Room cleanliness, or more specifically patient satisfaction with room cleanliness, is not always at the top of the priority list for quality improvement initiatives, but it is an issue that is important to overall operations and patient satisfaction. In the American context today, it is measured and reported in the federal Center for Medicare and Medicaid’s (CMS) HCAHPS Survey of indicators from a patient perspective. The National Health Services (NHS) regularly reports on patient satisfaction indicators across hospitals in the United Kingdom. Failing to meet minimum standards in relation to these indicators result in poor ratings, and even lower reimbursement according to some policies. One of these indicators is in relation to patient room cleanliness. Room cleanliness from a patient perspective is a complex variable. A low score does not necessarily indicate that the problem is a lack of cleanliness. Instead, it could also indicate that housekeeping program is not aligned with the expectations of a patient. Patients vary in their assessment of room cleanliness, and what they focus on in their evaluation.
What is patient satisfaction with room cleanliness?
Each patient can vary with regard to those aspects that indicate to them that a room is clean. A military background, for example, can set different understandings of cleanliness. Different cultural and national background creates divergence in determinations of room cleanliness. There are different approaches and values that relate to how cleanliness is understood. It is not possible to deal with every possible area of housekeeping in a way that can please every possible background. There is no question that room cleanliness is also relevant to indicators such as post-surgical infections, the rate of hospital acquired infections and other issues. That is a starting point, in that room cleanliness should contribute, and not impair, health outcomes. Beyond that, and perhaps despite that, there is little relationship between clinical room cleanliness, and patient satisfaction with room cleanliness. Put another way, having one optimal process and standard won’t lead to patient satisfaction. however it is possible to manage expectations on a patient by patient and room by room basis.
Patients tend to be happier when there are sufficient nursing staff to care for them. Despite this, increasing nursing staff when the staffing is sufficient does not increase patient satisfaction, and it has no impact on satisfaction with room cleanliness. Studies have shown that increasing time or resource allocations does not, by itself, lead to a higher quality standard with regard to room cleanliness. The most effective ways of improving quality, including room cleanliness are not based on increasing time or resource allocations, but rather it is a shift in the framework that determines action. Currently, approaches to most performance measures, and therefore the quality improvement of those measures, focus on assessment by hospital staff. Now that patient perspectives affect reimbursement of the facility, this needs to change.
The study findings in this topic area are somewhat counterintuitive. A study by Rupp, Adler, Schellen and colleagues (2013) warned that there was little correlation between the state of room cleanliness and time spent cleaning a room. This brings up an important point, which is that it is the approach which creates a quality outcome, rather than the effort or time which is put forth on a goal.
One study by Knelson (2015) measured room cleanliness from the perspective of a facilities housekeeping managers and that of researchers measuring the extent to which surfaces were contaminated by bacteria or viral infections. While housekeeping managers used an objective assessment measure, the difference in approach led to a lack of resonance between the independent assessments by the two groups.
Hockenberry and Becker (2016) described a regression analysis study which attempted to determine if increased ratios of nurses to patients had a positive impact on patient satisfaction scores. The researchers found that there was indeed a more positive rating on a number of measures, including room cleanliness, however the improvement was most dramatic when comparing understaffing with sufficient staffing. Once understaffing has been dealt with and sufficient staff have been recruited and scheduled for all given shifts the return on the investment of additional nurses decreased.
Neither increasing nursing staff, nor increasing time spent on room cleaning resulted in the desired quality goal. This is not surprising, because as stated previously it is not the allocation of time nor resources which increases quality, but rather the implementation of a perspective and processes to support it which lead efficiently to increased quality outcomes.
Case Study: The IMPACT Program
Just wanting to make improvements does not always work. Take, for example, the IMPACT leadership program described by Keith et al. (2015). The IMPACT program was implemented at a 210-bed, level III community-based acute care hospital that served a significant Medicare/Medicaid population. The purpose of the IMPACT leadership program was the development of leadership skills to tackle service standard issues. In this case, several leaders spent time in a classroom on a development retreat. The need for a gold service standard in services was the focal point of discussions and lectures. Each participant was required to commit to a gold service standard policy for their area of responsibility. After the training, they were required to enforce a gold service standard policy, taking actions such as identifying problems, determining the staff responsible and instituting new probationary periods until deficiencies in were rectified. Ultimately, eight managers resigned, and a further eight were terminated as a direct results of the program. The room cleanliness patient satisfaction indicators showed no improvement. Frankly, the real outcome of this case seems to have been plunging morale and possibly a toxic work environment.
Case Study: Patient rounding at Magee-Women’s Hospital of UPMC
Things went far better in the initiative at the Magee-Women’s Hospital of University of Pittsburgh Medical Center (UPMC). Kramer (2016) described the core of the program, which was a patient rounding schedule. The program consisted of an add-on module to housekeeping services. Each patient was asked about three times per week whether there were any housekeeping or environmental services problems. This was more than just a process approach. The face to face contact and inquiry were part of the approach to leveraging a new organizational culture of patient service excellence. Patients had the opportunity to communicate cleanliness issues, and staff had the opportunity to resolve any issues. Some of the idiosyncratic issues that were discovered were a matter of timing or circumstance. For example, a patient who needed to throw away packaging needed for self-care treatments found that the garbage bin filled up early in the day, leaving nowhere to refuse until housekeeping came in the late afternoon. Another was an irritating mark of questionable origin on the wall that was is in the line of sight of the patient while lying immobile in bed which led irritation. Evaluation after the program was first put into place revealed a 20% increase in patient satisfaction with room cleanliness, as well as increased patient satisfaction generally.
The quality improvement must address the quality deficiency
The cause of patient satisfaction with room cleanliness as a quality issue is the patient dissatisfaction. There can be two reasons for this. The first and most obvious reason is that the regular program of housekeeping actually inadequate. The second reason is less obvious from a systematic operational perspective. Even in facilities that have excellent housekeeping programs, the patient may have expectations that differ from that plan which has been implemented. Cultural expectations, personal traits, or other may result in the patient finding some aspect of housekeeping to be lacking. If, in fact, the housekeeping program is adequate, then it is a waste of time to address every area of housekeeping, rather than simply addressing the patient’s concern.
To summarize, the two simple steps that lead to the performance improvement issue are:
- The implementation of an appropriate room cleaning schedule and protocols;
- Asking the patient if they are satisfied with room cleanliness, and taking action if they are not.
These are both prevention and recovery steps.
Just Ask The Patient
Just ask the patient. Ask patients regularly if they have any concerns, whether they want their sheets changed, or whether there are any issues. If there is a reasonable concern, then it should be dealt with promptly by contacting Housekeeping Services. If many patients voice concern with regard to a specific area, then returning to the adequacy of the core housekeeping program might be the effective strategy. The quality improvement process can be made easier by process mapping the common responses and what nurses or other health care professionals should do as a result of different responses and scenarios, and then providing training and practical experience in rounding scenarios.
Many complicated strategies have been devised in order to increase patient satisfaction, but not enough of these strategies are actually driven by patient perspectives. Healthcare is not a practice that is “done to” people. It is a practice of caring for and supporting patients so that they can achieve or maintain well-being. The best means of ensuring this is achieved is to ask the patient. This works for more than just room cleanliness. It is part of the mission to heal the sick and maintain wellness in the community, and to ensure that all staff and patients are treated with respect and dignity.
Technological approaches to rounding
Patient rounding is a time-tested and centuries old practice, however there are many ways to modernize the approach through automation, digital communications, and quality communications. What we ask, and how we ask it, becomes part of the experience. This therefore needs to be carefully considered. The core principle is to ask the patient if they are satisfied, or what they need in order to be satisfied. Given communications technology today, it is possible that new methods of patient rounding could take advantage of this capacity. For example, a pilot project could test the use of patient rounding using video chat or text. An app can provide for instant communication directed to the appropriate area. Such an app might even provide language support or other additional features.
Call to Action
Quality improvement doesn’t have to be difficult, technical or expensive. Sometimes the key to a positive change is obvious, but obscured by perspectives which miss that core role of the patient. Not only is the approach to quality improvement easy to implement, the financial and other costs are minimal. The outcome is likely to save both time and resources in the long term, particularly if it contributes to internalizing a higher standard for ensuring patient satisfaction. Just ask the patient. They will be able to do what no machine or screening instrument can evaluate with the same accuracy- the extent to which the patient is or is not satisfied.
Dive in to the Research
Hockenberry, J. M., & Becker, E. R. (2016). How Do Hospital Nurse Staffing Strategies Affect Patient Satisfaction?. ILR Review, 69(4), 890-910. doi: 10.1177/0019793916642760 https://journals.sagepub.com/doi/abs/10.1177/0019793916642760
Keith, J. L., Doucette, J. N., Zimbro, K., & Woolwine, D. (2015). Making an impact: Can a training program for leaders improve HCAHPS scores?. Nursing management, 46(3), 20-27. doi: 10.1097/01.NUMA.0000459093.40988.78 https://journals.lww.com/nursingmanagement/FullText/2015/03000/Making_an_impact__Can_a_training_program_for.6.aspx
Knelson, L. P. (2015, October). Self-monitoring of hospital room cleaning by Environmental Services (EVS) may not accurately measure cleanliness. In IDWeek 2015. Idsa. doi: 10.1093/ofid/ofv131.85 https://academic.oup.com/ofid/article/2/suppl_1/732/2633996
Kramer, A. (2016). HCAHPS: a review and management strategy to improve hospital cleanliness and the importance of organizational culture in its sustainability (Doctoral dissertation, University of Pittsburgh). http://d-scholarship.pitt.edu/27494/
Liu, S. S., Wen, Y. P., Mohan, S., Bae, J., & Becker, E. R. (2016). Addressing Medicaid Expansion from the Perspective of Patient Experience in Hospitals. The Patient-Patient-Centered Outcomes Research, 9(5), 445-455. doi: 10.1007/s40271-016-0167-y https://link.springer.com/article/10.1007%2Fs40271-016-0167-y
Rupp, M. E., Adler, A., Schellen, M., Cassling, K., Fitzgerald, T., Sholtz, L., … & Carling, P. (2013). The time spent cleaning a hospital room does not correlate with the thoroughness of cleaning. Infection Control & Hospital Epidemiology, 34(01), 100-102. doi: 10.108610.1086/668779/668779 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/abs/time-spent-cleaning-a-hospital-room-does-not-correlate-with-the-thoroughness-of-cleaning/92D3CFCB3B33EFE0830936C206A9CD22
Cite this article
Duncan, K. (2021). Understanding Patient Satisfaction with Room Cleanliness. Nursification, (Spring/Summer). doi: 10.6084/m9.figshare.14551389 http://nursification.com/emerging-research-and-evidence/understanding-patient-satisfaction-with-room-cleanliness/