Background
Contaminated environmental surfaces are a reservoir of pathogens causing healthcare-associated infections (HAIs). Reference Otter, Yezli and French1 While optimal cleanliness to prevent pathogen colonization from the environment is unknown, cleaning practices applied frequently and consistently can reduce the environmental bioburden, disrupting transmission of these pathogens and preventing HAIs. Reference Donskey2
Initiatives to improve environmental cleaning practices have focused on targeted cleaning of high-touch surfaces (HTS) and monitoring of environmental cleaning processes. Reference Sehulster and Chinn3 However, cleaning compliance remains low which may be partially explained by practice variation. Reference Trajtman, Manickam, Macrae, Bruning and Alfa4
Given the importance of effective cleaning of HTS, the Centers for Disease Control (CDC) developed checklists to ensure all steps/actions are taken in cleaning and disinfecting these surfaces. Reference Guh and Carling5 However, a recent systematic review found that checklists in healthcare are often lacking human-centric design. Reference Kramer and Drews6 A recent review of healthcare cleaning strategies highlights the human element in manual cleaning processes and the need to evaluate human factors to improve environmental cleaning quality. Reference Doll, Stevens and Bearman7 Important human factors principles to incorporate in improving cleaning practices include human-centric participatory design to engage end users during development and developing and using mental models (representations formed by a user of a system and or task, such as pictographs of ‘cleaning patterns’ and ‘contaminated/dirty areas’). Reference Edwards Iii, Zagarese, Tulk Jesso, Jesso, Harden and Parker8
To improve cleaning compliance in HTS-occupied rooms, we conducted a quality improvement (QI) intervention pilot project to modify and evaluate a daily cleaning checklist using a human-centric, participatory design to evaluate mental models of environmental. Because our preliminary work found patient presence in the room was associated with lower cleaning rates, Reference McKinley, Goedken and Balkenende9 we included VA’s internal housekeeping service (environmental management services, EMS) staff and Veteran patients as participants. EMS staff follow evidence-based practices including CDC resources; however, individual VA facilities have latitude on implementation (e.g., training, procedure development).
Methods
We engaged EMS staff and Veteran patients to modify the CDC checklist for daily cleaning of HTS in occupied rooms. A Plan-Do-Check-Act cycle (Supplemental Figure 1) was used to develop, pilot, and evaluate the modified checklist intervention in acute and long-term care settings at one VA Hospital. The project was determined to be QI.
Plan
We conducted two focus groups (one with Veterans and one with EMS staff) to identify checklist modifications that may address barriers and facilitators of cleaning occupied rooms. Veterans from an existing patient engagement panel and EMS staff were purposively sampled (in collaboration with EMS supervisors) for focus group participation. Participants viewed an illustration (Supplemental Figure 2) depicting patients and EMS interacting during the daily cleaning process. Trained QI team members used a semi-structured interview guide to ask participants about 1) patients’ and EMS’s possible notions upon EMS entering the patient room and 2) how these insights could be addressed during the cleaning process.
Do
The QI team used these responses to modify the CDC checklist (Supplemental Figure 3), focusing on changing mental models for cleaning patterns and surface area during checklist application.
The checklist intervention was piloted to evaluate its effectiveness on HTS cleaning. The QI team provided “just-in-time” training on the modified checklist to four EMS staff, all of which were included in the pre-intervention focus groups.
Check
To evaluate HTS cleaning, trained researchers conducted direct observations of EMS staff performing daily environmental cleaning of patient rooms. The data collection tool was developed and utilized previously by the team. Reference McKinley, Goedken and Balkenende9 Observations were pre-arranged with EMS supervisors for one-week periods during the pre-intervention phase (no checklist) and intervention phase (checklist); observers rounded daily on acute and long-term care units and observed EMS activities to note which HTS were cleaned during daily room cleanings. Cleaning adherence rates (number of surfaces cleaned/total number of surfaces) were calculated before and during use of the modified checklist. Pre- and post-intervention cleaning adherence rates were compared using paired t-test.
Act
Post-intervention interviews were conducted with EMS staff to evaluate checklist usability. All interviews and focus groups were audio-recorded, transcribed, and analyzed using rapid qualitative inquiry methods. Reference McKinley, Goedken and Balkenende9
Results
The Veteran patient (N = 8) and EMS staff (N = 5) focus groups identified recurrent themes of discomfort cleaning HTS within patients’ vicinity and having physical barriers (e.g., clutter) to accessing HTS.
“If you’re wiping the rails while they’re in bed, they [the patient] don’t like that.” [EMS]
“When you have the bed table, sometimes it’s just loaded with stuff. You can’t clean it anyway.” [EMS]
“[The checklist says] ‘bed rails, if the patient isn’t in it.’ I didn’t leave that bed for 30 to 40 days. That’s why they didn’t clean my bedrails.” [Veteran]
“Or every nurse comes in and brings this in, and pretty soon that counter is so cluttered that nobody will wipe that counter.” [Veteran]
These perceived barriers were addressed by incorporating two changed mental models into the checklist (Figure 1):
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1) start the cleaning pattern with HTS near the patient first (‘dirty to clean’) rather than ending with those HTS (‘clean to dirty’)
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2) clean any possible surface area when encountering clutter (‘partial surface is better than no surface’) rather than skipping the entire surface if it cannot be cleaned (‘all surfaces or nothing’)
Figure 1. Modified mental model: a. cleaning patterns and b. cleaning surface areas.
Direct observations showed that cleaning compliance improved from 36% (N = 9 rooms; 89 surfaces) before using the checklist to 75% (N = 10 rooms; 93 surfaces) when using the modified checklist (Table 1).
Table 1. Check phase (observations): high-touch surface cleaning compliance
Note. *P < 0.001.
Post-intervention interviews were conducted with EMS staff (N = 2) to assess checklist usability. Participants reported ease of using the checklist and discordance of modified cleaning patterns with previous training and practices.
“[The checklist] is reasonable because it doesn’t take that much time.”
“The rail is something that we were never told to do, but I’ve been trying to do those.”
Discussion
Our study found that HTS cleaning rates were improved using an HTS cleaning checklist with modifications to mental models of cleaning patterns and surface area.
Current cleaning checklists do not address contextual factors of navigating the environment surrounding patients. Our work has shown the presence of patients in a room is a barrier to cleaning HTS. Reference McKinley, Goedken and Balkenende9 Modifying checklists through human factors principles—such as engaging key participants (end users) in re-evaluating existing mental models—may address this gap. Further evaluation is needed to understand the potential role of checklists and other human factors approaches in reducing practice variation and improving cleaning.
This QI study was limited to one site and the number of observations is not sufficiently powered for results to be conclusive. Further, limited interviews and focus groups were conducted. Participant and observation bias are possible because EMS staff used to inform checklist modification were also observed during the intervention and EMS staff were aware of observations during cleanings due to the nature of direct observations.
This study provides considerations for updated models for daily cleaning of HTS in occupied patient rooms. Further research is needed to evaluate this checklist and modified cleaning processes in a larger sample of care settings. Overall, human factors tools and approaches are useful to navigate the complex intersection of patient care and environmental cleaning.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ice.2024.112.
Acknowledgements
This work was supported by the SHEA 2021 Research Scholar Award and Merit Review Award #HX002332 from the United States Department of Veterans Affairs Health Services Research and Development Service and by the Clinical and Translational Science Award program, through the National Institutes of Health (NIH) National Center for Advancing Translational Sciences, grant UL1TR002373. The funding sponsors were not involved in the preparation, submission, or review of the manuscript.
We thank the patient and Veteran members of the UW—Madison and Madison VA Patient Engagement in Education and Research Group for their partnership in our HAI prevention research. We thank the VA employees and Veterans who participated in the QI project for their time and willingness to share their experiences.
Competing interests
All authors report no conflicts of interest relevant to this article.
