Cleaning Programs

Overview

Environmental cleaning programs in healthcare facilities involve resources and engagement from multiple stakeholders and departments, such as administration, IPC, WASH, and facilities management. They require a standardized and multi-modal approach, as well as strong management and oversight, to be implemented effectively.

The scope of the environmental cleaning program and its implementation can vary (e.g., in-house management versus external contract), based on the size of the facility and level of services provided. Comprehensive environmental cleaning programs are most important at acute healthcare facilities and higher tiers of healthcare, where the burden of HAIs is highest.

Regardless of type of facility, the key program elements for effective environmental cleaning programs include:

• Organization/administration
• Staffing and training
• Infrastructure and supplies
• Policies and procedures
• Monitoring, feedback, and audit

This chapter describes the best practices for each of these key program elements.

Externally contracted programs

Environmental cleaning programs are increasingly implemented by external companies through a contract or service level agreement. Contracted staff, including cleaning staff and cleaning supervisors, should work closely with the environmental cleaning program focal person and IPC staff at the facility to ensure that environmental cleaning is performed according to best practices and facility policy.

It is essential that all the standard program elements be described explicitly in the service level agreement with the external company, to ensure accountability.

In general, the components of the service level agreement should be similar to the facility cleaning policy and at a minimum should include:

• An organizational chart for all contracted employees, including functional reporting lines and responsibilities.
• The staffing plan for each patient care area, including contingency plans for additional staff.
• The training content and frequency for contracted employees.
• A summary of the cleaning schedules and methods for each patient care area, in line with the facility policy.
• The methods for routine monitoring and feedback.
• The supplies and equipment to be used.

2.1 Organizational elements

Facility-level organizational support is a key program element in the implementation of an effective environmental cleaning program. The main areas of support include:

• Administrative and leadership support.
• Formalized communication processes and integration of the cleaning program and IPC.
• Defined management structure.

2.1.1 Administrative support

Required support from the healthcare facility administration for the environmental cleaning program includes a designated cleaning program manager or focal person.

Designated cleaning program manager or focal person

A facility staff member or manager who acts as a focal person is essential to an effective environmental cleaning program.

This focal person is essential regardless of whether the program is managed internally or by an external company.

The focal person can be part-time or full-time:

• A full-time cleaning program manager may be best for in-house managed programs, especially at secondary or tertiary care facilities.
• The focal person should have a written job description/terms of reference, along with salary allocation, to cleaning program activities.

Specific responsibilities include:

• Developing the facility-specific environmental cleaning policy and corresponding service level agreement or contract (as applicable).
• Developing and maintaining a manual of standard operating procedures for all required cleaning tasks at the facility.
• Ensuring that structured training activities are carried out for all new staff and on a recurring basis.
• Ensuring that routine monitoring is implemented and results are used for program improvement.
• Ensuring that cleaning supplies and equipment are available in required quantities and in good condition (i.e., preventing stock-outs).
• Addressing staff concerns and patient questions about the cleaning program.
• Communicating with the external company on any of the program elements (if applicable).

Leadership validation of cleaning program policy

The ultimate responsibility for the environmental cleaning program lies at the facility leadership level.

Engage leadership on the development and validation of the facility cleaning policy and service level agreement (if contracted services are used), both of which outline the key technical and programmatic elements (e.g., monitoring and training requirements) of the program. See 2.4.1 Cleaning policies.

Annual budget

An annual budget is essential to an effective environmental cleaning program. The major elements of a budget include:

• Personnel (salary and benefits for cleaning staff, supervisors, and an overall program manager).
• Staff training (at least pre-service and annual refresher).
• Environmental cleaning supplies and equipment, including PPE for cleaning staff.
• Equipment for program monitoring (e.g., fluorescent markers, UV-lights).
• Administrative costs.
• Production and printing costs for checklists, logs, and other job aids.
• Infrastructure/services costs, such as supporting water and wastewater services (as applicable).

2.1.2 Communication

An effective environmental cleaning program requires strong communication and collaboration across multiple levels of the facility, at both the program development and implementation stages. Strong communication systems also improve understanding of the importance of environmental cleaning for IPC and patient safety among all clinical staff. The primary communication structures to establish include:

• Multi-sectorial planning committee.
• Routine meetings with key stakeholders.

Multi-sectorial planning committee

A multi-sectorial planning committee engages all facility stakeholders during the development of policy, procedures, and (if contracted services are used) service level agreements.

The planning committee could include:

• A representative from the IPC committee.
• A clinical staff representative from each ward (e.g., nurse in-charge).
• Facilities management or WASH staff.
• Administrative staff in charge of procurement.

Routine meetings with key stakeholders

Routine meetings with key stakeholders, particularly those representing IPC, facilitate regular communication between the cleaning program manager, IPC, and other stakeholders at the facility (e.g., ward in-charge staff).

These meetings should be conducted at least monthly with:

• The cleaning program manager and the IPC or hygiene committee to review and update technical aspects of the program (e.g., outbreak-related changes in cleaning). Rather than a separate meeting, this could be best accomplished by the cleaning program manager participating in standing IPC or hygiene committee meetings.
• The cleaning program manager and person in-charge for each ward or department to inform ward-level staff of the overall cleaning policy and specific cleaning schedules (e.g., who cleans what) for their wards and to allow feedback from the ward staff on any deficiencies in cleaning procedures, cleaning staff, or supplies.

The cleaning program manager and the external company should have a monthly meeting to review performance and report deficiencies.

2.1.3 Management and supervision

An effective environmental cleaning program requires a defined management structure, including organizational and reporting lines and on-site supervision. The required elements include:

• Cleaning program organizational chart.
• On-site supervisors.

Cleaning program organizational chart

An organizational chart outlines the functional reporting lines between cleaning staff, supervisors, manager, and any other direct or indirect relationships (e.g., to the facility IPC focal person, to ward in-charge staff).

If supervisors are from an external company, include a functional reporting line from supervisors to the facility cleaning program manager or focal person who can communicate with the IPC committee and other facility staff, such as facilities management and administrative staff.

On-site supervisors

On-site supervision of cleaning staff ensures:

• Compliance to best practices through direct monitoring and feedback.
• Consistent availability of cleaning supplies and equipment.

On-site supervision also allows cleaning staff to communicate any challenges or concerns about compliance (e.g., supply shortage, safety concerns).

All cleaning staff should know to whom they report and who they can contact if any issues arise during their work.

Supervisor-cleaner ratios should allow routine performance observations and monitoring (e.g., on a weekly basis). There is no definitive benchmark for this ratio, which will vary based on a number of factors. An upper limit of 20 cleaning staff per supervisor might be recommended. See PIDAC, 2018 in Further reading.

2.2 Staffing elements

Appropriate number of staff (staffing levels) and training and education are key program elements.

Cleaning staff should always be paid positions that have:

• Written job descriptions or terms of reference.
• Structured, targeted training (e.g., pre-service, annual, when new equipment is introduced).
• Defined performance standards or competencies.
• Access to an on-site supervisor to ensure they can safely perform their work (e.g., address supply shortage, safety concerns).

According to best practices, cleaning staff should:

• Be familiar with their job descriptions and performance standards.
• Perform duties only for which they were trained (e.g., cleaning staff should not be asked to clean high-risk wards (e.g., operating room) unless they have received specific training for that patient care area).
• Know the identities and hazards of the chemicals that they could be exposed to in the workplace.
• Have supplies and equipment, including PPE, to perform their duties.
• Have working shifts consistent with acceptable norms for the given context.

2.2.1 Staffing levels

Adequate staffing is one of the most important factors for an effective environmental cleaning program. In small primary care facilities with limited inpatient services, cleaning staff might be part-time positions or have other responsibilities, such as laundry services, but most hospitals require full-time, dedicated cleaning staff.

Determining adequate staffing levels

The required number of cleaning staff will vary based on several of factors, including:

• Number of patient beds.
• Occupancy level.
• Type of cleaning (e.g., routine or terminal).
• Types of patient care areas (e.g., specialized care areas such as ICUs and ORs).

Staffing levels should include consideration of reasonable shift length and the need for breaks as well as extra staff for contingencies, such as outbreaks and other emergencies.

There are a variety of methods for estimating staffing needs, ranging from time studies to workload software, but there is no one single best-practice method.

Facilities should consult available expertise to determine resources (e.g., workload software) and existing data (e.g., from other similar facilities) for estimating their cleaning staff needs.

In the absence of existing data, staffing levels should be estimated empirically, based on performing cleaning according to facility policy, and refined over time. See 2.4 Policies and procedural elements.

2.2.2 Training and education

Training for cleaning staff should be based on national or facility environmental cleaning guidelines and policies. It should be mandatory, structured, targeted, and delivered in the right style (e.g., participatory) and conducted before staff can work independently within the healthcare facility.

• Training content should include, at a minimum:
  • General introduction to the principles of IPC, including: transmission of pathogens; the key role cleaning staff play in keeping patients, staff, and visitors safe; how cleaning staff can protect themselves from pathogens; and detailed review of the specific environmental cleaning tasks for which they are responsible, including review of SOPs, checklists, and other job aids.
  • When and how to safely prepare and use different detergents, disinfectants, and cleaning solutions.
  • How to prepare, use, reprocess, and store cleaning supplies and equipment (including PPE).
  • Participatory training methods, hands-on components with demonstration and practice.
  • Easy-to-use visual reminders that show the cleaning procedures (i.e., without the need for a lot of reading).
  • Orientation to the facility layout and key areas for the cleaning program (e.g., environmental cleaning services areas).
  • Other health and safety aspects, as appropriate.
• Develop the training program according to the intended audience, in terms of education and literacy level.
• Develop training content specifically for cleaning staff who could be responsible for cleaning procedures in specialized patient areas—particularly high-risk areas, such as intensive care units, operating rooms, and maternity units.
• Maintain training records, including dates, training content, and names of trainers and trainees.
• Select appropriate, qualified trainers at a facility or district level—generally, staff with IPC training who have been involved in the development of environmental cleaning policy are best qualified. They could be members of existing IPC or hygiene committees, the cleaning program manager, or local or district-level Ministry of Health staff.
• Conduct periodic competency assessments and refresher trainings as needed (e.g., at least annually, before introduction of new environmental cleaning supplies or equipment).
  • Focus refresher trainings on gaps identified during competency assessments and routine monitoring activities.

If cleaning services are contracted out, the training requirements and content should be specified in the service level agreement.

Promptly address supplemental training needs identified by facility staff (e.g., cleaning program manager) within the scope of the contract.

2.3 Supporting infrastructure and supply elements

The facility infrastructure is critical for an effective environmental cleaning program. The main areas of needed infrastructure include:A

• Designated physical space.
• Access to adequate water and wastewater services/systems.
• Systems to procure and manage environmental cleaning supplies and equipment.
• Appropriate selection of finishes, furnishings, and patient care equipment.

2.3.1 Designated space

For the implementation of effective environmental cleaning programs, it's important that the facility has:

• Designated physical space for storage, preparation, and care of cleaning supplies and equipment.
• Separated sluice rooms or areas (soiled and clean) for reprocessing of noncritical patient care equipment.

These areas must be available within the facility itself, regardless of whether the program is managed in-house or by an external company.

The recommended layout and location of these areas according to best practices are included in 3.5 Care and storage of supplies, equipment, and personal protective equipment and 4.7.2 Sluice rooms, respectively.

2.3.2 Water and wastewater services

Environmental cleaning requires large quantities of water and produces almost as much wastewater, which must be disposed of safely and appropriately to prevent contamination of the environment and surrounding community.

The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) facilitates a comprehensive process to assess, prioritize, and improve basic water, sanitation, and hygiene services at healthcare facilities according to the defined indicators. See 1.3 Environmental cleaning and WASH. Table 1 (below) uses these indicators to describe the additional water and wastewater services needed to perform environmental cleaning according to best practices.

These services must be available within the facility itself, regardless of whether the program is managed in-house or by an external company.

Table 1. Water, sanitation, and hygiene services needed for environmental cleaning programs, expanded from WASH FIT indicators

2.3.3 Supplies and equipment procurement and management

The selection and appropriate use of environmental cleaning supplies and equipment is critical for effective environmental cleaning programs. These aspects are covered in 3. Environmental Cleaning Supplies and Equipment.

To prevent stock-outs, it is important to effectively manage the procurement, upkeep, and maintenance of environmental cleaning supplies and equipment. This requires establishing systems and processes in multiple departments within the facility.

If an external company manages the cleaning program, the contract or service level agreement should include:

• Approved environmental cleaning products and supplies.
• Equipment specifications.
• Maintenance schedule.

The best practices for supplies and equipment management for in-house managed programs are as follows:

• A master list of the supplies and equipment (i.e., detailed specifications and supplier information) and required quantities (e.g., annual basis) developed by the cleaning program manager, facility procurement team, and facility IPC or hygiene committee.
• The results of routine inspections and maintenance activities should determine the required quantities of supplies and equipment.
• Regular (e.g. monthly) inventories and inspections of supplies and equipment will:
  • Prevent stock-outs.
  • Anticipate supply needs.
  • Ensure availability of additional materials for contingencies such as outbreaks.
• Large facilities might have a central store that receives supplies and equipment after inventory reports and distributes them to designated environmental cleaning services areas throughout the facility on a regular basis. The cleaning program manager should manage the inspections and restocking of the environmental cleaning services areas.
• The facility procurement team should manage supplies at the central store.

2.3.4 Finishes, furnishings, and other considerations

It's important to ensure that all finishes, furniture, and patient care equipment can be effectively cleaned and are compatible with the facility disinfectant(s). The facility procurement team, the cleaning program manager, and the IPC or hygiene committee should collaboratively develop a decision-making process and policy to guide selection and procurement and selection of finishes (e.g., flooring for new construction of patient care areas).

The recommended characteristics for finishes and furniture are summarized in Table 2 (below). For direct patient care equipment, there are often fewer options for material composition. Therefore, finding compatible disinfectants could be the main driver rather than the equipment type itself—see 4.7.1 Material compatibility considerations.

Table 2. Ideal characteristics of finishes, furnishings, and other surfaces (e.g., floors)

2.4 Policies and procedural elements

The development of facility cleaning policy, SOPs, checklists, and other job aids are key elements for implementing an effective environmental cleaning program according to best practices.

2.4.1 Cleaning policies

The facility-specific environmental cleaning policy provides the standard to which the facility will perform to meet best practices and enables a common understanding among staff of the required program elements.

If an external company manages the cleaning program, the facility policy can be used to develop the contract or service level agreement.

Facility environmental cleaning policies

Facility environmental cleaning policies should always include the following elements:

• Defined lines of accountability and functional reporting lines and responsibilities for all implicated staff.
• Cleaning schedules for every patient care area and noncritical patient care equipment, specifying the frequency, method, and staff responsible.
• Contingency plans and required cleaning procedures for environmentally hardy organisms and for outbreak management.
• Training requirements and performance standards for cleaning staff.
• Monitoring methods, frequency, and staff responsible.
• List of approved cleaning products, supplies, and equipment and any required specifications on their use.
• List of necessary PPE and when hand hygiene action is recommended for staff and patient safety.

It is best practice to consult national or subnational (e.g., provincial) governmental policies during the development of facility policies, to ensure that governmental standards for healthcare environmental cleaning are incorporated into the document. For example, governmental bodies might have lists of environmental cleaning products that are approved for use in healthcare. There could also be national accreditation bodies for hospitals that have requirements for healthcare cleaning programs and policy.

Cleaning schedules

Provide details on key technical requirements for environmental cleaning, including:

• Frequency.
• Method (product, process).
• Staff responsible for specific cleaning tasks.

These requirements affect staffing and scheduling needs, oversight, and monitoring needs and have implications for supply and equipment needs (particularly consumable materials).

• Use facility-specific risk assessments to develop cleaning schedules. See Appendix A – Risk-assessment for determining environmental cleaning method and frequency.
• In the early stages of cleaning program development, use the results of this risk assessment to prioritize the development of SOPs and other job aids for higher-risk areas.
• 4. Environmental Cleaning Procedures can also be consulted as a reference for developing cleaning schedules.

2.4.2 Standard operating procedures

Facility-specific SOPs for each environmental cleaning task are essential to guide cleaning staff practices. The SOPs should be readily available to cleaning staff, cleaning supervisors, and other ward staff as needed for reference.

If an external company manages the cleaning program, the facility should provide their SOPs to the contracting company or, at a minimum, internally validate the company SOPs to ensure they are in line with the facility policy.

Standard operating procedures (SOP)

Environmental cleaning SOPs should always include the following elements:

• The specific supplies and equipment needed for the cleaning session; refer to 3. Environmental Cleaning Supplies and Equipment.
• Preparatory steps, including hand hygiene and required PPE session; refer to 3.4 Personal protective equipment for environmental cleaning.
• Step-by-step instructions on the cleaning process, in the order they should be performed; refer to 4.1 General environmental cleaning techniques.
• Final steps, including collection of soiled cleaning supplies for reprocessing or disposal, safe removal of PPE, and hand hygiene; refer to 3.5 Care and storage of supplies, equipment and personal protective equipment.

Use manufacturer's instructions to develop SOPS and include:

• Preparation of environmental cleaning products (i.e., dilution, if applicable).
• Reprocessing of reusable cleaning supplies, equipment, and personal protective equipment.
• Reprocessing (i.e., cleaning and disinfection) of noncritical patient care equipment.

These are additional best practices for SOPS:

• Always develop SOPs and other written or pictorial job aids with careful consideration of literacy levels and preferred language of cleaning staff.
  • Use infographics to present a clear message.
• A manual with all the facility SOPs should be available with the cleaning program manager.

Individual SOPs should also be available in a central location(s) within each ward or service area, as close as possible to where they are needed.

2.4.3 Cleaning checklists, logs, and job aids

It is best practice to develop supplemental materials to assist with the implementation of SOPs.

Cleaning checklists are an interactive tool that can help ensure that all steps of an SOP are completed. For example, a checklist with the individual high-touch surfaces can supplement an SOP for routine cleaning in a specific patient care area.

Cleaning logs are job aids that can help guide the daily workflow for cleaning staff and ultimately become records.

They specify the location (i.e., room, ward), cleaning session (e.g., routine cleaning, terminal cleaning), date, and name/signature of cleaning staff. They are typically developed using occupancy records, where clinical staff (e.g., ward in-charge) record the occupied beds/areas.

They are also important as records that environmental cleaning is occurring as specified in facility policy and accountability and tracking mechanisms.

• Make logs available in central locations or where the cleaning task occurs so that supervisory staff can manage them on a daily basis, along with staff (e.g., IPC focal person) responsible for periodic monitoring activities.
• Also develop logs for required periodic or scheduled cleaning tasks (e.g., weekly, monthly), such as replacement of window coverings (e.g., curtains).

Cleaning job aids include posters, pictorial guides, and other visual reminders for key cleaning tasks.

For monitoring environmental cleaning supplies and equipment:

• Use checklists and logs to facilitate routine inspection and maintenance of these items.
• To prevent stock-outs, keep checklists and logs in the designated environmental cleaning services closet, and the cleaning program manager should periodically review them (e.g., weekly, monthly) to inform the procurement staff or contracting company of supply needs.
• Post job aids (e.g., pictorial guides) in the designated environmental cleaning services closet for the preparation of environmental cleaning products, supplies, and equipment (e.g., cleaning cart, if applicable).

2.5 Monitoring, feedback, and audit elements

Structured monitoring programs ensure that environmental cleaning is conducted according to best practices. There must be organizational support and resources to address deficiencies identified during monitoring activities. Use a standardized methodology for monitoring, apply it on a routine basis, and provide timely feedback to cleaning staff and program leadership.

If an external company manages the cleaning program, facility staff such as the cleaning program manager or focal person or a member of the IPC committee should still periodically conduct monitoring activities.

Common monitoring methods are summarized in Table 3 (below) and described in detail in 4.8 Methods for assessment of cleaning and cleanliness.

Given the advantages and disadvantages of these methods, it is best practice to:

• Use both direct (e.g., performance observation) and indirect methods (e.g., environmental marking).
• Use objective (e.g., ATP bioluminescence) over subjective methods (e.g., assessments of cleanliness), if resources allow.

Table 3. Suggested monitoring staff and frequency for common routine monitoring methods

2.5.1 Routine monitoring

In the inpatient setting

It is best practice to routinely (e.g., weekly) monitor; see Options for Evaluating Environmental Cleaning, CDC:

• At least 5% of beds (≥150 bed facilities) or a minimum of 15 patient care beds/areas (for hospitals with less than 150 beds).
  • For facilities with less than 15 beds, this can be increased to 25%.
• If resources allow, 10-15% of beds should be monitored on a weekly basis during the first year of the monitoring program.

It is important that the agreed-upon frequency (e.g., weekly) can be consistently maintained in order to establish benchmarks and track changes in practice and performance over time.

In the outpatient setting

It is best practice to monitor at least 10-15% of examination or procedural areas on a weekly basis. If resources allow, this can be increased to 25% weekly, allowing every examination or procedural area to be monitored on a monthly basis.

2.5.2 Feedback mechanisms

Promptly return monitoring results to cleaning staff, so they can make immediate improvements to practice, and management (e.g., cleaning program manager), to make more general improvements to the cleaning program. Feedback mechanisms should include:

• Direct feedback to staff.
• Reporting to management.

Direct feedback to staff:

Provide multiple types of direct feedback to cleaning staff, including:

• Real-time feedback and coaching, during or following performance observations.
• A regular verbal debrief (e.g., monthly), usually during a one-on-one meeting between the cleaning staff and their direct supervisors.
• Performance reviews (written or verbal), usually on an annual basis.

Reporting to management:

Share monitoring results with the cleaning program manager and the facility IPC or hygiene committee so they can present summary or aggregate reports—both at facility level and stratified by patient care area (e.g., ward) or type of clean (e.g., terminal vs routine)—to administration and management. This analysis will identify trends and program-level gaps that require corrective action. For example, there may be consistently lower clean scores for terminal cleans or within a particular patient care area, identifying a need to further understand the barriers and gaps for these cleaning procedures. Generally, these high-level trend reports will be more useful over time when there is more data available from the program.

During early stages of cleaning program development, the most valuable form of feedback is directly "coaching" cleaning staff and supervisors in a non-punitive manner so they can make prompt improvements to practice.

2.5.3 Program audits

In environmental cleaning programs with functional routine monitoring programs, it is best practice to periodically perform a comprehensive program audit to review the major program elements and identify areas for improvement at the programmatic level.

• Program audits should review all the key program elements.
• Perform them annually or every two years.
• Auditors should not be facility staff or at least should not be directly involved with the program implementation.
• Options for auditors will be context-specific, but some potential options include auditors from an external company, Ministry of Health or subnational (e.g., district/provincial) health officers, or staff from another healthcare facility in the same network.
• File program audit reports and records on-site at the facility to allow benchmarking and to inform the development of remedial action plans and quality improvement projects.

Audit results can also inform needed modifications to contracts or service level agreements if the cleaning program is managed by an external company.