Use of human-centric and participatory design for modifying a daily environmental cleaning checklist: a quality improvement study

Abstract

A major tenet of healthcare environmental cleaning focuses on high-touch surfaces (HTSs). HTSs have high rates of contamination, yet cleaning compliance remains low, particularly in patient-occupied rooms. This quality improvement study aimed to use human-centric and participatory design to modify an HTS cleaning checklist and conduct initial trial and evaluation.

Background

Contaminated environmental surfaces are a reservoir of pathogens causing healthcare-associated infections (HAIs). ¹ While optimal cleanliness to prevent pathogen colonization from the environment is unknown, cleaning practices applied frequently and consistently can reduce the environmental bioburden, disrupting transmission of these pathogens and preventing HAIs. ²

Initiatives to improve environmental cleaning practices have focused on targeted cleaning of high-touch surfaces (HTS) and monitoring of environmental cleaning processes. ³ However, cleaning compliance remains low which may be partially explained by practice variation. ⁴

Given the importance of effective cleaning of HTS, the Centers for Disease Control (CDC) developed checklists to ensure all steps/actions are taken in cleaning and disinfecting these surfaces. ⁵ However, a recent systematic review found that checklists in healthcare are often lacking human-centric design. ⁶ A recent review of healthcare cleaning strategies highlights the human element in manual cleaning processes and the need to evaluate human factors to improve environmental cleaning quality. ⁷ Important human factors principles to incorporate in improving cleaning practices include human-centric participatory design to engage end users during development and developing and using mental models (representations formed by a user of a system and or task, such as pictographs of ‘cleaning patterns’ and ‘contaminated/dirty areas’). ⁸

To improve cleaning compliance in HTS-occupied rooms, we conducted a quality improvement (QI) intervention pilot project to modify and evaluate a daily cleaning checklist using a human-centric, participatory design to evaluate mental models of environmental. Because our preliminary work found patient presence in the room was associated with lower cleaning rates, ⁹ we included VA’s internal housekeeping service (environmental management services, EMS) staff and Veteran patients as participants. EMS staff follow evidence-based practices including CDC resources; however, individual VA facilities have latitude on implementation (e.g., training, procedure development).

Methods

We engaged EMS staff and Veteran patients to modify the CDC checklist for daily cleaning of HTS in occupied rooms. A Plan-Do-Check-Act cycle (Supplemental Figure 1) was used to develop, pilot, and evaluate the modified checklist intervention in acute and long-term care settings at one VA Hospital. The project was determined to be QI.

Plan

We conducted two focus groups (one with Veterans and one with EMS staff) to identify checklist modifications that may address barriers and facilitators of cleaning occupied rooms. Veterans from an existing patient engagement panel and EMS staff were purposively sampled (in collaboration with EMS supervisors) for focus group participation. Participants viewed an illustration (Supplemental Figure 2) depicting patients and EMS interacting during the daily cleaning process. Trained QI team members used a semi-structured interview guide to ask participants about 1) patients’ and EMS’s possible notions upon EMS entering the patient room and 2) how these insights could be addressed during the cleaning process.

Do

The QI team used these responses to modify the CDC checklist (Supplemental Figure 3), focusing on changing mental models for cleaning patterns and surface area during checklist application.

The checklist intervention was piloted to evaluate its effectiveness on HTS cleaning. The QI team provided “just-in-time” training on the modified checklist to four EMS staff, all of which were included in the pre-intervention focus groups.

Check

To evaluate HTS cleaning, trained researchers conducted direct observations of EMS staff performing daily environmental cleaning of patient rooms. The data collection tool was developed and utilized previously by the team. ⁹ Observations were pre-arranged with EMS supervisors for one-week periods during the pre-intervention phase (no checklist) and intervention phase (checklist); observers rounded daily on acute and long-term care units and observed EMS activities to note which HTS were cleaned during daily room cleanings. Cleaning adherence rates (number of surfaces cleaned/total number of surfaces) were calculated before and during use of the modified checklist. Pre- and post-intervention cleaning adherence rates were compared using paired t-test.

Act

Post-intervention interviews were conducted with EMS staff to evaluate checklist usability. All interviews and focus groups were audio-recorded, transcribed, and analyzed using rapid qualitative inquiry methods. ⁹

Results

The Veteran patient (N = 8) and EMS staff (N = 5) focus groups identified recurrent themes of discomfort cleaning HTS within patients’ vicinity and having physical barriers (e.g., clutter) to accessing HTS.

“If you’re wiping the rails while they’re in bed, they [the patient] don’t like that.” [EMS]

“When you have the bed table, sometimes it’s just loaded with stuff. You can’t clean it anyway.” [EMS]

“[The checklist says] ‘bed rails, if the patient isn’t in it.’ I didn’t leave that bed for 30 to 40 days. That’s why they didn’t clean my bedrails.” [Veteran]

“Or every nurse comes in and brings this in, and pretty soon that counter is so cluttered that nobody will wipe that counter.” [Veteran]

These perceived barriers were addressed by incorporating two changed mental models into the checklist (Figure 1):

1. 1) start the cleaning pattern with HTS near the patient first (‘dirty to clean’) rather than ending with those HTS (‘clean to dirty’)

2. 2) clean any possible surface area when encountering clutter (‘partial surface is better than no surface’) rather than skipping the entire surface if it cannot be cleaned (‘all surfaces or nothing’)

Figure 1. Modified mental model: a. cleaning patterns and b. cleaning surface areas.

Direct observations showed that cleaning compliance improved from 36% (N = 9 rooms; 89 surfaces) before using the checklist to 75% (N = 10 rooms; 93 surfaces) when using the modified checklist (Table 1).

Table 1. Check phase (observations): high-touch surface cleaning compliance

Note. *P < 0.001.

Post-intervention interviews were conducted with EMS staff (N = 2) to assess checklist usability. Participants reported ease of using the checklist and discordance of modified cleaning patterns with previous training and practices.

“[The checklist] is reasonable because it doesn’t take that much time.”

“The rail is something that we were never told to do, but I’ve been trying to do those.”

Discussion

Our study found that HTS cleaning rates were improved using an HTS cleaning checklist with modifications to mental models of cleaning patterns and surface area.

Current cleaning checklists do not address contextual factors of navigating the environment surrounding patients. Our work has shown the presence of patients in a room is a barrier to cleaning HTS. ⁹ Modifying checklists through human factors principles—such as engaging key participants (end users) in re-evaluating existing mental models—may address this gap. Further evaluation is needed to understand the potential role of checklists and other human factors approaches in reducing practice variation and improving cleaning.

This QI study was limited to one site and the number of observations is not sufficiently powered for results to be conclusive. Further, limited interviews and focus groups were conducted. Participant and observation bias are possible because EMS staff used to inform checklist modification were also observed during the intervention and EMS staff were aware of observations during cleanings due to the nature of direct observations.

This study provides considerations for updated models for daily cleaning of HTS in occupied patient rooms. Further research is needed to evaluate this checklist and modified cleaning processes in a larger sample of care settings. Overall, human factors tools and approaches are useful to navigate the complex intersection of patient care and environmental cleaning.