Acheiving Sustained Improvment in Environmental Hygiene Using a Coordinated Benchmarking in 12 Hospitals

Background:   Microbial contamination of the near patient environment has become increasingly recognized as having a role in the transmission of healthcare associated pathogens.  Indeed, since 2007, the Center for Medicare Services has required that “The infection and prevention control program (for healthcare facilities) must include appropriate monitoring of housekeeping activities to insure that the hospital maintains a sanitary environment”(CMS, Condition of Participation Guideline 482.42.). 

Objective:   In order to determine if a previously validated indirect method of analyzing the thoroughness of disinfection cleaning (TDC) could serve as a benchmarking metric, we undertook a prospective analysis of 12 related acute care hospitals within a single healthcare system to assess the potential impact of such a coordinated program in achieving process improvement. 

Methods:   The 12 hospitals ranged from 200 to 500 beds and included both tertiary and secondary care institutions.  The TDC of 14 high touch objects was evaluated at the time of discharge using a fluorescent dye based targeting system.  A structured three phase intervention was then utilized as previously described (ICHE 2008; 29:1035-1041).  During each phase, cleaning scores (proportion of objects cleaned) were provided to the environmental services staff and each hospital's leadership and were reviewed on a regular basis during system-wide quality assurance meetings where they were further analized.

Results:   Covert pre-intervention analysis of the TDC of  5040 surfaces in 360 patient rooms in the 12 hospitals disclosed cleaning scores ranging from 3  to 71%.  Following structured educational interventions with environmental services personnel (Phase II), scores improved to between 24 and 98% with  5 of the hospitals scoring greater than 80%.  Following education, further analysis of TDC was undertaken and feedback provided (Phase III) which led to scores improving to between 53 and 96 %.  Cyclic re-monitoring and feedback as well as ongoing discussion at monthly system-wide review sessions led to a sustained high level of terminal TDC (greater than 85%) in 11 of the 12 study hospitals.

Conclusions:   1.)  Phase I of the study disclosed previously unsuspected differences in TDC despite the existence of essentially identical terminal room cleaning policies in all hospitals.  2.)  Rapid improvement in TDC following educational alone was realized in 10 of the 12 hospitals prior to inter-group benchmarking.  3.)  Group benchmarking of TDC scores substantially facilitated further improvement in cleaning.  4.)  The ongoing transparency engendered by the system-wide program has facilitated the ability to sustain gains over time.  5.)  A patient safety oriented, non-punative environment as well as individual hospital and system-wide leadership support were critical components of the success of the program.