What Clean Really Means To A Healthcare Organization’s Culture

If people do not feel safe, or if they feel they don’t have the support or resources to provide safe care, poor PX scores, high infection rates and staff attrition can result

By Christopher Marley / Special to Healthcare Facilities Today
October 13, 2020

Hospitals and healthcare organizations stay competitive in today’s consumer-driven environment by continually improving the experiences of patients and families, as well as healthcare providers, and employees. A growing body of evidence supports the need for high-performing healthcare organizations to commit to building healthy workplace environments (Merlino & Raman, 2013; Grawitch & Ballard, 2016; Jiménez, Winkler & Dunkl, 2017). In other words, not only should organizations prioritize goals to improve patient and family experiences, they also need to focus efforts on improving workplace culture. One specific department that is cardinal to organizational outcomes is environmental services (EVS). From fostering a culture of safety to improving HCAHPS as well as employee engagement, the EVS department plays a vital role in transforming the culture of an organization.

Culture of Safety

The effects of organizational culture in the health care environment extend beyond operations, processes, and stewardship; culture affects the people who are responsible for providing care

to the people who need care. Just as emphasis should be placed on the health, safety, and well- being of the patients being served, organizations also need to emphasize those outcomes for their workplace personnel, across all care teams. This begins with care teams perceiving the care provided and workplace environment as high quality. This happens from the moment they enter the front door of the organization, and it continues as they move through the entire facility. A clean environment translates to a safe environment, from the perspectives of patients and families receiving care, as well as the perspectives of care teams providing care.

A healthy culture is a safe culture and is essential to positive outcomes. Psychologist Abraham Maslow developed the theory ‘hierarchy of needs’ (Figure 1). According to Maslow’s theory, humans seek first to satisfy the lowest level of needs, such as air, food, and water. Once this is achieved, humans continue to satisfy each higher level of need until all are reached. Adopting this theory for the workplace, we’d say paychecks meet basic human needs like food and shelter. High- performing organizations understand the new economic reality: providing safe environments, providing a sense of security, and helping care teams feel purpose and meaning in their work are the differentiators (Perlo, Balik, Swensen, Kabcenell, Landsman & Feeley, 2017).  It is up to organizations to provide the right conditions and environments so that caregivers can achieve their highest potential and produce outstanding work (Nielsen, et al., 2017).


Maslow's Hierarchy of Needs

Figure 1: Maslow’s Hierarchy of Needs

Perception of cleanliness matters 

Top performing organizations understand that short-term tactics do not cultivate long- term success. This first impression, and all the perceptions that follow, serve as the foundation of the patient experience (PX), as well as the experience of their families and care teams. This directly impacts margins, market share, and staff morale. Bottom line: if people do not feel safe, or if they feel they don’t have the support or resources to provide safe care, decreased PX scores, high infection rates, and staff attrition prevail. With the inception of publicly reported surveys and collection data such as HCAHPS, which stands for Hospital Consumer Assessment of Healthcare Providers and Systems, organizational performance and outcome measures help consumers and care teams make informed decisions about the culture, safety, and care delivery of US healthcare organizations.

Significance of cleanliness

In addition to providing transparent data to consumers and care teams, the Centers for Medicare and Medicaid Services (CMS) also reimburses or penalizes healthcare organizations on performance measures. Since improving the quality of healthcare is a national priority, hospital performance measures are increasingly being used to benchmark quality through CMS (IOM, 2001; CMS). Under the Patient Protection and Affordable Care Act (P.L.111–148), CMS reimburses hospitals based on their performance. Specific to the Patient Experience of Care Domain score, which is also referred to as the Person and Community Engagement Domain, hospitals increase their chances of maximizing reimbursement dollars based on the Hospital Value- Based Purchasing (VBP) program.

There are nine measures from HCAHPS that are included in the Hospital VBP. This includes six composite measures (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Communication about Medicines, Care Transition, and Discharge Information), two individual measures (Cleanliness of Hospital Environment, and Quietness of Hospital Environment), and one global measure (Hospital Rating, formerly known as Overall Rating of Hospital).

Data Analysis & Interpretation

  • Organizations that continuously improve PX data and initiatives understand that short-term actions are less likely to impact long-term success. It is critical for organizations to utilize qualitative and quantitative data analysis as the underpinning of their improvement processes. Conducting different kinds of analyses helps organizations identify relative strengths and weaknesses:
  • Review HCAHPS scores to national and peer benchmarks.
  • Review trends of patient comments specific to departments, behaviors, and processes.
  • Compare current HCAHPS scores to the organization’s past performance (year over year improvements).
  • Assess which aspects of performance are most relevant for improvement.

Understanding the relevancy of improvement initiatives is critical. Percentiles indicate how often patients gave positive assessments of their hospital experience. With “top-box” scores, the higher, the better. For example, on “Cleanliness of Hospital Environment,” 5% of hospitals scored 90 or higher (95th percentile) in the “top-box,” while 5% scored 63 or lower (5th percentile). The median (50th percentile) score on this measure was 75 (Figure 2).

Data analysis & interpretation

Cleanliness of the hospital environment is highly correlated with how a patient or family member rates Communication with Nurses (.39), Communication with Doctors (.28), Responsiveness of Hospital Staff (.35), and Communication About Medicines (.33) (Figure 3). The chart below includes patient-level Pearson correlations of rescaled linear means of HCAHPS measures for patients discharged between July 2017and June 2018 (2.9 million completed surveys). Note: All correlations are significant at p<0.001. Correlation coefficient formulas are used to find how strong a relationship is between data. The formulas return a value between -1 and 1, where:

•   1 indicates a strong positive relationship.
•   -1 indicates a strong negative relationship.
•   A result of zero indicates no relationship at all.

Source: Centers for Medicare & Medicaid Services, Baltimore, MD. October 27, 2019.

Key Takeaways

•  Identify and value EVS departments as key stakeholders in the delivery of safe, effective, quality care.
•  Optimize the cleanliness and perceived cleanliness of hospital rooms and common areas through open communication with EVS teams.
•  Train and reinforce service excellence standards within EVS departments.
•  Foster a culture of teamwork, communication, and collaboration between EVS staff and other organizational care teams.


Christopher Marley is the System Patient Experience Manager for Support Services, Ochsner Health at ABM Industries.


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