Methods of assessing the quality of cleaning in health care facilities

According to the SCC report prepared on the basis of results of nutrition and cleaning control in public hospitals (Reg. 9/2009/P08141/LKR) “The way in which hospitals were kept clean was unsatisfactory due to a significant number of irregularities and deficiencies. Hygiene procedures used in controlled hospitals were developed unreliably, as they were inconsistent and often not adapted to real conditions (. . . ). SCC’s objections were raised especially by the use of household chemicals instead of more effective and cheaper professional agents, which was a wasteful activity (. . . ) The inspection showed that only the epidemiological nurse was responsible for supervising cleaning activities, or these activities were entrusted to the head nurse. In one of the 12 hospitals visited, a committee was set up to control the effects of the company’s work, consisting of the hospital’s employees and a representative of the company (. . . )”. Among the recommendations and post-cleaning recommendations of the SCC in the field of cleaning addressed to hospitals was the need for systematic supervision and continuous analysis and monitoring of the state of cleanliness. This has given the management of hospital facilities the task of not only providing properly trained staff and developing appropriate cleaning procedures, but also of developing and selecting appropriate cleaning control methods. What SCC has not explicitly identified in its report is the issue of cleaning quality assessment, which appears to be an essential tool for monitoring cleaning in hospital facilities.

In this article, the authors discuss two different methods of assessing the quality of cleaning – their own method of organoleptic measurement of the quality of cleaning, developed years ago, and as an example, used in Scandinavia, a standardised method described in the Danish Cleaning Quality Assessment Standard, on the basis of which the quality of cleaning services and surface cleaning is measured.

The first of the above mentioned methods is visual evaluation, consisting in rubbing an object with a clean hand and observing the contamination collected by hand from the surface (recently popularized in the media as a “white glove test”), in which the unit of measurement is the quotient of the number of cleaning operations performed correctly by the number of commissioned operations. If the quotient is multiplied by 100, the result is in %. This type of measurement is inherently subjective.

This approach requires a precise definition of the cleaning range, taking into account the frequency of measurement and recording it in the contract with the cleaning company. Table 1 gives an example of the daily cleaning range control protocol for patient rooms. Analogous protocols can be created for any premises (toilets, conference rooms, workshops, office spaces, chapels, cellars, pavements, lawns, car parks) in any facility (hospital, cinema, steelworks, shop) at different intervals (after each treatment, every day, once a week, once a month, every quarter) or according to foreseeable needs (snowfall, leaffall in autumn, lawn mowing).

In this way, the daily cleaning range can be described for any room or outdoor area. You can check all rooms every day, or random, from time to time. It depends on how many people can take care of this type of control and how much time they can spend on it.

Every approach has flaws. If the inspection is carried out by a single person, he or she shall then set the same requirements, but if there are more than one inspector, the inspectors may have different ideas about the minimum quality accepted and may assess it differently. For example: for some, light limescale deposits on the tap where the battery is connected to the spout will be acceptable, for others it will be unacceptable. For one, the dust on the ventilation grid will be a sign of proper operation of the installation, someone else will treat the dust as gross negligence. Therefore, the same quality of service can be assessed differently.

On the other hand, it makes sense to meet and comply with the individual requirements of the client when they correspond to the hospital’s cleaning procedures.

Unfortunately, the reference method for measuring cleaning quality has not been developed. From a statistical point of view, the larger the sample size, the more confident the measurement result is.

It is difficult to interpret the calculation of the mean value from the measurements taken. Therefore, the quality can be determined by the arithmetic mean, or any other measure of the middle value, e. g. median*.

In this case, the calculated centre values for the whole object are not similar. If the facility is cleaned by an external company, the financial manager faces a difficult question: to pay 100% of the agreed amount, because overall it is good (median=100. 0), or to pay 93. 9% because not everything has been done properly (arithmetic mean 93. 9%).

An analysis of the protocols over time can also show which tasks are difficult and which are performed over a long period of time without reservations

Cleaners have no problems with cleaning mirrors, they clean taps and washbasins a little bit worse, the hospital scale is the worst with windowsills.

The implementation of cleaning quality measurements makes sense if the results are presented in front of a specific decision maker and cleaning company. If the results are to go into a drawer, no decision-making body will ever take corrective action.

A very interesting and detailed solution for assessing the quality of cleaning and surface quality after the use of professional cleaning products has been developed in Denmark – the standard for the assessment of the quality of cleaning and surface after

the use of professional cleaning products. quality assessment of DS/INSTA 800 E cleaning. This standard allows for organoleptic measurement, by observation, and instrumental measurement, using measuring equipment. It also gives classes of pollutants and divides the areas into 6 categories according to their availability and type.

Most importantly, the standard gives several acceptable quality levels (3 to 6) for instrumental (non-organoleptic) measurements for the following parameters:

  1. Dust on the surface;
  2. Hygiene level, i. e. microbiological load on the surface;
  3. Friction on the surface;
  4. Surface gloss;
  5. Surface antistaticity;
  6. Specific resistance (resistivity),

for which the limit values for each quality level are given.

Measuring the amount of dust on surfaces is an optical method consisting in measuring the light transmission through a transparent foil covered with adhesive. The drop in transmission compared to a pattern not exposed to a dusty surface is proportional to the dust that has stuck to the foil. Measurements on hard surfaces should be taken over a minimum distance of 20 x 30 cm. 1 to 3 samples must be taken from each of the test plots.

This method can also be used to test dust residues on carpets, but a special attachment is needed. The result is given as a percentage of the surface covered with dust.

It is recommended to measure the amount of dust on the surface in rooms offices, conference rooms, school classrooms, hospital wards, laboratories, corridors, etc. However, it is not recommended to use this method to assess the quality of indoor cleaning and the increased level of air humidity, i. e. kitchens, entrance halls. Dust measurements on hard and semi-flexible floors for evaluation and quality control of cleaning are only recommended for floors protected with polymer protective coatings.

The authors of the standard differentiated quality levels for different areas depending on availability.

There are 5 quality levels for 4 or 5 surface categories:

  • surfaces in the vicinity of objects (i. e. computer, desk);
  • easily accessible furniture surfaces (i. e. sill, desk);
  • hardly accessible furniture surfaces (chandelier, cornice ect.);
  • easily accessible surfaces of hard floors i. e. transition areas, “paths”;
  • hard flooring surfaces, i. e. under the desk;
  • easily accessible surfaces of carpet floors.

The measurement of the microbiological load of a surface is a measurement method consisting of testing the quantity and types of microorganisms on surfaces subjected to a purity check. This method is mainly used in the food industry. It consists in taking samples using the imprint method with microbiological agar medium. The composition of the substrate depends on specific conditions, use of the rooms. The classification of quality levels according to the number of colony-forming units per plate with an agar substrate of 26cm2 for surfaces in contact with food is given below.

Friction measurement is a method used to determine the level of safety and risk of slipping on the floor. The measurement is made on hard and flexible floor surfaces (stone, PVC, linoleum) and consists of measuring the friction force between a given flat floor and a standard plastic shoe pressed against the floor with a force of 24N, moving at a speed of 200mm/s. The dynamic friction coefficient µ is the quotient of the friction force (measured) and the pressure (in this case 24 N). Measurement should be made with a Floor Slide Control device (the standard specifies the FSC 2000 Sellmaier or equivalent with a similar measuring scale).

The standard also defines 5 anti-slip safety levels recommended for different types of surfaces:

  • Level 5 – recommended for kitchens, industry where there is greasy slippery soil;
  • Level 4 – hospitals, supermarkets, schools (where there is a lot of traffic or people with reduced mobility);
  • Level 3 – offices (where there is little traffic);
  • Level 2 – where it is recommended to wear suitable anti-slip footwear;
  • Level 1 – not recommended for rooms with normal traffic.

The measurement of floor gloss is performed on hard and flexible flooring surfaces (i. e. stone, PVC, linoleum) coated with polymer protective coatings to check for the desired gloss level (shopping malls, supermarkets). Measurements can be taken at 10 – 25 points in the room, depending on the size of the room, at least once a quarter after the daily floor care has been completed. Of course, the desired gloss level can be freely determined by the customer, which does not mean that the highest level is preferred by everyone. The standard distinguishes 5 gloss levels, of which the highest level 5 is recommended for perfectly smooth floors without any surface structure and levels 1 and 2 are recommended for floors covered with polymer protective coatings.

The measurement method consists of measuring the light reflected from different angles, which is practised when assessing paints and varnishes. When the gloss of the surfaces to be cleaned is tested, the light reflected from the floor is measured at an angle of 60°. A scale from 0 to 100, where 0 is no reflection. Floors covered with a polymer protective coating may have a maximum reflection level of 85 units.

The device used for gloss measurement is a glossometer compliant with ISSO 2813 standards, where 60° is a geometric mirror reflection.

The degree of electrostatic charge of a surface is a method of measuring the quality of care used to examine the level of electrostatic charges on surfaces. This method is used in places where the lowest possible level of electrostatic charges is desired, i. e. in offices, computer rooms, switchboards. The purpose of the measurement is to verify whether the company providing cleaning services provides surface care which results in the desired level of charge on the floor and in front of the computer screen and other electronic equipment.

The measurement of this parameter and the measuring device is described in a separate standard in DIN 54345:1992 and consists of two measures: the amount of electric charge collected by a person walking on the floor and the electrostatic field strength of computer screens and electronic devices. The measurement is usually made according to the size of the room in 1 – 5 areas.

Electrostaticity level 4-5 applies to rooms with sensitive electronics. Additionally, level 5 is recommended for allergy sufferers and people susceptible to skin irritation. Level 1 provides sufficient protection against cargo and is sufficient for the following rooms hotel corridors etc. The results of these measurements depend on the type of surface and relative humidity, which should be taken into account when interpreting the results.

Surface (electrical) resistance is a quality parameter of cleaning services that is important for dissipating electrical charges, e. g. in operating theatres. The lower the resistance in Ohm [Ώ], the better the dissipation and discharge of electrostatic charges, but also the worse insulating properties. The device used to measure this parameter is an ohmmeter.

Both of these approaches confront the functioning of two different hygiene control systems in different countries. They are at the same time a proposal, resulting from the willingness to present to you existing in the world and possible to be used, also in our conditions, means of evaluation of the quality of cleaning used for its systematic, precise and, what is the most important, easy to evaluate monitoring. The methods contained in this standard are statistical methods relating to the measurement of specific measurable parameters. In the next article we will try to explain to you how the evaluation of individual quality parameters of cleaning and how to adjust the evaluation criteria to the individual conditions of the facility.

*MEDIAN (also known as middle value or second quantile) is the statistical middle value dividing a collective (ordered series) into two equal parts; it is the value of the statistical series, above and below which the same number of words of the series in ascending or descending order is found (odd number of words in the series). In the case of an even number of words in a row, the median is equal to the arithmetic mean of two middle values. The median is one of the middle values.

Literature:

  1. Report of the SCC 9/2009/p08141/lkr information on the results of nutrition and cleaning control in public hospitals, March 2009.
  2. DS/INSTA 800 E, Cleaning quality – Measuring system for assessing the quality of cleaning services, Danish Standard Association, 2003-03-27.

Other from: Maintenance of cleanliness

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