The hospital’s physical environment plays an important role in patient acquisition of healthcare-associated pathogens. Multiple different pathogenic organisms have been cultured from surfaces within patient rooms and many (eg, vancomycin-resistant Enterococcus, multidrug-resistant Acinetobacter, and Clostridium difficile) can persist on dry surfaces for weeks to months. Patients admitted to a room where the previous occupant was colonized or infected with a multidrug-resistant organism are, independent of other factors, more likely to acquire the same multidrug-resistant organism, highlighting the essential role of adequate room cleaning and disinfection.Reference Drees, Snydman and Schmid ¹ Healthcare workers’ hands also can be a vehicle for transmission of pathogens from environmental surfaces near the patient. Pathogen contamination of healthcare workers’ gown and gloves at room exit is related to the number of surfaces touched.Reference Rock, Thom, Masnick, Johnson, Harris and Morgan ² Despite this risk of pathogen transmission, studies have found that less than half of hospital room surfaces are adequately cleaned and disinfected.Reference Carling, Parry and von Beheren ^{3 ,} Reference Goodman, Platt and Bass ⁴

Adequate microbiologic disinfection of surfaces can be achieved with appropriate cleaning proceduresReference Carling, Parry and Rupp ⁵ ; however, implementation and adoption of these practices in real-world settings has been difficult and incomplete. Although considerable efforts have been made to improve education and training on patient room cleaning and to develop strategies for monitoring and providing feedback on cleaning performance,Reference Han, Sullivan, Leas, Pegues, Kaczmarek and Umscheid ⁶ there remains considerable variability in cleaning practices by environmental services (EVS) staff. A large trial to enhance environmental cleaning in multiple intensive care units via educational and programmatic interventions found between 6% and 30% of surfaces were still potentially contaminated in the postintervention period.Reference Carling, Parry and von Beheren ³ Given the complexity of the patient room cleaning process, the associated work system, and the barriers to effective implementation, an approach guided by human factors engineering (HFE) principles may be helpful to design and implement effective and sustainable interventions for improving patient room cleaning and disinfection. Development of an HFE approach to patient room cleaning could then be adapted for cleaning and disinfection of other high-risk hospital environments, such as the operating room.

HFE is “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimize human wellbeing and overall system performance.” ⁷ Evidence has shown the effectiveness of HFE in improving healthcare quality and safety with issues such as medication errors, readmissions after complex surgery, and safe implementation of the electronic health records.Reference Xie and Carayon ⁸ Several researchers proposed the application of HFE to infection prevention, such as improving central line care.Reference Gurses, Seidl and Vaidya ^{9 ,} Reference Yanke, Carayon and Safdar ¹⁰ Yanke et alReference Yanke, Carayon and Safdar ¹⁰ have used this methodology to evaluate a C. difficile prevention bundle. In this article, we describe an HFE approach to hospital room cleaning that emphasizes the 3 core characteristics of HFE: (1) using a systems approach, (2) being design-driven, and (3) focusing on both system performance and human well-being.

An HFE approach to patient room cleaning highlights interactions among work system elements and levels, the dynamic impact of individual work system elements on the whole system, and links between work system, care processes, and system outcomes.Reference Waterson ¹¹ According to the Systems Engineering Initiative for Patient Safety 2.0 model,Reference Holden, Carayon and Gurses ¹² a systems engineering model anchored within HFE, patient room cleaning is collaborative work of EVS associates, healthcare providers (eg, nurses), and patients and their families, who perform different tasks (eg, cleaning high-touch surfaces, communication), with various tools and technologies (eg, cleaning tools and supplies, checklists), under certain organizational conditions (eg, safety culture, work schedule), in an internal (eg, patient room and bathroom) and external (eg, social attitude, regulations) environment. A combination of these interrelated work system elements influences the patient room cleaning process and other care processes, which further influence patient (eg, healthcare-associated infections, patient satisfaction), employee (eg, employee satisfaction, motivation), and organization (eg, reputation and reimbursement based on healthcare-associated infection rates) outcomes (Figure 1).

FIGURE 1

Systems Engineering Initiative for Patient Safety model for patient room cleaning. EVS, environmental services.

EVS associates, in the center of the work system, face a number of challenges associated with different work system elements (Table 1). The knowledge and skills of EVS associates are important work system elements. Training EVS associates to improve their knowledge and skills, however, is not sufficient to ensure high-quality patient room cleaning. Other work system elements also need to be well designed for optimal performance. For example, a well-trained EVS associate may need support from peers (teamwork) to clean a large unit with many patient rooms. Some work system elements are difficult to change and may be addressed by improving other work system elements. For example, well-designed cleaning tools may facilitate the work of EVS associates who are not able to reach certain surfaces due to their physical limitations (eg, height, musculoskeletal disorder). Table 1 provides examples of potential intervention ideas for improving patient room cleaning.

TABLE 1

Challenges to Patient Room Cleaning and HFE-Informed Intervention Ideas for Improving Patient Room Cleaning

NOTE. EVS, environmental services; HFE, human factors engineering.

Various HFE methods (eg, proactive risk analysis, task analysis, usability evaluation)Reference Stanton, Salmon, Walker, Baber and Jenkins ¹³ and principles (eg, HFE principles for checklist design, HFE implementation principles)Reference Carayon, Alyousef and Xie ¹⁴ can be used to facilitate the redesign process. This includes analysis of the existing system, design and implementation of interventions, and evaluation of the impact of the interventions. In addition, an HFE approach emphasizes the participation of different stakeholders who can affect, or are affected by, patient room cleaning in the redesign process. This is known as participatory ergonomics.Reference Wilson, Haines and Morris ¹⁵ Patient room cleaning involves multiple stakeholders, including front-line EVS associates, healthcare providers (eg, nurses, physicians), EVS managers, and hospital leaders. These different stakeholder groups have varied values, norms, responsibilities, experience, tasks, skills, and priorities. They possess heterogeneous perspectives regarding patient room cleaning; these different perspectives are invaluable and need to be considered and integrated in the redesign process.

Finally, an HFE approach to patient room cleaning aims to improve both system performance and human well-being. The ultimate goal of patient room cleaning is to improve quality of care and patient safety by decreasing pathogen burden in the near-patient environment. Quality of care and patient safety can be assessed with measures of cleaning processes and patient outcomes. The cleaning process can be measured by use of fluorescent markers; invisible fluorescent gel markers are placed on high-touch surfaces before cleaning and assessed for removal with a black light after cleaning. Measures of patient outcomes include rates of healthcare-associated infections and patient experience scores. In addition to quality of care and patient safety, an HFE approach to patient room cleaning should enhance well-being of EVS associates (eg, job satisfaction, motivation) because poor employee outcomes are likely to be related to poor patient outcomes. This also impacts organizational outcomes because enhanced EVS associate well-being should result in improved staff retention. In addition to impacting patient safety outcomes, enhanced patient room cleaning affects organizational reputation and finances. Public reports of rates of healthcare-associated infections and patient satisfaction scores and the impact of these metrics on reimbursement are further incentives for healthcare facilities to seek improvement of environmental cleaning and disinfection.

Using an HFE approach, we highlight several challenges and potential interventions to enhance patient room cleaning. The integration of an HFE approach into infection prevention challenges is likely to lead to improved interventions that are effective and sustainable. This is a much needed step towards creating a cleaner and safer patient environment. This article demonstrates the complex system of patient room cleaning through the lens of the Systems Engineering Initiative for Patient Safety 2.0 model. However, implementation of an HFE approach is not without challenges, including budgetary constraints, insufficient manpower, and resistance to change. There are likely additional barriers to be uncovered, and different institutions may have a different hierarchy of challenges, which may require different strategies.Reference Carayon ¹⁶ Further work needs to be performed in this area, but this article proposes one framework for understanding and addressing the role of the EVS work system in the transmission of pathogens in the healthcare environment.