Your Secret Weapon in War on HAIs

We hear a lot about "employee engagement" in healthcare human resources.

Unfortunately, in many hospitals, efforts to engage staff may vary depending upon the job title. Most of the engagement talk appears to be directed at nurses, which is understandable, considering how expensive it is to recruit and retain nurses.

However, getting nurses and other highly skilled clinicians to buy into the mission does not mean that lower-tiered staff should be ignored. No hospital or any business can say truly that it has engaged employees unless all its workers are engaged.

One class of workers that engagement efforts have generally ignored is the cleaning crew. But that appears to be changing as more hospitals understand the difficulties and costs of fighting hospital-acquired infections and the positive and immediate effects that an engaged and informed cleaning staff can have on that fight.

Maryn McKenna, author of Superbug: The Fatal Menace of MRSA, and a noted blogger on hospital-acquired infections, says she is seeing attitudes change as hospital leaders come to understand that it is easier and more cost-effective to prevent these increasingly common and alarmingly drug-resistant and life-threatening HAIs on the front end than it is to treat patients after they become infected. 

"You can't look at something that is highly resistance and say 'there is another drug on the shelf to treat this patient,' because there aren't. As a result, prevention of these infections becomes much more important because there is no treatment on the back end," McKenna tells me.

"I don't think that that connection was really made or at least emphasized before. People thought it was important to have the hospital clean because a hospital should be clean. But the job performance of the environmental services staff actually having a direct effect on infection rates is a relatively new realization and institutions are still working their way through that."

The prevailing wisdom for a long time, McKenna says, was that cleaning staff was not important on the hospital hierarchy. "They are all the way at the bottom. People assume there is going to be high turnover. They don't pay them well or train them well. For a significant number of them English is a second language. Nobody thinks about the difficulties of that. They think of them as these faceless people chugging through the room doing these basic necessary tasks," McKenna says.

"Then all of a sudden they realize, 'Wow we have to turn our understanding of our hospital hierarchy on its head because these people who we have always taken for granted might turn out to be the key piece of the puzzle.'"

Swedish Covenant Hospital got the memo. The 320-bed hospital in Chicago was featured in Not Just a Maid Service, an HAI prevention video put out by the Illinois Department of Public Health that stresses the role of cleaning crews. 

Gregg Gonzaga, infection control manager at Swedish Covenant, says Clostridium difficile infection rates have fallen 20% since they instigated a collaborative in mid-2010 that engaged cleaning staff in the fight.

"One thing we initially noticed was that certain departments in the hospital were in silos. For housekeepers it was 'this is my job. I just clean the rooms,'" Gonzaga says. "We wanted the environmental staff to understand that we don't look at them as housemaids. We look at them as an integral part of our infection prevention effort.  We approached them and said 'we know that what you do in the hospital is very important and we want you to be a part of our team.' They understood that."

Swedish Covenant supervisors took the time to explain to staff what C. diff. is, how it is spread, and what it can do to a patient. They made it clear to staff that their jobs could literally be a matter of life or death. They explained why it was necessary to provide a thorough cleaning and to avoid shortcuts.

Supervisors daubed florescent markers on high-touch areas before cleaning and then doubled back when the cleaning crew finishes to make sure rooms were properly disinfected.

Initially the results weren't very good, Gonzaga says, and only 50%-60% of high-touch areas were cleaned. One housekeeper wept when she was told that her patient rooms failed inspections. "She was upset because she felt like she did not do a good job. She said 'I clean this room like it is my own house,'" Gonzaga says.

"We told her the goal is not to punish you when we do these inspections, but to make sure we can identify the housekeepers who need to be retrained so they can be consistent in their jobs and make our hospital safer."

Ben Modica, manager of environmental services at Swedish Covenent, says the 80 or so people on cleaning staff have come to embrace the inspections because they "understand why we are doing what we are doing and that we want their opinion. We could be dictators and tell them to do this and that. But they need to know why and sometimes they have better methods than we do."

In addition to improved safety, Modica says the engagement with cleaning crew has improved retention. "Since I have been here, the turnover has been very low. I don't have the exact numbers, but I know because I do the hiring," he says.

There is a lot to like about what they're doing at Swedish Covenant and at other hospitals that understand the important role of cleaning crews. Beyond the obvious and positive effects that this has on decreasing HAIs, there is also the effect that this engagement has on the employees themselves and how they view the job that they do and the place where they work.

Everybody wants to think that their work matters. Good things happen when supervisors take the time to explain to their cleaning staff that what they do can greatly affects the lives of patients. When mistakes are seen as opportunities to improve instead of failures that must be punished, employees will try that much harder.

Staff will respond when they understand what's on the line, when their opinions are asked for and acted upon, and when they are given the tools they need to get the job done.

That sounds like engagement to me.