cleaning and disinfection. EVS professionals will tell you those are the responsibility of nursing professionals. Ask a critical care nurse about this responsibility, and they will tell you the focus is on patient care. If something needs to be taken care of, they do it when there is time. I have asked if they receive any training ever for cleaning and disinfection. They may be shown how something is cleaned but no clear directions. They use whatever is available to clean. What is interesting is the instinctual desire of a family to help keep a patient room clean. Are we missing an opportunity here? I am aware of a few healthcare facilities that educate and engage family members in the daily cleaning process. This, however, requires training as well.”

While the best solution is for healthcare institutions to establish and implement evidence-based environmental hygiene programs, additional interventions include awareness campaigns, education and training efforts, and improved communication.

“It is important again to note we are talking about human behavior,” Lybert emphasizes. “I am familiar with a few healthcare facilities that have created in-house educational training programs that are accessed online. EVS staff must complete this program which includes quizzes and hands on training. Completion of this program as well as ongoing performance are a part of staff annual reviews.” Lybert continues, “This program is updated when policies and procedures change. Staff can reference processes and procedures at any time. If nursing staff has responsibility this type of program could be offered to them as well. Family members could access information for simple daily cleaning and disinfection through something similar and could be part of a packet of information when patients are admitted.”

Members of the University of Pennsylvania Health System experienced first-hand what cultivating a shared sense of accountability can achieve in improving environmental cleaning in the healthcare environment. The Hospital of the University of Pennsylvania, 700-bed institution within this healthcare system, created a multidisciplinary-shared accountability model for cleaning the patient environment and equipment, establishing a specific protocol to ensure environments and equipment were clean, staff could speak to the cleaning process, and overall cleanliness was improved.

Uncovering vulnerabilities in the cleaning and disinfection process is often the first step, and as UPHS discovered through its gap analysis, assumptions can be incorrect.

“The initial motivation for establishing the organization’s ‘Who Cleans What’ Committee was to prepare for a major regulatory survey in the next calendar year,” says Betty Ann Boczar, MS, BSN, nursing director of regulatory compliance HUP/CPUP. “This impending regulatory survey prompted the launching of this program as an organizational survey readiness strategy. The ‘Who Cleans What’ committee immediately recognized that they faced a crucial juncture, and the team could implement a cohesive, far reaching and sustainable cleaning and disinfecting plan. Team leaders invested time and resources into changing the culture, and thus moved the initiative beyond just survey readiness. This was done by developing a clear mission, attending to all details, and repeatedly emphasizing the shared accountability of maintaining a clean and safe patient environment.”
Boczar continues, “This model of shared accountability promoted enhanced awareness amongst all hospital employees regarding the importance of a clean environment. The positive outcomes associated with this initiative included improving the patient and employee experience. The initiative correlated with a substantial reduction in hospital-acquired infections. In addition, staff continue to be able to articulate their responsibility for the cleaning process. They demonstrate a clear understanding of the importance of instructions for use (IFUs) in properly cleaning patient equipment. The organization achieved successes are widely shared, and thus support the project throughout the organization and build on momentum.”

The University of Pennsylvania Health System team reports that it accomplished several key objectives through the pilot study.

“Innumerable organizational goals are met by addressing cleaning and disinfecting in a standard, visible and structured way,” says Diane Leichter, director of infection prevention at the Hospital of the University of Pennsylvania. “The most identifiable goal is reducing the chance of transmission of infections. Another goal is to be consistently ready for surveys. Finally, and overlapping with these two goals is the insight that maintaining a clean and safe environment is an underlying precept to reaching the level of a high-reliability organization in healthcare.”

She continues, “During the years prior to this project, leadership teams from all departments including nursing, environmental services, and infection control, to name a few, had done exemplary work preparing their individual departments. The efforts had evolved into an effective but fragmented system that was difficult for employees to speak to. When the ‘Who Cleans What’ team conducted a formal gap analysis, the team identified areas wherein a shared accountability model would better serve key stakeholders and lead to even more improvements, standardization across the organization, and increased survey readiness.”

Leichter says their organization achieved a 40 percent reduction in reportable HAIs. Additionally, it had what she calls “a resoundingly successful” large-scale survey during this past year. “In terms of sustainability, the organization has maintained the initiative for three years at this point,” she adds.

Presenting the study findings to a standing-room-only crowd at a recent annual meeting of APIC, Caroline Haggerty, RN, MSN, MBA, manager of quality and patient safety at Chester County Hospital, says that their push for accountability is resonating with healthcare organizations across the country, indicating that the struggle is real.

“Organizations work consistently to promote a clean and safe environment for patients, families and employees,” Haggerty says. “The challenges are perennial, and the scope of cleaning all surfaces in a hospital environment is vast. An initial step in this project was surveying our employees to measure their knowledge about cleaning and disinfecting the patient care environment. The survey revealed gaps in their knowledge. The team identified the need to focus on standardizing and increasing the visibility of who is responsible for cleaning specific pieces of equipment. The team agreed upon a cleaning philosophy early in our project planning stage; this is essentially a mission statement. The philosophy is shared on all educational tools and job aids created for the project.”

The pilot study showed the benefits of clear lines of demarcation around cleaning accountability and demonstrates that other organization can adopt similar strategies based on their local and global cleaning challenges.

“Consistent, standardized processes for cleaning medical equipment and surfaces in the patient and unit environments is critical to maintain a clean and safe environment,” Haggerty says. “This includes codifying the who, what, when and how of hospital surfaces are to be cleaned. Identifying the pieces of equipment and surfaces that need to be cleaned and referencing the manufacturer’s IFUs was the first step. Next step was to identify which employees were responsible for cleaning what. Once those decisions were made, the team developed a highly visible algorithm for communicating the cleaning requirements for medical equipment in all inpatient units. This algorithm was widely communicated in the form of a professionally designed and colorful cleaning grid. The columns in the grid use the scrub uniform colors as key to reflecting each employee’s role in cleaning. For example, nurses wear a navy scrub and the nurses’ column on the grid was a light navy color. Using the grid, employees easily identify their column and their own responsibilities as well as other employees’ responsibilities. In many instances, responsibility is shared. For example, if a nurse, nursing assistant, or physical therapist use a portable vital sign machine in a patient room it is their responsibility to clean it after use. Employees gave us feedback that visualizing and referencing the grid was an extremely effective communication tool. The visibility of this grid made it simple to convey the plan to surveyors during their recent visit; many surveyors took pictures of our grid citing us for having a “best practice.”

Since the launch of the pilot study, additional work has continued, including ensuring the sustainability of ‘Who Cleans What,’ which was a key imperative for eventually forming the secondary, higher level steering committee, according to Boczar. “Steering committee efforts to ensure sustainability included leadership role modeling, frequent scheduled rounding on the patient care units, engaging frontline staff and widely sharing positive feedback, and positive outcomes,” she explains. “During the summer of 2019, there was a deliberate and focused approach by the steering committee to visit every inpatient unit and measure the compliance with the ‘Who Cleans What’ plan. Unit visits, or rounding, consisted of education and support for all staff. Surveillance included an audit tool which captured the key components of the initiative, such as visibility of the ‘Who Cleans What’ posters, appropriate utilization of green bags to identify clean equipment, verification of approved hospital wipes in patients’ rooms and staff questions about the cleaning process. Simultaneously, there was adenosine triphosphate (ATP) testing done on specific equipment to validate cleaning effectiveness. ATP tests the level of bioburden left on equipment after cleaning. Overall the results were extremely positive, and it was a great way for staff to see the success of their work and the impact to patient safety. Additional strategies include embedding the language into ongoing Environment of Care (EOC) rounds, employee orientation programs, and widespread communication in existing organizational forums and meetings. The team incorporated ATP testing into EOC rounds as a continued monitoring process. We invite the unit employees s to join us as we make the rounds. At the end of rounds, we share the results of the ATP tests. The stakeholders are eager to hear the results to see how successful they are in keeping the environment clean.”

Successful collaboration is a main driver of accountability, and Haggerty describes how stakeholders came together to support the accountability efforts.

“There are multiple healthcare disciplines required to maintain hospital environments that are clean and safe for patients and employees,” Haggerty explains. “The’ Who Cleans What’ team brought these groups together to negotiate solutions that reflect this widespread accountability. One unique supporting resource the ‘Who Cleans What’ team had was an expert project manager assigned and committed to facilitate committee structure. The expert project manager taught the team to utilize project management tools, focus scope and direction, develop educational tools and increase productivity. The team developed a project charter that was iterative, dynamic and inclusive. We decided upon a cleaning philosophy that guided all future project decisions. We met weekly for a year, in order to keep the team on track and moving forward. All disciplines were required to be active participants, and all disciplines were required to identify areas of increased accountability for their own department and suggest changes that other departments might be required to make.”

Leichter reports that the ‘Who Cleans What’ approach was successful for the inpatient units and the patient equipment in these areas. “The initiative has since been rolled out to several specific procedural areas including apheresis and dialysis,” she adds. “In the coming year, the approach will focus on other areas of the organization and across the health system. The goal will be to develop a customized grid delineating the specific plan for cleaning all equipment in every department of the organization.”

The take-away from this pilot study – that every facility can establish better lines of communication around cleaning and disinfection responsibilities – must become ingrained in institutional policy for it to have sustained momentum.

“The philosophy and mission initially developed by the committee has proven to be the most essential aspect of sustainability and alignment,” Leichter says. “Every question that arises is reviewed by every team member using that cleaning philosophy as a lens. The philosophy and mission are embedded into the fabric of each department; every department is proud to share in the successes we have achieved.

Reference: Dumigan DG, et al. Who is Really Caring for Your Environment of Care? Developing Standardized Cleaning Procedures and Effective Monitoring Techniques. Am J Infect Control. Vol. 36, No. 5, Pages E63–E64. June 2008.