Clean Hospitals Corner With Alexandra Peters, PhD: The Issues Around Outsourcing

Clean Hospitals Corner with Alexandra Peters, PhD

Outsourcing is often cited as a problem in ensuring health care facilities’ ability to provide quality environmental hygiene. However, it's becoming increasingly common in many regions.

If a health care facility lacks specialized in-house knowledge about environmental hygiene or the capacity to spend time finding, hiring, and training environmental service workers. In that case, outsourcing can address a significant need, especially considering the high turnover rate in environmental hygiene positions. The job is generally not a very attractive one; it’s physically demanding and requires long hours and repetitive movements around sick people and a variety of chemicals for relatively low pay.

The concept makes sense: specialized companies with the staff and knowledge to train them to your healthcare facility’s needs and specifications can provide a flexible and agile workforce at a cost generally lower than developing the same in-house workforce. Unfortunately, the services often delivered to health care facilities don’t correspond to the quality needed for those facilities to provide safe patient care.

We all know the outbreaks are expensive in terms of the monetary cost to a health care system, the human cost, the increased use of antibiotics, and the associated issues concerning antimicrobial resistance. Although there's still a lot of research to be done to quantify the full extent of the role of the health care environment, we are learning more and more about how a well-managed health care environment prevents disease transmission. One large-scale multicenter randomized controlled trial focusing on improvements in terminal room disinfection estimated that 10 to 30% of all MDROs are transmitted to people from the health care environment.⁵

Costs: the visible and the invisible

When health care facilities outsource their environmental services, they mainly do so because the in-house staff is more expensive to train and maintain. Outsourced contracts guarantee a steady supply of a workforce that has theoretically been trained to a “professional level” (although sometimes we are left wondering exactly what that means). The truth is that many external service providers can provide quality environmental hygiene services, so why are there often so many quality issues? The blame falls largely on the health care facilities themselves.

Health care environmental hygiene (HEH) programs are often victims of limited resources. They've been easy targets for hospitals to cut budgets without immediate fallout. Even if hospital outbreaks are expensive, hospitals tend not to calculate budgets for averted infections or reduced patient bed days.

There are 2 main reasons for this: Either hospital administrations still don’t appreciate the importance of environmental hygiene to infection prevention and control (IPC), or they are aware but simply don’t think that it is an issue in their facilities, even though every study that I am aware of which looks at how often or how well high touch points are cleaned and disinfected shows shockingly low adherence (there are more, but here are a few of the more recent ones).^1–3

I have visited more than 1 hospital where eadership told me that they either didn’t have any health care-associated infections (HAIs) or that there were so few that their current systems were more than sufficient. Having seen the inner workings of the HEH programs of the hospitals mentioned above, I can assure you that there was an extremely low likelihood that this was the case. However, until there is a widespread paradigm shift in how health care facilities view and approach environmental hygiene, it will be impossible to address the current challenges associated with outsourcing.

Who outsources?

Although we don’t have much data on this, outsourcing seems to be mainly concentrated in high-income economies.4 It’s almost ironic that more straightforward HEH programs with fewer options can be better from a human factors point of view. An experience that left a lasting impression on me was a visit to a small rural hospital in Türkiye. The director showed me around and allowed me to observe how the rooms were cleaned and ask questions about how the HEH program was implemented.

What stayed with me wasn’t how the training was conducted or what products they were using; it was that the hospital director knew the EVS staff by name and asked the worker who showed me around how her children were and other personal information. When I asked him about it, he said that at the hospital, they were like a family and that they had been working together for well over a decade. This is a far cry from the environment we see in many far wealthier hospitals, where, ultimately, the bottom line trumps any other considerations.

Who is responsible for quality?

An EVS workforce’s performance can only be as good if staff can be trained, motivated, and monitored. Health care facilities’ HEH and IPC departments must be the ones to decide on the products, processes, and microbiological standards that are implemented by the workforce, even if it’s outsourced. If facilities cannot measure quality (let alone ensure it!), then they cannot provide safe care to their patients.

At the very least, when HEH staff is outsourced, the hospital should employ someone who ensures that the workforce is adequately trained to the same standards as an internal workforce, in compliance with internal IPC recommendations, and given sufficient time and resources to do their jobs well.

This last item on the list is a big sticking point because it comes back to the issue of the constant cost-cutting in HEH. When hospitals are putting out tenders for external companies, they must evaluate the relationship between the price, quality of the workforce, relationship with current suppliers, quality and scope of the proposed service, etc. If over a third of a facility’s purchasing decision is based on the price of the outsourcing, price will always be the deciding factor, to the detriment of quality.

So, yes, currently, there are many issues with outsourcing, but there don’t necessarily have to be. If there is a single takeaway I can offer from this conversation, it is that you usually get what you pay for.

Reference

1. Xie A, Carayon P, Cox ED, et al. Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach. IISE Trans Occup Ergon Hum Factors. 2018;6:178.

2. Ramphal L, Suzuki S, McCracken IM, Addai A. Improving hospital staff compliance with environmental cleaning behavior. Proc (Bayl Univ Med Cent). 2014;27:88.

3. Fram DS, Wendt R, Gouker A, et al. High-touch surfaces disinfection compliance in a COVID-19 intensive care unit. Am J Infect Control. 2023;51:469-471.

4. Peters A, Schmid MN, de Kraker MEA, Parneix P, Pittet D. Results of an international pilot survey on health care environmental hygiene at the facility level. Am J Infect Control. 2022;50:1302-1310.

5. Chen LF, Knelson LP, Gergen MF, et al. A prospective study of transmission of multidrug-resistant organisms (MDROs) between environmental sites and hospitalized patients—the TransFER study. Infect Control Hosp Epidemiol. 2019;40:47-52.