Hand hygiene (Adobe Stock)
Few jobs are as important and often as thankless as environmental services (EVS). These teams are key players in ensuring patient satisfaction and combating health care–associated infections (HAIs), but many of them are virtually invisible, without professional job titles or presence in the hospital organizational chart. Many health care facilities around the world employ (or outsource) relatively untrained cleaners for low wages. They then demand EVS staff work long hours in relatively demanding conditions and often in contact with dangerous chemicals and fail to recognize the importance of these jobs or understand how this work can disrupt the chain of transmission. As a growing body of evidence demonstrates the hygienic health care environment is important for patient safety,1-3 many institutions still do not consider healthcare environmental hygiene (HEH) there needs to be a shift in how facilities view health care environmental hygiene (HEH). The focus of this shift must center on EVS teams.
At the Geneva University Hospitals (HUG) in Switzerland, environmental hygiene holds special importance. Prior to becoming the director of WHO Collaborating Center on Infection Prevention & Control and Antimicrobial Resistance, the Infection Prevention and Control (IPC) Department led by Didier Pittet, MD, restructured the way cleaning was performed at the hospital, including the practice of hand hygiene. These changes were organized into what would become the World Health Organization (WHO) multimodal hand hygiene improvement strategy, which includes 5 elements: system change, training and education, monitoring and feedback, workplace reminders, and institutional safety climate.4 Ultimately, many of these changes directly affected the EVS teams, reducing cost and staff turnover and improving quality. Although this restructuring was radical at the time, its continued success may provide some guidance for improving HEH programs, especially the challenges facing EVS teams. At HUG, EVS staff have living wages and opportunities for career advancement and remain employed at the hospital for an average of 22 years.
To initiate these changes and avoid the increasingly common outsourcing of EVS staff to an external service provider, HUG conducted an analysis of the HEH program. Resources from overcleaned, noncritical areas were reallocated to more important zones. Non–health care areas such as offices and conference rooms were outsourced to an external service provider, and all health care areas were exclusively cleaned by in-house staff. HUG redeveloped the training system, educating staff not only on cleaning procedures but also on the transmission of pathogens and the importance of cleaning itself. Because EVS staff often come from a lower-income demographic, HUG and regional authorities developed national part-time certification programs of 2 to 3 years. Any staff member who desires to improve their knowledge may do so for free. The courses not only cover EVS management but also reading, writing, and other subjects. Individuals participating in the program can attend these courses during their work time; HUG pays for the courses, the hours staff members spend in them, and the cost of additional staffing when individuals are in class. All EVS team managers are hired directly out of the pool of graduates of the certification program. This formula not only motivates the team but also lends legitimacy to the management, as they have first-hand knowledge of what the job entails.
Because HUG is a public institution, EVS teams have job security once they pass their trial period and can be terminated only for a major transgression or instance of misconduct. EVS staff have the option of joining the union, and the union meets regularly with hospital management.
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After initial training, staff continue to receive additional training on specific environments and procedures and may receive individualized training if needed. Managers are always onsite, although EVS staff mostly clean alone. They have pretreated flat mops and cloths for every room and a detailed checklist for procedures on their cart. Tasks are clearly divided between the EVS staff and nursing staff so that no areas are unassigned and left uncleaned.
Monitoring of staff performance is conducted twice a year for each individual and consists of visual and adenosine triphosphate (ATP) tests. Both tests are designed to verify the process; the goal is not to trap someone who missed a spot but to ask an individual to clean a surface to be evaluated and examine the process with the manager if the surface does not pass the ATP test. If needed, monitors will reexamine the cleaning procedure in a pedagogic setting, identify and address the issue causing the lapse in quality, and retest the procedure. If performance is consistently good, staff members may train to become increasingly specialized, such as working exclusively in operating theaters.
Employees can be taught to wipe a surface correctly, whether they are directly employed or outsourced by the hospital. The problem does not lie with outsourcing itself but that institutions usually get what they pay for. It is common practice for health care facilities to cut funding for their HEH programs when budgets are tight, and those cuts affect the EVS teams directly. It is easy to see why EVS workers may receive minimum wages; they usually come from a lower-income, relatively uneducated demographic and the skills required of the position rarely lend themselves to specialization. But failure to invest in employees has a detrimental effect on staff morale, retention, and quality of work.
To perform at their best, EVS teams need all 5 components of the WHO multimodal strategy: necessary cleaning products and equipment, continuing training and education, regular monitoring and feedback that is constructive and includes individualized plans for improving performance, reminders that include HEH safety posters and tasks to be performed, and other elements that are more difficult to quantify but build a strong institutional safety climate. This last component is the most difficult to achieve because it requires ownership of the work and mutual respect and benevolence among EVS teams, medical and nursing staff, and management. It is therefore crucial for the HEH program that EVS management work closely with the institution’s IPC department.
All these measures, from decent wages and benefits to onsite management and certification programs, incur a significant cost to the institution. So how can such measures be justified? To do so, one must look at the cost in context. According to the WHO report on HAI, the pooled HAI prevalence in high-income countries was approximately 7.6%.5 The annual estimates of the financial cost of such infections is approximately $6.5 billion for the United States and $7 billion for Europe.5 For improved hand hygiene practices (estimated to cause between 50% to 70% of HAIs), some studies estimate between a 35- and 92-fold return on investment.6 Even if only 15% to 20% of HAIs are spread through the environment, they remain a huge financial burden. The Centers for Disease Control estimates that of the $45 billion cost of HAIs, $25 billion to $31.5 billion could be saved with better IPC programs.6 In short, although limited data exist about HEH on its own, infection prevention has a higher return on investment than nearly any other cost-reducing medical intervention. The issue with HEH is that indirect costs of HAI are often not calculated in the same budget, making the connection more difficult to quantify.
Because HEH practices are generally heterogeneous and not usually based on best practices or evidence, there is much room for improvement. Nevertheless, the HUG model for environmental hygiene is not universally applicable in its current state. Most health care facilities around the world do not have access to the same level of resources or institutional support. The IPC research team at HUG is working on creating a transposable model of its HEH program so elements from their experience can be adapted and adopted to all levels of resources and cultural contexts.
Global improvement will require a major cultural shift in how hospitals see HEH programs as a whole, starting with the realization that EVS teams are an integral part of infection prevention and as deserving of support and respect as any other staff. Simple, low-cost interventions can make a real difference. Better training, clearer instructions, and more respect and communication in the workplace will have a positive effect on the health care facility’s budget, EVS teams, and patients.
1. Peters A, Schmid MN, Parneix P, et al. Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review. Antimicrob Resist Infect Control. 2022;11(1):38. doi:10.1186/s13756-022-01075-1
2. Mitchell BG, Dancer SJ, Anderson M, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect. 2015;91(3):211-217. doi:10.1016/j.jhin.2015.08.005
3. Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clin Microbiol Rev. 2014;27(4):665-690. doi:10.1128/CMR.00020-14
4. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. World Health Organization. 2011. Accessed August 20, 2022. https://apps.who.int/iris/handle/10665/70030
5. Report on the burden of endemic health care-associated infection worldwide: clean care is safer care. World Health Organization. 2011. Accessed August 20, 2022. https://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf
6. Townsend J, Greenland K, Curtis V. Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China. Trop Med Int Health. 2017;22(1):74-81. doi:10.1111/tmi.12808
7. Peters A, Schmid MN, de Kraker MEA, Parneix P, Pittet D. Results of an international pilot survey on healthcare environmental hygiene at the facility level. Am J Infect Control. Published online March 6, 2022. doi:10.1016/j.ajic.2022.02.029