Ensuring Quality of Outsourced Cleaning and Sanitisation

Considering the gradual outsourcing of technical-administrative services to support the "core" services of health facilities, ANMDO, the National Association of Hospital Department Physicians and CERMET, a certification institute with extensive experience in the health sector, have developed a standard for good environment and health facility cleaning and sanitisation practices, complete with an adequate and computer-backed control system.

The service presented by ANMDO and CERMET aims at assessing, on an objective basis, the hygienic and quality standard of the outsourced cleaning and sanitising service, promoting a better integration of the service with the routine management of activities performed in hospitals.

The refinement of the service has been made possible thanks to the experimental application of the standard in conjunction with the L'Operosa Cooperative involving the contract of Bologna's Azienda Ospedaliero- Universitaria (Hospital-University Corporation), S.Orsola-Malpighi General Hospital and Markas Service s.r.l., as well as that of Health Unit 15 Alta Padovana. To date other major companies in the sector have started qualification procedures and recognised the importance of the service above all in terms of the chance to set up a partnership with the contracting body so as to achieve ongoing improvement for the better satisfaction of end users.

The Role of the Third Body

The involvement of CERMET, as independent third body, in the outsourced service qualification system is keyed to ensuring principles at the bottom of service quality assessment sustainability over time, and more specifically:

• Impartiality in the technical-operational management of the qualification process and therefore the same treatment for all applicants; 
• Independence as regards auditing for issuing qualification and therefore the absence of conflicting interests; 
• Cultural, technical and professional expertise of the auditors who follow coded procedures to carry out the assessment activities and use tested and validated instruments.

To ensure compliance with such principles, which convey value and credibility to the qualification process, CERMET operates by referring to standards recognised at national and international level and effective within international certification systems.

The Standard

The ANMDO–CERMET Standard, pre-concerted within a specific work team, made up of representatives of health facilities, cleaning companies and other stakeholders, fully expresses the quality concept applied to the service sector comprising:

• System requisites, which outline the minimum quality system for ensuring company management governance;
• Process requisites, of a general nature, aimed at ensuring service governance; 
• Element-specific result standards, aimed at ensuring the quality of the service provided.

In particular, system requisites comply with ISO 9001:2008 international standard and relate to basic aspects concerning staff training, control of cleaning service (quality controls, process controls, internal inspection audits) and the management of relations with clients (client satisfaction, complaints management). The process requisites refer to the need on the part of the company to define criteria able to ensure the quality of the provided service, in terms of the drawing up of protocols and cleaning methods and related equipments and products. The effectiveness of the cleaning process is checked in terms of actual "dirtiness/ cleanliness" by means of direct on-site inspections with respect to defined result standards. The "dirty/clean" control system exploits, instead of normally used methods such as the Bacharach Scale or the floor dust meter, the bioluminescence phenomenon and use of the Bioluminometer.

The Control System

Consistently with the standard structure, the assessment system has been defined entrusted to the third body and which contemplates three types of audit:

1. System audits, carried out annually at the supplier's facility to determine the company organisation system. 
2. Process/service audits of direct type, carried out quarterly at the facility of the contracting entity to determine:
   • Compliance with service performance procedures;
   • The appropriateness of the equipment given to the staff, with respect to established quality plans; and
   • The quality of the provided service in terms of "dirtiness/cleanliness". 
3. Process/service audits of indirect type, carried out continuously, which consist of continuous monitoring of the controls entrusted to the first party, second party and third party for the identification of the critical areas in which to implement suitable upgrading measures.

The entire evaluation procedure is backed by a technological platform (SGI – ARGO Management Inspection System) able to manage: The personal details of those charged with controls (company, contracting entity, CERMET), personal details of the staff charged with carrying out the audits and details of the specifications/ - contract where all the information is configured needed to perform controls on elements according to the critical situation level, as well as information relating to the type of job to be done per area/environment/ element and relevant cleaning protocol. The system makes available to those involved the required planning data, with the option of using the application offline. The results of the controls are communicated online to the CERMET data centre which issues reports personalised to the type of user and function for which access to the software was configured, as well as allowing the processing of the global quality index of the contracted service, an indicator expressing the "state of health" of the cleaning service provided obtained from the weighted sum of three different sub-indices, i.e., the results of the system audits, the process/service audits of direct type and the process/service audits of indirect type.

The sampling of the areas subject to assessment is established according to principles that correlate the risk of infection to control intensity.

Within a single area (e.g., hospital ward, operating theatre, intensive care...) at least one environment per type is controlled (hospital room, bathroom, locker room, closet, kitchen...) along with all the elements, critical and non-critical, inside it.
Third-party audits must be performed within one hour from cleaning, depending on the type of environment (e.g., the bathroom must be inspected immediately after cleaning).
The "dirty-clean" audit of the elements is mainly based on two procedures:

• Visual inspection of all the elements 
• Instrumental inspection (BIOLUMINOMETER) of 10 percent of critical elements 

The percentage of elements to undergo instrumental control has been defined with reference to the indication of the UNI ISO 2859-1:2007 standard "Sampling procedures in attribute inspection - Part 1: Sampling diagrams indexed according to acceptable quality limit (AQL) in lot by lot inspections" considering 10 percent represents a good compromise between control cost cutting and significance of obtained result. 

The proposed control system is "zero tolerance" meaning the way it has been designed does not contemplate "nonconformities" and consequently the AQL is to be deemed always identical to 1. As specified above in fact, the "dirty/clean" control is made straight after the cleaning services has terminated, and consequently the "dirty/clean" inspection provides indications on the validity of the process in terms of: Staff training, effectiveness and correct implementation of the cleaning protocols and adequacy of the cleaning equipment used. In brief, the control does not aim merely at inspecting in terms of "dirty/clean" but at determining the effectiveness of the cleaning system furnished by the company.

Representation of Results

Audits are carried out with the aid of control sheets for recording the findings in the different environments undergoing assessment. The overall result is recorded in the audit report given to the supplier and a copy to the contracting body. The number of nonconforming elements with respect to the total of the critical and noncritical ones assessed is represented using histograms, for:

• Risk area; 
• Hospital Unit / Ward; 
• Type of premises; and 
• Type of element.

This ensures easier interpretation of results in order to identify any causes of systematic nonconformities requiring remedial actions in a perspective of continuous upgrading.

The Benefits for Health Facilities

The ANMDO-CERMET services for companies provide concrete benefits for the health facilities where they are implemented, i.e.:

• Supplier/contracting company partnership for the benefit of the parties stimulated in a perspective of continuous upgrading thanks to the supervision of the reciprocal contractual undertakings entrusted to an independent third body; 
• Efficiency meant as rationalisation of the control system for the monitoring of the outsourced service, thanks to the use of the software platform for planning and recording the results of first, second and third party controls visible to all the parties involved; and 
• Effectiveness thanks to supervision by the third body of the successful implementation of the remedial actions undertaken by the company with respect to the conformities found during first, second and/or third party audit in a perspective of continuous upgrading for the satisfaction of the client, the end user and more in general, the parties involved. 
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Conclusions

The contract control system developed for the cleaning and sanitisation of health facilities has the following advantages:

• The joint commitment of ANMDO and CERMET to periodically revise the standard, to keep it updated to the state-of-the-art and ensure continuous upgrading; 
• The general worthiness of the criteria adopted as reference for the definition of the control system, which allows its easy declension depending on the different types of supplied services; and 
• The reproduction of the guarantee elements for safeguarding the parties involved (clients, supplier, users), which form the basis of the sustainability of the health facility service outsourcing process over time.

In the light of the substantial impact outsourced services have on the quality of the provided health service, ANMDO and CERMET will continue their cooperation, with the aim of contributing to the continuous upgrading of the health system.