Evidence of cleanliness

In June 2011 the British Standards Institution (BSI) published the Publicly Available Specification (PAS) 5748:2011, a specification for the planning, application and measurement of cleanliness services in hospitals.

Sponsored by the Department of Health (DH) and the National Patient Safety Agency (NPSA), the PAS is designed for use on a voluntary basis by healthcare organisations in England, but may also be of interest to other organisations.

The PAS was written by David Griffiths, Director of David Griffiths Associates Ltd (DGA), an independent consultancy specialising in assisting healthcare organisations to improve the provision of cleanliness and other facilities management services. However leading organisations involved in healthcare cleanliness have also contributed valuable input to the specification alongside David Griffiths, the DH and NPSA, such as the the Association of Healthcare Cleaning Professionals.

Dr Liz Jones, head of patient environment at the Department of Health, who launched the PAS at the annual conference of the Association of Healthcare Cleaning Professionals, said: “PAS 5748 is a major milestone along the road to clean, safe hospitals and healthcare environments. It represents the culmination of a process to identify and standardise healthcare cleaning processes and procedures which started a decade ago.”

Clearly, this new specification is intended as a landmark document for the NHS in England, and indeed its very number commemorates the founding of the National Health Service on 5 July 1948. This article looks at what this important new system seeks to do, why it was needed, how it was developed, what challenges its implementation will create for NHS organisations, and how its principles might be employed beyond England.

A safe environment
A key priority for all healthcare organisations will always be the provision of a clean and safe environment in which clinical activity can take place. This is important not just for the control of infection, but also because a visibly clean environment promotes patient, public and staff confidence.

Moreover, in England, healthcare organisations are required to register with the Care Quality Commission (CQC). In order to do so, they must meet requirements specified in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. A major part of these requirements relate to cleanliness and infection control.

PAS 5748 seeks to provide healthcare organisations with a risk-based system with which to critically evaluate, plan, apply and measure cleanliness provision. Its adoption by a healthcare organisation is likely to be used as part of a healthcare organisation’s evidence of intent to comply with the registration requirements of the CQC.

It is important to stress, that PAS 5748 has not arrived out of the blue. It is, rather, the culmination of many years of work in this difficult field. Specifically, it builds on the experience and content of the National Patient Safety Agency’s ‘national specifications for cleanliness in the NHS’ (NSC), the most recent version of which was published in April 2007.

Healthcare organisations will remain free to continue to use the NSC, although it will no longer be updated by either the NPSA or Department of Health. The new PAS is expected to be used in conjunction with May 2009’s ‘Revised Healthcare Cleaning Manual’ – developed by the National Patient Safety Agency in conjunction with the Association of Healthcare Cleaning Professionals – and of which David Griffiths was the lead editor.

The PAS also draws on work from the management of cleanliness performed outside of a healthcare setting, and is consistent with the existing British Standard for the measurement of the quality of cleaning services, BS EN 13549:2001.

What does AS 5748 DO?
Essentially PAS 5748 provides a detailed methodology for:
• the governance of cleanliness provision
• the assessment of cleanliness risk
• the planning and provision of the performance of cleaning tasks
• the measurement of cleanliness
• the implementation of corrective actions
• the analysis of performance and the implementation of systematic improvements to cleanliness provision
• the reporting of cleanliness performance.

So, for example, with regard to governance, PAS 5748 clearly describes the way in which a healthcare organisation must document:
• its cleanliness policy
• the accountability of named persons for cleanliness within each ward or department
• the accountability of named persons for the provision of cleaning services performed by a group of staff, such as nurses, cleaners, and         estates personnel
• cleaning method statements, work schedules and pro formas.

A risk assessment tool
The PAS’s innovative approach to the assessment of cleanliness risk is perhaps the clause likely to attract the most attention. The PAS contains a clause describing in detail the required risk assessment methodology.

In what amounts to a synthesis of previous practice the framework gives equal value to infection control risk on the one hand, and public, patient and staff risk on the other. Moreover, the framework is subtle enough to recognise that an element (i.e. any item which needs to be cleaned), may carry a different risk rating dependent on where it is located.

The expectation is that this will arm healthcare trusts with a standard, state-of-the-art risk assessment tool which will permit it to make an accurate assessment of the actual cleanliness risk which exists in each area of each trust, and to use this information to make informed and minutely-detailed decisions about frequencies for the performance of cleaning tasks and for the frequencies with which cleanliness is monitored.

Why was there a need for this new specification?
Clearly a major driver was to give trusts a tool which would allow them to make an informed decision about the allocation of resources required in their particular organisation to mitigate the cleaning risk identified in their particular trust. The aim is to move away from the one-size-fits-all, centrally-imposed directive which was a characteristic of previous specifications for cleanliness.

These specifications sought to generally drive up cleanliness standards. Whilst they did not impose precise standards as such, they included what were styled ‘indicative aims’. We are now witnessing a development in approach. This recognises that a more detailed and location-specific approach is needed, recognising that each healthcare organisation is itself best placed to assess its own particular risks, and to decide how most effectively to mitigate them.

In light of this, it is expected that PAS 5748 will be particularly attractive to Foundation Trusts, which will want to sculpt service delivery in a way which is appropriate to its own local requirements within a nationally-recognised framework.

This concept of national recognition is, of course, very important. We have already touched on the role of the PAS in demonstrating a healthcare organisation’s intention to comply with the CQC’s requirements for registration. There is also, however, a further potential benefit to healthcare organisations choosing to comply with PAS 5748. It is highly likely that patients making an informed choice about which healthcare organisation to use will use cleanliness as part of their decision-making process. The new specification, which carries with it the prestige of the trusted BSI brand and of the sponsoring and contributing bodies, is likely to assist healthcare organisations compliant with the PAS in giving confidence to and attracting potential patients.

A meeting of minds
How then, was the process of creating this landmark specification approached? Its genesis came in a meeting of minds between experienced officials at the DH, NPSA and BSI, who identified a potential need for a strictly unambiguous specification carrying the imprimatur of all three bodies.

Very quickly, a series of study days was set up to which a huge variety of stakeholder organisations were invited. From these initial study days the basic outline of the new specification was developed. A steering group was then set up, comprising the DH, NPSA, BSI, representatives of key stakeholder organisations and the technical author, and then a series of drafts were developed.

These early drafts were governed by clear principles set by the steering group. One such principle was to retain the best elements of the existing specifications, and where changes did prove necessary, to keep them to a minimum. So, for example, the familiar basket of 49 representative measured elements (items whose cleanliness is measured), was kept at a similar level, increasing to 50, and the composition of the elements was amended slightly to ensure that the new standard would be appropriate for use in mental health and continuing care, as well as in acute settings. The result is that a familiar and recognisable concept has been retained, but refined and improved upon.

Stakeholder feedback
Once the first round of drafting was complete, a public consultation was conducted, and this drew in several hundred comments from a large range of stakeholders. In addition, an important series of trial implementations at the fourteen participating NHS trusts was undertaken. Both processes fed into the content of the development of the document and led to a number of simplifications designed to make compliance with the specification easier to achieve.

Finally, the draft was put through a further round of revision, designed to ensure total compliance with the BSI style, and the ruthless removal of any potential ambiguity.

The systematic avoidance of ambiguity has clearly been an absolutely key priority throughout, and, as stated earlier, was certainly one of the major factors which led the sponsors to seek to work with BSI at the commencement of the project.

This has a particular relevance for the auditing of cleaning. In just one example, the PAS makes it quite clear that ‘the cleanliness of each scored element shall be assessed as it appears on first inspection. If the element does not conform to the cleanliness criterion, it shall be scored 0, irrespective of whether it is immediately cleaned thereafter.’

Moving to the more tightly specified process set out in the PAS will provide trust boards with the challenge of agreeing a cleanliness performance level for the organisation. So that patients and the public can be assured that high standards are being maintained, the PAS also requires that information about the achievement (or otherwise) of that level be made available on request. This will pose one of several challenges to implementation.

What other issues are likely to face healthcare organisations wishing to implement PAS 5748? As we have seen, the specification is admirably clear and well-written, so interpretation and ambiguity should not be a problem. However, the process of implementation will require a root and branch review of current cleaning service delivery, and the governance, risk assessment and documentation processes will require commitment and input at senior and operational level within organisations. It is anticipated that implementation of the provision of this PAS will be entrusted to appropriately qualified and experienced people for whose use it has been produced.

Undoubtedly PAS 5748 will in due course be used by the majority of healthcare organisations within England. What is its future elsewhere? At this moment it is difficult to say, but it seems likely that other organisations will wish to adopt some of the principles contained within it, perhaps utilising the risk assessment tool without adopting the governance requirements, and may even wish to comply fully with it. This would be warmly welcomed by the creators of the PAS.