Improving Daily Patient Room Cleaning: An Observational Study Using a Human Factors and Systems Engineering Approach

OCCUPATIONAL APPLICATIONS

Environmental care (EVC) associates are often considered solely responsible for suboptimal cleaning of patient rooms. Thus, performance improvement efforts have focused on EVC monitoring and training. Little attention, however, has been paid to the large work system that may impede the performance (e.g., completeness of cleaning, efficiency) and well-being (e.g., job satisfaction, burnout) of EVC associates. Using a human factors and systems engineering approach, we conducted observations of EVC associates performing daily patient room cleaning and identified various work system factors that could influence the quality of daily patient room cleaning (e.g., patient and family presence, cleaning patterns, interruptions). Effective and sustainable interventions for improving daily patient room cleaning need to address these factors by redesigning the work system and the cleaning process.

TECHNICAL ABSTRACT

Background: While playing a critical role in preventing healthcare-associated infections, patient room cleaning is often unsatisfactorily performed. To improve patient room cleaning, a human factors and systems engineering (HFSE) approach is needed to understand the complex cleaning process and associated work system factors. Purpose: We conducted an observational study to assess the performance of environmental care (EVC) associates during daily patient room cleaning and identify work system factors influencing their performance. Methods: This study was conducted in eight adult medicine inpatient units at a large urban academic medical center. An HFSE researcher shadowed 10 day shift EVC associates performing daily patient room cleanings and used a semi-structured observation form to collect quantitative data (e.g., duration of room cleaning, orders for surface cleaning) and qualitative data (e.g., challenges to patient room cleaning). Descriptive statistics (e.g., median, interquartile range) were reported for cleaning performance, and bivariate and regression analyses were conducted to identify factors influencing cleaning performance. We also performed link analyses of the workflow of EVC associates and qualitative analyses of observer notes to identify challenges to daily patient room cleaning. Results: We observed 89 patient room cleanings. Median duration of cleaning a room was 14 minutes, and median percentage of surfaces cleaned in a room was 63%. High-touch surfaces that were frequently missed during daily cleaning included the bedrails, telephone, patient and visitor chairs, and cabinet. Work system factors that could influence cleaning performance included the type of unit, the presence of the patient and family members in the room, cleaning patterns and orders of EVC associates, and interruptions EVC associates encountered while cleaning. Conclusions: Daily patient room cleaning was influenced by a number of work system factors. To improve daily patient room cleaning, multifaceted interventions are needed to address these system-level factors.

Keywords:

• Infection control
• healthcare environmental hygiene
• daily patient room cleaning
• human factors engineering
• systems approach
• observations

ACKNOWLEDGMENTS

Authors would like to thank members of the Environmental Care Facilities Department and the Department of Hospital Epidemiology and Infection Control at the Johns Hopkins Hospital for their support throughout this study. They would also like to thank Christine G. Holzmueller, BLA from the Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine for reviewing and editing the manuscript.

Additional information

Funding

This study was supported by the Centers for Disease Control and Prevention (CDC) Prevention Epicenter Program (3U54CK000447).