a wide discrepancy between thoroughness and efficiency.
Although a few rooms were fairly well cleaned within 30
minutes (which is an accepted industry benchmark), many
of the rooms with below-average cleaning took considerably
longer to clean.
As Rupp, et al. (2013) explain, “Unexpectedly, there was
no correlation between the amount of time spent cleaning a
room and the thoroughness of cleaning high-touch surfaces
as documented by the UV-tagged marking system. This
finding has important implications for institutions that devise
strategies to optimize cleaning. Our study lends support
to and may explain earlier studies that have shown that
improved cleaning performance can be achieved without
substantial additional cost. Clearly, adequate time must
be allotted for personnel to clean a room properly, but it is
apparent that additional time taken to clean a room is no
guarantee of adequate cleaning. These data also support
additional evaluation to discern whether an optimum outlier
(positive deviance) process improvement program could be
employed to improve environmental cleanliness. Because
several of the environmental service staff in our study appear
to be optimum outliers and are able to clean hospital rooms
quickly and thoroughly, they may be able to provide personal
and programmatic insights to explain their proficiency and
serve as models for their coworkers.”
The researchers concluded that their findings emphasize
that process improvement interventions should evaluate both
the efficiency and thoroughness of hospital surface cleaning
to optimize the cost effectiveness of cleaning practice in
healthcare settings.
This study paved the way for follow-up research by
Mark Rupp, MD, professor in the Department of Internal
Medicine; chief of the Division of Infectious Diseases; and
medical director of infection control and epidemiology at
the University of Nebraska Medical Center, and colleagues,
who conducted a more extensive survey to test the premise
that a positive deviance or “optimum outlier” model for
improving cleaning might be possible. The researchers
sought to ascertain whether a subgroup of housekeepers
could be identified as role models in an optimum outlier
improvement model.
Rupp says this 2014 study confirmed their original
observations; however, they were able to document the
presence of a small group of housekeepers who perform
faster and better than others.
Rupp emphasizes that they termed these workers
“optimum outliers” (instead of using the term “positive
deviance”). “We hypothesized that we could study their
habits and procedures and learn,” Rupp says, adding that
he’d like to see the term “optimum outlier” achieve more
traction within the infection prevention community.
The study was conducted in three patient-care units (a
burn unit, a telemetry unit, and a medical surgical unit)
from April 2011 to August 2011 at a 689-bed academic
medical center. Following routine terminal cleaning by EVS
personnel, a convenience sample of rooms was assessed
during regular work hours by measuring ATP levels on 18
designated surfaces (exterior door handle, bed rail, nurse call
button, bedside table, toilet flush handle, bathroom door
handle, toilet seat, bedside chair, light switch, mattress, sink
16
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encouraged higher scoring if turnover times (average
set-up and clean-up turnover times for all cases was
less than 25 minutes.
As Macario (2006) observes, “Most U.S. hospitals
perform all cases scheduled by their surgeons, provided
a case can be done safely. This reflects the desire to
retain and grow surgeons’ practices, to enhance market
share and reputation, and to fulfill community-service
missions. Getting the right case in the right room at
the right time is the goal for every OR director. For
anesthesiologists, efforts to increase anesthesia group
productivity are the same as increasing the efficiency of
use of OR time. Often, though, defining how well the
OR suite runs depends on who you ask. The hospital
administrator may want the most “throughput” with
the least cost, whereas the surgeon wants first case
of the day block time, rapid turnover, low cancellation
rate, and on-time starts. Nurse managers may focus
more on flexibility to move cases around, disposable
supply costs/case, the percentage of cases in compliance
with flash sterilization policy and having adequate
reserve capacity for add-on cases or emergency cases.
Risk management, on the other hand, will want to
know the percentage of patients without injury (e.g.,
wrong-side surgery).”
“The main challenge of turnover between cases is
time, as pressure from both surgeon and administration
to begin next case as soon as possible is continually
at the forefront,” acknowledges Karen deKay, MSN,
RN, CNOR, CIC, perioperative practice specialist at
AORN). “However, a clean and safe environment for
our patients should be first and foremost. Performing
qualitative and quantitative monitoring methods to
evaluate the thoroughness of cleaning, as well as a gap
analysis to determine compliance with guidelines and
policies and procedures can provide documentation
of any shortcomings that may be a result of the time
pressure. These findings should then be shared with
environmental, infection prevention, and perioperative
administration for development of an improvement
plan that includes continued monitoring.”
The great many pieces of equipment and the numer-
ous OR personnel rushing around can pose significant
challenges to EVS personnel who are trying to follow
AORN and AHE guidance on operating suite hygiene.
“Irregular surfaces, such as knobs and dials,
components of the OR bed specifically beneath the
mattresses, and complex pieces of equipment such as
a robot, imaging devices and microscope,” deKay says.
“Most often, EVS personnel converge all at once to
clean/turnover a room and these items may be missed or
quickly swiped over. In an organizational experience to
improve between case cleaning, Pedereson, et al. found
that when a ‘pit crew’ concept was introduced that
assigned personnel specific tasks, the overall compliance
with cleaning protocol increased from 79 percent to
93 percent. I have also heard of facilities dividing the
room into zones and a team captain assigning zones
march 2020 • www.healthcarehygienemagazine.com