Author: John Weir

This article is from several years ago but touches on many suggestions we can try today.

Best Practices: The Latest & Greatest in Housekeeping and Maintenance

Mary P. Malone, MS, JD, CHE, Executive Director, Consulting Services Division

An important lesson I’ve learned about patient satisfaction with room cleanliness is that it’s not always about how “clean” a room is. Several years ago, a client observed that one nursing unit had lower room cleanliness scores, but by all “objective” measures the rooms were as clean as any of the others. Rather than reprimand the housekeeper, the quality team continued to investigate. They observed that many patients on this unit were older women who had immigrated from Eastern Europe, and worked as cleaning people for decades. These women “knew dirt.” Armed with this insight, the team decided to conclude room cleaning with one step, asking the patient, “Is there anything that I missed?” Most patients say no, but some ask for something to be touched up, which the housekeeper graciously accommodates.

The lesson: it’s not only what you do, but how you do it. The quality team also had another important insight. They recognized that hospitalization takes away patients’ identities and strips them of control over the situation and environment. Housekeepers added a few simple steps that acknowledged the patients’ expertise and gave them back a little control over their situation. This resulted in improved patient experiences and better scores. You can extend this notion to all patients, not just women who worked as domestics. Housekeeping is one of the “home relevant” services that hospitals provide (another is food service). Most patients feel like they have some degree of expertise in these areas. Included below are other observations about cleanliness that can help improve your quality improvement efforts. (Note: the term housekeeper is used generically, we know many hospitals have integrated this function into other positions.)

• Patients want to see the person that cleans the room, or at least see some tangible evidence that the room has been cleaned. (Following the lead of the hospitality industry, many hospitals have housekeepers leave behind a card or put a “saniwrap” on the toilet.)

• Patients are also familiar with the “germ theory” of disease, and are accustomed to fighting germs. The new “antibacterial cleansers” are another indication of the extent to which we are afraid of germs. Patients worry about “catching things” from their roommates. (We all got the same lectures from our moms about what you can get from a public toilet.)

• Cheerful, pleasant, and concerned (but not prying) interactions with a housekeeper can make a positive impact on a patient and help to reduce stress and anxiety. The housekeeper can support the image of the hospital as a caring place, and a team working together to care for the patient. Likewise, a housekeeper can detract from the image.

• Cleanliness isn’t just about the absence of dirt. Cluttered rooms can give the appearance of being dirty. The same is true of walls with chipped plaster or rooms with broken curtains or blinds. Another pitfall: wastebaskets that get emptied early in the morning, but no one empties throughout the day, particularly after bandages are changed. Some hospitals have decided to save money by changing unsoiled linens every other day. The patient perception is that this is not a sanitary procedure.

We’ve collected a few practical ideas for improving patient perceptions of room cleanliness, housekeeping, and maintenance. We hope you find these helpful as you continue to work on your quality improvement processes.

1. Tom Peck, Director of Environmental Services at the University of Wisconsin Hospital and Clinics, sent us an e-mail describing some of his activities. Like others, his department leaves a calling card in every patient room after cleaning, and makes it easy for a patient to call with a problem or concern. Department supervisors are speaking informally with patients as part of their daily routine. To promote employee ownership, Tom is currently experimenting with a monthly meeting involving the patient unit manager, housekeeping supervisor, and area cleaner to discuss the needs of the patients and staff on the unit.

2. Chris Coyne, Vice President of Crothall Health Care, shared a simple, yet profound observation. “One of the standard points of everyday cleaning is the floor around the patient’s bed. However, when you think about it, patients spend most of their time looking up toward the ceiling and lights, or at the wall at the foot of the bed.” Today, housekeepers have added light checks as a more routine part of housekeeping.

3. One maintenance department tags everything that’s broken and assigns a repair date and the reason for their repair. This sends the message to the patient: we are aware of the problem and we are taking care of it. It also creates an accountability for the maintenance department to make the repairs by the stated date.

4. Here’s another maintenance tip. The department assigns one person to be a liaison with each patient care area. This person stops by the area at least once a week and checks a designated white board for a list of things that are broken. He/She also meets with the nursing unit leader or area manager, and periodically attends team meetings.

5. Mary Jo Coyne, our corporate contact at ServiceMaster, shared their philosophy. Beyond their corporate management services offering “Best of Practice” programs for environmental services, they have also developed on-site programs to enhance patient perceptions. An important part of these programs is developing interview and selection criteria for hiring service workers that seek out “courtesy skills,” in addition to technical skills. They also use innovative cleaning procedures that allow for additional patient contact and courtesy as an integral part of the process. They build flexibility in regimented cleaning procedures that allow for interaction between the patient and service partner.

6. Several clients have recognized that housekeeping staff who don’t speak English well are sometimes perceived as unfriendly by patients and family members. Several clients have developed language skills classes that focus on teaching basic English for interacting with patients. Often the classes help housekeepers feel more comfortable looking directly at patients, which is a desirable trait for many patients, but may be a cultural taboo in the housekeeper’s country of origin.

7. We know of one hospital that designates a time after dinner for all trash baskets to be emptied. Everyone in patient care areas participates, which helps make the room presentable for visitors. It also serves to remind everyone on the care team of their responsibilities for keeping the room neat.

8. Mike Murphy, environmental services director for ARAMark, indicated that an important focus on the firm’s corporate program for environmental services is their Best Practices policy and procedure manual. The program emphasizes training and skills development. In addition to technical training, support service personnel also receive Team Excellence Training. Patient service associates — multi-tasked employees — also receive training in light maintenance tasks, such as changing a light bulb, unclogging a toilet, and tightening loose screws.

9. One housekeeping manager reported that he worked with maintenance, and reallocated a position to focus solely on repainting chipped and scraped walls that otherwise wouldn’t be scheduled to be repainted for several years.

10. Several clients have adopted an interactive cleaning approach. The support staff might visit the patient’s room in the morning, introduce himself/herself to the patient, and empty the trash. By quickly visiting each patient, the housekeeper can get a sense of any potential problems and inform the patients about the day’s schedule. The housekeeper can ask the patient about his or her room cleaning preference (“Would you like to be here, or should I clean it while you are out of the room”). Finally, when the housekeeper enters the room, he or she asks, “Is this a good time for me to clean your room?” Again, this shows respect for the patient and gives them back a little control over their environment.

11. Sodexho-Marriott’s Rick Gunsorek, Director of Environmental Services at Huntsville Hospital System, described a number of practices his department has implemented. Along with increased training, they have also focused on rewards and recognition. Each quarter the top five scoring units are treated to lunch in the hospital cafeteria. The department also has a Quality Manager who is responsible for handling customer and patient relations.

Remember, patients do notice things, just like anyone else. As mentioned, several hospitals have adopted cost-saving policies of changing unsoiled sheets every other day. From what we have heard (and seen in the data), patients are responding negatively. It seems to be just another thing that makes patients think that we are more concerned about finances and our convenience than we are about them. (After all, how would you like to spend 48 hours in bed with all sorts of germs without clean sheets.) If this cost-saving initiative is critical to your success, you might want to involve the patient in the decision. Look at the sheets and the patient and have a conversation that gives them the benefit of your decision, “Doesn’t look like the sheets got dirty yesterday, if it’s okay with you, we can plan to change them tomorrow, and that way we won’t have to disturb you today.” This seems a better approach than not saying anything and having a disparaging comment show up on your surveys.

This article originally appeared in the Satisfaction Monitor (July/August 1998).