Major article| Volume 43, ISSUE 2, P147-153, February 01, 2015

Failure analysis in the identification of synergies between cleaning monitoring methods

Published:December 12, 2014DOI:


      The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method.


      FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks.


      FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation.


      When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gordon L.
        • Bruce N.
        • Suh K.
        • Roth V.
        Evaluating and operationalizing an environmental auditing program: a pilot study.
        Am J Infect Control. 2014; 42: 702-707
        • Mitchell B.G.
        • Wilson F.
        • Dancer S.J.
        • McGregor A.
        Methods to evaluate environmental cleanliness in healthcare facilities.
        Healthcare Infection. 2013; 18: 22-30
        • Sherlock O.
        • O'Connell N.
        • Creamer E.
        • Humphreys H.
        Is it really clean? an evaluation of the efficiency of four methods for determining hospital cleanliness.
        J Hosp Infect. 2009; 72: 140-146
        • Carling P.C.
        • Huang S.S.
        Improving healthcare environmental cleaning and disinfection: current and evolving issues.
        Infect Control Hosp Epidemiol. 2013; 34: 507-513
        • Malik R.E.
        • Cooper R.A.
        • Griffith C.J.
        Use of audit tools to evaluate the efficacy of cleaning systems in hospitals.
        Am J Infect Control. 2003; 31: 181-187
        • Griffith C.J.
        • Cooper R.A.
        • Gilmore J.
        • Davies C.
        • Lewis M.
        An evaluation of hospital cleaning regimes and standards.
        J Hosp Infect. 2000; 45: 19-28
        • Lewis T.
        • Griffith C.
        • Galo M.
        • Weinbren M.
        A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces.
        J Hosp Infect. 2008; 69: 156-163
        • Boyce J.M.
        • Havill N.L.
        • Havill H.L.
        • Mangione E.
        • Dumigan D.G.
        • Moore B.A.
        Comparison of fluorescent marker systems with 2 quantitative methods of assessing terminal cleaning practices.
        Infect Control Hosp Epidemiol. 2011; 32: 1187-1193
        • Trajtman A.N.
        • Manickam K.
        • Macrae M.
        • Bruning N.S.
        • Alfa M.J.
        Continuing performance feedback and use of the ultraviolet visible marker to assess cleaning compliance in the healthcare environment.
        J Hosp Infect. 2013; 84: 166-172
        • Galvin S.
        • Dolan A.
        • Cahill O.
        • Daniels S.
        • Humphreys H.
        Microbial monitoring of the hospital environment: why and how?.
        J Hosp Infect. 2012; 82: 143-151
        • Humphreys H.
        • Fitzgerald-Hughes D.
        Search and you will find: detecting extended-spectrum beta–lactamase-producing Klebsiella pneumonia from a patient's immediate environment.
        Infect Control Hosp Epidemiol. 2013; 34: 534-536
        • Hota B.
        • Blom D.W.
        • Lyle E.A.
        • Weinstein R.A.
        • Hayden M.K.
        Interventional evaluation of environmental contamination by vancomycin-resistant enterococci: failure of personnel, product or procedure?.
        J Hosp Infect. 2009; 71: 123-131
        • Vickery K.
        • Deva A.
        • Jacombs A.
        • Allan J.
        • Valente P.
        • Gosbell I.B.
        Presence of biofilm containing viable multi-resistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit.
        J Hosp Infect. 2012; 80: 52-55
        • Huslage K.
        • Rutala W.A.
        • Gergen M.F.
        • Sickbert-Bennett E.E.
        • Weber D.J.
        Microbial assessment of high-, medium-, and low-touch hospital room surfaces.
        Infect Control Hosp Epidemiol. 2013; 34: 210-212
        • Dancer S.J.
        Hospital cleanliness: establishing a new science.
        J Hosp Infect. 2012; 80: 354-356
        • Smith P.W.
        • Beam E.
        • Sayles H.
        • Rupp M.E.
        • Cavalieri R.J.
        • Gibbs S.
        • Hewlett A.
        Impact of Adenosine Triphosphate detection and feedback on hospital room cleaning.
        Infect Control Hosp Epidemiol. 2014; 35: 564-569
      1. Victorian State Government, Department of health state. Cleaning standards for Victorian health facilities. State of Government Victoria, Melbourne, Australia; 2011.

        • Luick L.
        • Thompson P.A.
        • Loock M.H.
        • Vetter S.L.
        • Cook J.
        • Guerrero D.M.
        Diagnostic assessment of different environmental cleaning monitoring methods.
        Am J Infect Control. 2013; 41: 751-752
      2. IEC 31010:2009(E); Risk management – risk assessment techniques: International standards Organisation (ISO). International Electrotechnical Commission, Geneva Switzerland (accessed September 2013).

        • Monti S.
        • Jefferson J.
        • Mermel L.
        • Parenteau S.
        • Kenyon S.
        • Cifellie B.
        Use of Failure mode and effect (FMEA) analysis to improve active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) at a university affiliated medical center.
        Am J Infect Control. 2009; 33: E158
        • Chiozza M.L.
        • Ponzetti C.
        FMEA: A model for reducing medical errors.
        Clin Chim Acta. 2009; 404: 75-78
        • Geum Y.
        • Cho Y.
        • Park Y.
        A systematic approach for diagnosing service failure: service specific FMEA and grey relational analysis approach.
        Math Comput Model. 2011; 54: 3126-3142
        • Australian Council on Safety and Quality in Healthcare (ACSQH)
        National safety and quality health service standards.
        ACSQH, Sydney, Australia2012
        • McDermott R.E.
        • Mikulak R.J.
        • Beauregard M.R.
        • Taylor and Francis Group
        The basics of FMEA.
        2nd ed. Productivity Press, New York, NY, USA2009
        • Xiao N.
        • Huang H.-Z.
        • Li Y.
        • He L.
        • Jin T.
        Multiple failure modes analysis and weighted risk priority number evaluation in FMEA.
        Engineering Failure Analysis. 2011; 18: 1162-1170
        • Derry C.
        • Attwater R.
        Risk perception relating to effluent reuse on a university campus.
        Water. 2006; : 44-49
      3. Rutala WA, Weber DJ. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities. Centre for Disease Control, Department of Health and Human Services, Government of the United States of America, Atlanta, Georgia, USA; 2008.

      4. NHMRC (National Health and Medical Research Council). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Department of Health and Ageing, Canberra, Australia; 2010.

        • Jackson C.
        • Griffiths P.
        Dirt and disgust as key drivers in nurses' infection control behaviours: an interpretative, qualitative study.
        J Hosp Infect. 2014; 87: 71-76
        • Ganime A.C.
        • Carvalho-Costa F.A.
        • Mendonca M.C.L.
        • Vieira C.B.
        • Santos M.
        • Filho R.C.
        • et al.
        Group A rotavirus detection on environmental surfaces in a hospital intensive care unit.
        Am J Infect Control. 2012; 40: 544-547
        • Whiteley G.S.
        • Derry C.
        • Glasbey T.
        The comparative performance of three brands of portable ATP-bioluminometer intended for use in hospital infection control.
        Healthcare Infection. 2012; 17: 91-97
        • Shama G.
        • Malik D.J.
        The uses and abuses of rapid bioluminescence-based ATP assays.
        Int J Hyg Environ Health. 2013; 216: 115-125
        • Whiteley G.S.
        • Derry C.
        • Glasbey T.
        Reliability testing for portable adenosine triphosphate bioluminometers.
        Infect Control Hosp Epidemiol. 2013; 34: 538-540
        • Aitken Z.A.
        • Wilson M.
        • Pratten J.
        Evaluation of ATP bioluminescence assays for potential use in a hospital setting.
        Infect Control Hosp Epidemiol. 2011; 32: 507-509
        • Sciortino C.V.
        • Giles R.A.
        Validation and comparison of three adenosine triphosphate luminometers for monitoring hospital surface sanitization: a Rosetta stone for adenosine triphosphate testing.
        Am J Infect Control. 2012; 40: e233-e239
        • Mulvey D.
        • Redding P.
        • Robertson C.
        • Woodall C.
        • Kingsmore P.
        • Bedwell D.
        • et al.
        Finding a benchmark for monitoring hospital cleanliness.
        J Hosp Infect. 2011; 77: 25-30
        • Gibbs S.G.
        • Sayles H.
        • Chaika O.
        • Hewlett A.
        • Colbert E.M.
        • Smith P.W.
        Evaluation of the relationship between ATP bioluminescence assay and the presence of organisms associated with healthcare-associated infections.
        Healthcare Infect. 2014; 19: 101-107
        • Carling P.C.
        • Parry M.M.
        • Rupp M.E.
        • Po J.L.
        • Dick B.
        • Von Beheren S.
        Improving cleaning of the environment surrounding patients in 36 acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: 1035-1041
        • Carling P.C.
        • Briggs J.L.
        • Perkins J.
        • Highlander D.
        Improved cleaning of patient rooms using a new targeting method.
        Clin Infect Dis. 2006; 42: 385-388
        • Munoz-Price L.S.
        • Fajardo-Aquino Y.
        • Arheart K.L.
        Ultraviolet powder versus ultraviolet gel for assessing environmental cleaning.
        Infect Control Hosp Epidemiol. 2012; 33: 192-195