We can improve performance management of cleaning in healthcare environments

Posted: 19 September 2012 by Danish Malik

There is a problem of quality assurance around cleaning in healthcare environment – even though £500m a year is spent in the NHS on cleaning. Typically, cleaning is audited visually, but my research has found that this method is subjective and that there is a poor correlation between visual acceptability and more objective measures of surface cleanliness.

There is often an undue emphasis on floors and ceilings, which are not the key risk factors for patients. There are also problems around who is responsible for different aspects of cleaning. For example, in some of the hospitals we have studied, it was not clear who was meant to make sure the television remote control was decontaminated.

Measurement techniques based on traditional culture based methods are slow and difficult to routinely implement to assess environmental hygiene. A more objective approach to the process of cleaning is required – one that is performance orientated.

ATP testing in healthcare environments

I have looked at the feasibility of employing techniques used in the food industry to monitor environmental hygiene to minimise food contamination. The systems monitor the presence of adenosine triphosphate (ATP) on food preparation surfaces or equipment in contact with food preparation and handling e.g. meat slicers etc. ATP is present in all animal, vegetable, bacteria, yeast and mould cells and detection of residues from such sources indicates the presence of contamination and indicates inadequate cleaning. It may be possible to use this in health environments too, though healthcare is more complicated and less well regulated than the food industry so technology transfer may be problematic.

However, we have examined, using ATP testing as an objective and rapid means of monitoring, cleaning performance in order to achieve improvement. We introduced randomised ATP-based environmental monitoring within three hours of cleaning whilst also undertaking visual assessment (for comparison), in a range of ward environments, feeding back weekly to stakeholders. Readings were compared with the previous week and stakeholders were told what level was acceptable and what level was unacceptable. The outcome was real improvement over time and a fall in ATP levels as staff gained objective measures of what was working well.

Visual assessments compared with ATP measurements were shown to be poor indicators of surface soiling and proved to be an unreliable indicator of contamination. The conclusion is that the NHS needs a means for objectively checking the state of the environment after cleaning that can be fed back regularly to stakeholders to ensure good performance management. Evaluation of cleaning needs to be put on a more scientific footing. ATP testing systems have weaknesses. However, used with some care, they may provide the means for improved environmental hygiene monitoring.

Dr Danish Malik is a HaCIRIC Research Fellow and Senior Lecturer, Chemical Engineering Department, Loughborough University.