Cleanliness Counts - Driving Continuous Improvement in Hospital Hygiene Services


Cleanliness counts. Ensuring a clean environment is fundamental to the provision of safe and high quality care. The hospital environment is one of the first things which patients and their families experience when they seek care and ensuring this is clean gets the first impression right. Importantly, some aspects of hygiene services support the prevention and control of healthcare infection. Healthcare infection is a concern for those who receive and provide care alike and, while recent downwards trends in MRSA-related bloodstream infection are encouraging, there is no room for complacency.


Following two external and independent hygiene reviews which were commissioned by the HSE, the Health Information and Quality Authority (HIQA) undertook hygiene services quality reviews of all public hospitals in 2007 and 2008. Together, these reports showed that hospitals operated or funded by the HSE are on a path of improvement. The fundamentals are in place. Hospitals have generally scored well on service delivery standards. Importantly, the patient survey conducted as part of the 2008 reviewed showed that patients found hospitals were generally clean.


However, good services on the ground need to be supported by good corporate management - how services are led, planned, organized, monitored and reviewed. In 2007, HIQA indentified the need for the HSE to strengthen corporate management of hygiene services. This was necessary to sustain good performance in service delivery and to drive continuous improvement.

In 2008, in addition to maintaining good performance in relation to service delivery, the hospitals operated or funded by the HSE made significant progress with regard to corporate management of hygiene services, in particular clarifying governance arrangements. These improvements were noted by HIQA - in 2008, 92% of hospitals were awarded an A or B rating for corporate management standard five (organization structure for hygiene services); within corporate management standard five, criteria 5.2 (multidisciplinary hygiene services committee) was the criterion with the highest level of compliance across all hygiene standards.

However, against a background of overall improvement, a wide spread of performance emerged: a few hospitals are exemplary, most are making reasonable and steady improvement, however, some struggle to keep up with the pace of progress.

To drive improvement and to narrow the spread of performance, the National Hospitals Office of the HSE is applying a "targeted intervention" to hospitals which it has identified as making slower progress. The principles underpinning the intervention are as follows:

  • Accountability - being clear about who is responsible for what and to whom they must report. Clear accountability is a fundamental element of good governance for safe and high quality healthcare
  • Sharing of learning across peers - ensuring that good practice from exemplary hospitals is spread across all hospitals and in particular across hospitals making slower progress. Sharing of learning from peers is recognized as a strategy for improving performance of teams and organizations.

The elements of the targeted intervention are as follows:

  • For hospitals making slower progress, a series of meetings took place between those with responsibility for hygiene services (including Hospital Managers/CEOs), Hospital Network Managers and the National Director for the National Hospitals Office to discuss the results of the HIQA reviews. Barriers to progress and strategies to overcome these barriers were examined
  • Arrangements were then made for these hygiene teams at hospitals making slower progress to visit hospitals with strongest hygiene services performance so as to learn from their good practice
  • In response, these fourteen hospitals making slower progress have developed hygiene service quality improvement plans which will be implemented through 2009. To strengthen accountability, these plans are publicly available through on this website (see links below). These documents are locally produced and locally owned plans which set out the "who, what, when and how" of measures hospitals will implement to improve hygiene services. The implementation of these plans will be overseen by Hospital Network Managers. At the end of the year, a status update will be provided and also made public through the HSE website
  • In addition, the NHO has developed a benchmarking tool to be used at a hospital group level. This tool allows good practice to be identified and shared at a hospital group level (see link below)
  • Accountability in healthcare is a complex and multifaceted concept. It is important that there is accountability for good performance as well as poor performance. How else can we acknowledge what is done well and learn from it to drive further improvement? To augment the sharing of learning from peers which has been facilitated through the series of hospital visits set out above, early in 2009, the NHO contacted hospitals identified as having high performing hygiene services based on their results in HIQA's reviews in 2007 and 2008. Hospital Managers/CEOs and their hygiene service teams were asked to provide the NHO with examples of strategies which they use to drive high performance and continuous improvement. These tips on "winning ways" were collated by the NHO and the main themes were identified. A document for circulation across all hospitals has been produced which presents these strategies with examples of implementation (see link below).



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