According to the Centers for Disease Control and Prevention, environmental cleanliness
is a significant mitigating factor for healthcare associated infections and disease
transmission. The purpose of this performance improvement (PI) initiative was to improve
hospital cleanliness, using a multi-disciplinary approach, following a regulatory
visit that revealed several opportunities for improvement.
The setting was a 397 bed, acute-care medical center. The project focused on inpatient
units representing the highest risk to patient safety. A 90% benchmark was established
as a measure of success following process implementations and remediation efforts.
The goal was to improve cleanliness as measured and reflected through compliance audits
focused on regulatory findings. A multi-disciplinary approach was used to address
the findings. Once a corrective action plan was implemented, action items were established.
These included rounding on inpatient units by Infection Prevention (IP) and leaders
from environmental services (EVS), nursing, facilities, medical equipment, and supply
chain to establish cleaning expectations; formulating a riskstratification matrix
tool to assess damaged IV poles for a phased replacement strategy; creating an audit
tool to assess compliance; formulating a cleanliness campaign; and establishing a
cleaning responsibility grid and procedural policy. Point-prevalence audits were conducted
over 8 weeks and sustained through hospital-wide quarterly audits to assess compliance
and track success. Findings were disseminated to unit leaders and placed into an online
tracking system that required timely follow-up.
Initial compliance improved from 63% to 100% over the course of 8 weeks. Sustained
quarterly audit compliance rates averaged 92% over a 4 quarter period. The hospital's
annual accreditation survey resulted in 0 non-conformities related to cleanliness,
with the previous year's non-conformity resolved.
This PI initiative found that by engaging a multi-disciplinary team, hospital cleanliness
can be improved and sustained through a culture of shared responsibility and accountability.