Cleanliness is Contagious: Analyzing the Significance of HCAHPS' Question 8

By Kelly Teal

With flu season around the corner and the latest Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) deadline just passed, now seems the ideal time to explore the issue of cleanliness, the topic of Question 8 of that quarterly survey. Almost every aspect of the healthcare environment involves decontamination. After all, a hospital is the last place where germs should flourish and spread. And these days, with the HCAHPS reporting mandate in place, the subject of cleanliness – and the poll’s other questions as well – has become even more important. Patients’ responses to HCAHPS influence a hospital’s reputation and finances. Therefore, as fall and winter bring bouts of flu cases and facilities aim to stay at the top of their survey scores, some pointers on cleanliness principles and procedures may be what the doctor ordered.

HCAHPS is a 32-question, random patient-satisfaction survey that measures quality of care. It is administered by phone, mail, mail and phone, and interactive voice response, after adult inpatients (except those admitted for psychiatric reasons) leave the hospital. Questions run the gamut. Several cover whether a patient felt nurses and doctors listened, and treated him or her with respect. Others probe how quickly or whether help was provided when the patient requested it. Still more examine areas such as pain control, quiet hours, dissemination and understanding of information, and views on that specific hospital. The remainder inquire about the patient’s overall health, education and home life. But one of the most crucial questions, No. 8, asks about cleanliness: “During this hospital stay, how often were your room and bathroom kept clean?”

Since March 2008, the Centers for Medicare and Medicaid Services has required United States hospitals to conduct HCAHPS surveys and submit the results every three months (the survey is not restricted to Medicare recipients). The data are available on the Internet, which means patients can view other consumers’ observations of a facility and make informed decisions about where they want to go. In light of that, hospitals have incentive to earn positive feedback. The higher the ratings, the more funding an institution receives from the government. Sources agree, however, that money cannot be the driving factor in pursuing high HCAHPS rankings. They say this is especially true of Question 8 because “the real purpose of cleaning and disinfection is patient safety,” says Barbara Smith, RN, BSN, MPS, CIC, of Mount Sinai St. Luke’s/Mount Sinai West Hospitals. ”I think we need to be careful that the financial emphasis is not the main focus.”

Educate, Communicate, Cooperate
Ensuring that everyone from housekeepers to nurses knows the chief reason for cleanliness starts with the infection preventionist. This is the person who must educate, communicate and get all involved teams to cooperate on reaching the same goal: Maintaining patient safety.

Begin by fostering a culture of mutual assistance. Smith, who teaches an infection prevention coaches course, has found that environmental services workers can’t achieve a hospital’s desired cleanliness levels all on their own. “They need the support of the other staff, especially nurses and nursing attendants,” she said. That’s because areas such as the bedside table can hinder their work. When the table grows cluttered with a cell phone, papers, water pitchers and other personal belongings, “the housekeeper may not feel comfortable approaching the patient about moving these items,” Smith says. “Thus, teamwork is vital.”

Apropos of that, asking clinicians to explain to the patient why the housekeeper must move possessions can prove “a tough argument when workloads get high,” said Timothy Bowers, MT (ASCP), MS, CIC, corporate director of infection prevention and control for Inspiria Health Network. Do it anyway. “Cleanliness is up there with hand hygiene as some of the best horizontal interventions to prevent the spread of disease,” Bowers says. “As difficult as those conversations can be, they will lead to better outcomes for our patients so they are absolutely needed.” Besides, when everyone recognizes they can and should aid each other, patients will intuit that their well-being comes first. “If clinicians know the way something is supposed to be done, they are more apt to help identify when it isn’t being done correctly,” Bowers says. “And conversely, if housekeeping sees something out of place, they speak up for safety.”

It further is appropriate – and even a best practice – to call on the patient to take part in his or her own cleanliness care. “They, too, have a role,” Smith says. To that point, give patients tips for keeping germs at bay. The Association for Professionals in Infection Control and Epidemiology – Smith and Bowers both serve on the organization’s Communications Committee – offers resources on this front.

But don’t stop there. Equip housekeepers to talk with patients without the presence of nurses or other busy coworkers. Smith recommends training these employees to use a script. One goes by the acronym AIDET:
• Acknowledge – Greet the patient by name
• Introduce – Yourself
• Duration – Say how long the task will take
• Explanation – Tell the patient what you are doing and why
• Thank You – Wrap up and ask if the patient needs anything else

Of course, housekeepers can create accidental confusion with this approach, too, something infection preventionists will want to try to avoid.

Once, when Smith’s father-in-law was hospitalized, the housekeeper poked her head into the room several times after cleaning it. “Pop” was asleep but when he woke up, the housekeeper returned, mentioning more than once that she had cleaned the room, bathroom, chairs and table.

“She repeated it so many times we weren’t sure if she thought he was hard of hearing,” Smith says. “Pop thanked her profusely. I recognized her conversation as part of the ‘script’ but Pop wasn’t so sure. After she left, he leaned over and asked, ‘Barbara, is she looking for a tip?’”

“That encounter reminded me that we have to be aware how the patient will perceive what we’re saying and perhaps be more specific in why we are telling the patient the room was cleaned,” Smith says.

And while spoken communication about cleanliness is key, so is visual. Remember, that first impression remains vital. With the eyes of a newcomer, look at lobbies, elevators and main entrances, the spaces that influence initial judgments, said Bowers. “If you’re visiting a loved one or going to the hospital for your own care, that first impression will stay with you, and can filter your impressions and observations going forward.”

From there, think in terms of persistence. “Cleaning and disinfection isn’t a once-a-day task – it is an ongoing effort to keep the environment safe for our patients and colleagues,” says Bowers.

With that in mind, both Bowers and Smith hold frequent huddles with their teams and suggest their peers do the same.

At Mount Sinai, the infection prevention and housekeeping teams meet at the start of each shift. Housekeepers review the scripted introduction and are encouraged to chat with patients while they clean. 

Then, every week, Smith’s environmental leadership group – comprised of infection preventionists, and hospital transport, safety, engineering and other personnel – addresses the HCAHPS Question 8 scores. “We analyze why one unit may be performing better than another and try to spread the best practices,” Smith says.

On top of that, each month, Question 8 undergoes scrutiny in a larger staff conference. Participants share ideas for improving ratings, while high-performing units “are given a big shout-out and any individual who is mentioned by name in the survey is given special recognition,” says Smith.

Bowers conducts a similar routine at Inspiria. Housekeeping gathers prior to each shift and talks about cleanliness. Plus, “We discuss the HCAHPS scores when they are published and leadership at every level has an open dialogue with housekeeping to head off issues in real time,” he says.

Expert Tips
One way to head off issues is to have a plan for dealing with situations that inevitably will arise, making sure housekeepers know how to react. “The hardest part on a day-to-day basis is that staff have conflicting priorities,” Smith said. A room could be closed to cleaning because of a procedure, or an accidental spill may distract workers. But when they know the backup solution during events such as these, bigger problems can be averted. “I try to ensure the staff know the [cleanliness] expectation and have the tools to meet those expectations,” Smith says.

Another tactic includes instructing housekeepers to concentrate on even the seemingly smallest details. “Items like the light switch and doorknobs are more likely to be overlooked because they don’t appear dirty and partly because their connection to infections is less obvious to the worker,” Smith says. Refer to the sidebar, Patient Areas and

Items Requiring Daily Attention, for more information.
Further, assign housekeepers to take care of equipment that can be easy to disregard or slough off onto someone else. Don’t forget stretchers, ECG machine, walkers and other articles shared among patients. “There can be confusion as to who is responsible for cleaning a particular item,” Smith says. For instance, a staffer may wipe down an IV pump when the patient is discharged but wouldn’t while the patient remained attached to the pump, she said. To prevent that kind of mix-up, make a list of each item, including who cleans it, how often and which product to use.

Finally, despite facilitating cleanliness conversations, infection preventionists will want to do some sleuthing to check whether workers are following protocol. Smith recommends adenosine triphosphate (ATP) testing to monitor for any organic matter and fluorescent marking to check for germs left after cleaning. Before a room is cleaned, infection preventionists can stain areas, leaving, in essence, a harmless, removable invisible ink. After the housekeeper finishes, the infection preventionist can use special luminometers to look for missed areas. Smith prefers to employ the findings as teaching tools rather than competency evaluations. “My staff are excited to see their results and are proud when they perform well,” she says, noting that the method also “identifies some challenges for the housekeeper, e.g., perhaps they need a larger size disinfectant wipe.”

Keeping Question 8 in Perspective
The core reason for focusing on cleanliness, certainly, is to lower the risk of infection for patients, visitors and staff. But the secondary one – increasing those Question 8 scores in hopes of attracting more patients – also remains critical. Without a doubt, the more these consumers witness a hospital caring about preventing infections, the more likely they are to leave positive feedback on Question 8. Some of the memorable comments Bowers shared include:
• “The housekeeper was the best part of our stay!”
• “My mother wasn’t doing well and the housekeeper prayed with me.”
• “[Housekeeping] made my day when they came in.”

It’s no surprise to Bowers that several of his housekeepers have been offered jobs outside of the hospital.

Attaining glowing HCAHPS scores feels good. And infection preventionists play an indispensable part in garnering the favorable survey reactions that increase an institution’s brand perception and profit. They simply must put the patient’s needs before the hospital’s financial interests. One even can argue this all but guarantees high rankings.

But don’t rest on the proverbial laurels. Continue to use the HCAHPS feedback to tweak and improve methodologies.

“I see HCAHPS and other surveys as tools to gut-check what we know about our institutional practices,” Bowers says. “It’s mandated and not going away any time soon, so let us use this information for some good data from objective observers.”

Above all, maintain the right perspective for the sake of the patient, paying particular attention to Question 8. As Bowers put it, “Cleanliness is the basis for all other healing practices.”

Kelly Teal is a freelance writer.