Committing to a higher standard

Hospital cleaningThe launch of PAS 5748, the new British Standards Institution (BSI) specification for hospital cleanliness has been broadly welcomed both within the healthcare cleaning and infection control professions and by patients and the public. Sponsored by the Department of Health (DoH) and the National Patient Safety Agency (NPSA) the specification has been jointly developed by a range of key organisations in the field including the British Institute of Cleaning Science (BICSc), the Health Estates and Facilities Management Association (HeFMA), the Infection Prevention Society (IPS) and the Association of Healthcare Cleaning Professionals (AHCP).

Ensuring a clean environment
A Publically Available Specification or PAS for short, is a collaboratively developed, BSI endorsed specification intended to create management systems, product benchmarks and codes of practice within a specific sector. Developed for use within acute, community and mental health hospitals across the NHS in England, PAS 5748 is intended to provide assurance to the public that risks associated with hospital cleanliness have been fully assessed and that nationally agreed procedures are in place to ensure hospitals are clean and safe.

PAS 5748 aims to achieve these objectives by providing a risk-based system for the planning, application and measurement of cleanliness to ensure that healthcare organisations are able to provide a clean and safe environment for patients, staff and visitors. By introducing a risk assessment approach, PAS 5748 differs from the National Specifications for Cleanliness in the NHS (NSC), the existing ‘gold standard’ of healthcare cleaning. It is not, however, intended to replace the guidance given within the NSC but, rather, to exist alongside and supplement it.

The NSC was developed to define and standardise the healthcare cleaning process and specify the procedures and protocols that should be deployed in all healthcare premises. Published by the DoH in 2007, the current NSC was the culmination of the process to define and standardise healthcare cleaning processes, which started a decade ago with the publication of the first National Standards of Cleanliness in 2001 and the first edition of the Healthcare Cleaning Manual in 2003.

Assessing risks
Many key features of the NSC, such as the requirement to put structured cleaning plans in place, to analyse performance and report on outcomes, have been incorporated into PAS 5748. However, in a number of important areas PAS 5748 moves into new territory.

The first important extension is the use of risk assessment as a tool for monitoring cleanliness. PAS 5748 specifies requirements for assessing the risk of a lack of cleanliness on healthcare acquired infections (HCAIs) and on public, patient and staff confidence. In doing this it aims to take the process of embedding a cleanliness culture in our hospitals a stage further. It places outcomes – or rather the risk of bad outcomes as seen both by cleaning and infection prevention professionals and by patients, the public and other health staffm – centre stage.

The second innovation is that PAS 5748 places responsibility and governance at the highest level within any organisation using it. The intention is for PAS 5748 to be endorsed at board level and implemented by organisation directors whose responsibilities should include the provision of clean safe environments for healthcare.

The third important addition is the introduction of visual inspection as a key element of the measurement of cleanliness.

Positive effects
AHCP believes all these are valuable additions to the cleaning and infection control process and will have a positive effect on driving up standards of cleanliness. The use of visual inspection has been seen by some as a move away from the use of a science based approach to the measurement of cleanliness in hospitals.

However, this is a misunderstanding of the objectives of the PAS. The new specification does not propose abandoning scientific methods of evaluating cleanliness but seeks to build in the additional layer of public, patient and staff observation. In doing this PAS 5748 responds directly to the concerns expressed widely by patients and the public over many years.

Additional standards
While PAS 5748 has been broadly welcomed questions have been raised about the introduction of an additional set of standards and the bureaucracy that often goes with this, particularly given the challenging economic situation the NHS and the economy as a whole are in at the present time.

In this respect it is important to note that use of PAS 5748 is not mandatory and organisations will be free to choose whether they wish to adopt it. The Care Quality Commission (CQC), the body responsible for monitoring compliance, has indicated it will expect healthcare providers to show they have taken note of it as part of their evidence of compliance with the requirements set out in the Health and Social Care Act covering the prevention and control of infections. But CQC has also stated that providers will be able to demonstrate that they meet the requirements on cleanliness and infection control in different ways from that described in PAS 5748, equivalent to or better than the PAS standard.

This means that where hospitals and other providers have robust documentation and evidence as to their compliance with standards already in place they will not need to create yet further documents for PAS 5748. However, for organisations that have few or no systems in place, PAS 5748 will be very useful as it provides clear and concise guidance.

Nursing and care homes
This could be of particular relevance to nursing and care homes, organisations not included in the original remit for PAS 5748. The personal care provider sector is new to Care Quality Commission registration. As a result organisations are much less likely to have systems and may not be used to having to provide information. PAS 5748 provides an opportunity for them to adopt a system which is relatively simple to follow to ensure that evidence of compliance is available.

The PAS document notes that it has been developed to enable future revisions to accommodate other types of healthcare facilities. AHCP does not agree with some of the critics, that the exclusion of care and nursing homes weakens the specification. If PAS 5748 proves to be a useful tool to other sectors they should be free to adopt it and future revisions of the standard should reflect the specific needs of these users.

Implementing the system
While it is AHCP’s view that PAS 5748 need not result in increases in bureaucracy, it is clear, that it will create more work during the implementation phase. This would of course be true for any new system or a review of existing systems.

NHS hospital trusts up and down the country are now embarking on a review of both the PAS and the NSC to produce a gap analysis that will then enable them to decide on the best way forward. It is how this gap analysis is used that will determine the effectiveness of PAS 5748.

One of the key factors trusts will be taking account of is the time and effort that will be required to introduce PAS 5748 and to ensure staff are fully aware of what it entails. Many in the NHS will feel that this time and effort could possibly be better utilised to improve current standards. However, given the current financial climate, the usefulness of PAS 5748 as a public assurance tool needs to be weighted against this.

Measuring cleanliness
Another area that AHCP anticipates will prove challenging in the current financial climate will be the measurement of cleanliness. Many organisations will not have the resources to carry out weekly audits in all of the high risk categories, especially so if the trust is spread over a large geographical area.

It would, however, also be fair to say that the majority of trusts are already probably not meeting the recommended frequencies for cleaning, as specified in the NSC due to funding and operational issues. PAS 5748 can actually assist in demonstrating the decision making processes around these challenges if the risk assessment component is used effectively in operational settings. It even provides a free downloadable set of tools for this and other processes.

Initial feedback from AHCP members appears to indicate that uptake of PAS 5748 will not be as widespread as its creators, including the AHCP, might have hoped for. If this is the case it will be because current resources do not permit it. However, in AHCP’s view it would not be right to postpone the introduction of PAS 5748 and take away the possibility of getting the improvements in cleanliness and infection control it offers because of the current financial situation.

Having taken a key role in the consultation and development process, AHCP is fully committed to PAS 5748 and welcomes its introduction as a further step to improving cleanliness standards. The association will support organisations implementing it by gathering feedback, sharing information and participating in reviews. We will also be participating in the review process to ensure any problems which come to light in the future are ironed out.

Is PAS 5748 a blueprint for cleanliness or yet more bureaucracy? I hope I have shown that it is very much the former. For organisations new to the regulated cleanliness environment PAS 5748 offers a simple and hopefully effective code to follow. For organisations with a track record of excellence it offers an additional layer of checks and accountabilities to ensure systems are fit for purpose.

PAS 5748 provides a valuable additional set of tools to monitor and improve cleanliness and infection control. Notwithstanding the present difficult financial situation, the introduction of risk assessments and visual inspection represents an important step towards meeting patient and public expectations. For these reasons it should be welcomed.

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