Evaluating hygienic cleaning in health care settings: What you do not know can harm your patients

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1 Evaluating hygienic cleaning in health care settings: What you o not know can harm your patients Philip C. Carling, MD, an Juene M. Bartley, MS, MPH, CIC Boston, Massachusetts, an Detroit, Michigan Recent stuies using irect covert observation or a fluorescent targeting metho have consistently confirme that most near patient surfaces are not being cleane in accorance with existing hospital policies while other stuies have confirme that patients amitte to rooms previously occupie by patients with hospital pathogens have a substantially greater risk of acquiring the same pathogen than patients not occupying such rooms. These finings, in the context recent stuies that have shown isinfection cleaning can be improve on average more than 100% over baseline, an that such improvement has been associate with a ecrease in environmental contamination of high touch surfaces, support the benefit of ecreasing environmental contamination of such surfaces. This review clarifies the ifferences between measuring cleanliness versus cleaning practices; escribes an analyzes conventional an enhance monitoring programs; aresses the critical aspects of evaluating isinfection hygiene in light of guielines an stanars; analyzes current hygienic practice monitoring tools; an recommens elements that shoul be inclue in an enhance monitoring program. Key Wors: Enhance environmental hygiene monitoring; surface isinfection cleaning; health care process improvement; patient safety; health care-associate pathogen transmission; quality assurance. Copyright ª 2010 publishe by Elsevier Inc. on behalf of the Association for Professionals in Infection Control an Epiemiology, Inc. (Am J Infect Control 2010;38:S41-50.) The meical an economic toll of infections with increasingly antibiotic resistant pathogens has continue to escalate. Whereas efforts to improve han hygiene an isolation practices have been implemente to help mitigate this problem, recent stuies have ocumente the limitation of such interventions. 1-4 Although active surveillance protocols an rigorous aherence to precautions may ecrease methicillinresistant Staphylococcus aureus (MRSA) transmission, in certain settings 5 such interventions have not ecrease overall nosocomial infection rates in several northern European countries, which remain similar From the Infectious Diseases Section, Department of Meicine, Boston University School of Meicine, Boston, MA; an VP Epiemiology Consulting Services, Inc (ECSI), Detroit, MI. Aress corresponence to Philip C. Carling, MD, irector of Hospital Epiemiology, Carney Hospital, 2100 Dorchester Ave, Boston, MA Pcarling@cchcs.org. STATEMENT OF CONFLICT OF INTEREST: Dr. Carling has been compensate as a consultant of Ecolab an Steris. He owns a patent for the florescent targeting evaluation system escribe in the manuscript. Ms. Bartley reports no conflicts of interest. Publication of this article was mae possible by unrestricte eucational grants from The Clorox Company, the American Society for Healthcare Engineering, an the Facility Guielines Institute /$36.00 Copyright ª 2010 publishe by Elsevier Inc. on behalf of the Association for Professionals in Infection Control an Epiemiology, Inc. oi: /j.ajic to rates in southern European countries an the Unite States, 6 an have not been shown to be consistently effective or necessary in this country. 7 It has now been well ocumente that a wie range of particularly environmentally resilient hospital-acquire infection (HAI) pathogens can be reaily culture from near patient surfaces Eight recent stuies have now confirme that patients occupying rooms previously occupie by patients with vancomycin-resistant Enterococcus (VRE), MRSA, Clostriium ifficile, 17 an Acinetobacter baumannii 18 infection or colonization have on average a 73% increase risk of acquiring the same pathogen than patients not occupying such rooms (Fig 1). Over the past 4 years, 8 stuies using irect covert observation or a fluorescent targeting metho have confirme that only 40% of near patient surfaces are being cleane in accorance with existing hospital policies. 11,19-25 These finings, in the context of the fact that 11 stuies have now shown that the thoroughness of isinfection cleaning can be improve to 82% (on average more than 100% over baseline) 11,21,22,26-33 an the fact that such improvement has been associate with an on average 68% ecrease in environmental contamination of high-risk objects, 11,21,22,24,28,34 together support the likely benefit of ecreasing environmental contamination of such surfaces. In aition, 5 stuies have recently shown that improve routine isinfection cleaning practice is associate with an average 40% ecrease in transmission of VRE, 11-15,28 MRSA, 15,34 an A baumannii. 18 S41

2 S42 Carling an Bartley American Journal of Infection Control June 2010 Fig 1. Summary of stuies that provie support for improving heath care environmental cleaning practice. GUIDELINES AND STANDARDS During the past 6 years, there has been a ramatic evolution of recommenations an stanars as well as state laws relate to improving environmental hygiene in health care settings. In 2003, the Centers for Disease Control an Prevention (CDC) Guielines for Environmental Infection Control in Healthcare Facilities Environmental Surfaces recommene that hospitals clean an isinfect high-touch surfaces. 35 A subsequent CDC guieline strongly recommene (category 1B) that hospitals monitor (ie, supervise an inspect) cleaning performance to ensure consistent cleaning an isinfection of surfaces in close proximity to the patient an likely to be touche by the patient an health care professionals. 36 As a consequence of these recommenations, the 2007 revise Center for Meicare an Meicai Services Interpretative Guieline for its infection control stanar now requires that the infection prevention an control program of hospitals must inclue appropriate monitoring of housekeeping activities to ensure that the hospital maintains a sanitary environment. 37 These ocuments, as well as similar ones in Great Britain an Canaa, reflect an evolving manate that patient area environmental hygiene in health care settings be objectively analyze an optimize. 38,39 EVALUATING ENVIRONMENTAL CLEANING PRACTICE Problem-oriente environmental monitoring As a result of stuies that linke environmental contamination with the transmission of Staphylococcus aureus in the late 1950s, attempts were mae to use swab-base environmental culturing for S aureus as a means for evaluating low-level isinfection cleaning Fig 2. A comparison of the elements of conventional hygienic monitoring with enhance programs. practice in many hospitals. Although the practice iminishe in value as the prevalence of S aureus in HAIs ecrease an the unreliability of sporaic poorly stanarize environmental culturing became evient, environmental surface culturing continues to have a role in infection prevention practice. The CDC pointe to the lack of environmental stanars for routine sampling but also ientifie its value if use properly for research or eucation. 35 The use of environmental cultures has greatly enhance our unerstaning of the epiemiology of C ifficile transmission 40,41 as well as MRSA 42 an VRE. 43,44 Such cultures have also been useful in evaluating the role of environmental contamination in outbreak settings involving C ifficile, 45,46 Acinetobacter, 47 VRE, 11 MRSA, 48 an glycopeptie insensitive S aureus. 49 Although potentially useful, logistical challenges involve in the collection of a large enough number of cultures to permit proper epiemiologic analysis, the cost of ata collection an specimen analysis (typically incluing pulse-fiel gel electroforesis or other strain ientification process) as well as the intrinsic challenge of rawing epiemiologically soun conclusions from possibly erratic fluctuations in environmental contamination as a result of unknown confouning variables represent important challenges relate to problem-oriente environmental monitoring. Given these issues, the possible shortan long-term benefits of such information make it pruent to weigh carefully the overall value of collecting such ata. Conventional environmental cleaning monitoring The ongoing evaluation an monitoring of cleaning interventions to reuce the risk of transmission of environmental pathogens through efine proceures have been elements of infection prevention an control practice in

3 Vol. 38 No. 5 Supplement 1 Carling an Bartley S43 Fig 3. A comparison of the avantages an limitations of conventional versus enhance programmatic monitoring of EC process.

4 S44 Carling an Bartley American Journal of Infection Control June 2010 acute care hospitals for many years. Until recently, such evaluation has exclusively relie on visual assessment of the cleanliness of surfaces. Currently, 89% of a large sample of US acute care hospitals confirme that they perform visual assessments of cleanliness uring regular environment of care rouns as the primary means for evaluating cleaning practice in their hospitals. 50 The elements of what can be consiere conventional monitoring of low-level isinfection or environmental cleaning (EC) are outline in Fig 2. Traitionally, such rouns are performe on a regular basis an involve the infection preventionist (IP) an irector of emergency services (ES) as well as an aministrative representative from patient care services. Together, these iniviuals visit several patient care areas to monitor compliance with a range of safety practices an to assess visual cleanliness. The ientifie eficiencies, as they pertain to potential pathogen transmission issues, are reviewe an remeial activities approve by the infection control committee. Such assessment of EC, known as a visual auit in Great Britain, relies on the observation of visible soilage of surfaces by potentially infectious material or ust an irt. 9 Such finings are assume to represent practice failures by the iniviual or iniviuals irectly responsible for ensuring 36 the microbial safety of the surface in question. Whereas conventional monitoring may ientify sporaic gross lapses in cleaning practice as summarize in Fig 3, this practice has a number of limitations incluing the following: An inability to objectively assess actual EC practice; the reliance on episoic negative finings as a basis for remeial iniviual an programmatic interventions; placement of unue emphasis on the cleanliness of floors an walls, which have limite roles in pathogen transmission, 51,52 because of the ease with which gross contamination or irt can be visually ocumente on these surfaces; with the exception of gross contamination by potentially infecte material, a low sensitivity for efining what represents a microbiologically irty surface; poor correlation with microbial contamination, namely, what appears to be clean may harbor substantial levels of microbial contamination 53,54 ; poor programmatic specificity, ie, what may appear to represent a lapse in EC may not be; intrinsically subjective with a high potential for observer bias; the irect involvement of ES management an patient care leaership in a monitoring system with low sensitivity an specificity, which may lea to inconsistent an potentially misirecte responses to what appear to be lapses in EC; an inability to evaluate other than aily EC practice; limite ability to support The Joint Commission (TJC) stanar EC EP2, which states that the institution must be able to emonstrate that it uses the results of ata analysis to ientify opportunities to resolve environmental safety issues 55 ; limite ability to emonstrate compliance with the Center for Meicare Services (CMS) 37 Conitions for Participation (CoP), section ; the nee to utilize substantial leaership level personnel resources; a limite ability to evaluate more than a small sample of patient care areas on a frequent basis; an an inability to efine an respon to institutional or interinstitutional stanars of EC through benchmarking. As an ajunct to such conventional monitoring activities, 78% of hospitals also analyze patient satisfaction surveys to evaluate EC. 50 Whereas such surveys may episoically ientify gross lapses in EC, the very poor specificity an sensitivity of such surveys make it challenging to use them to evaluate overall practice within an institution. Enhance EC monitoring In response to an evolving unerstaning of the importance of the near-patient environment (also referre to as the patient zone ) 56 in the transmission of health care-associate pathogens (HAP) as well as stuies that ientifie opportunities for improving EC, an objective an substantially more structure approach to monitoring such activities has recently evolve. As currently practice an summarize in Fig 2, the basic components of Enhance EC monitoring encompasses the following elements: Uses an objective monitoring tool to evaluate the process of EC; is performance rather than eficiency oriente; is base on the evelopment of an inepenently functioning structure monitoring program incorporating specific EC policy-base expectations an goals; relies on the repetitive monitoring of actual EC by traine, unbiase iniviuals on an ongoing basis; an is incorporate inepenently into the institution s ongoing quality improvement process through the infection control committee. As summarize in Fig 3, the avantages of such an enhance program inclue the following elements: Allows for the irect evaluation of the process of hygienic cleaning; incorporates a built-in stanarization an uniformity of evaluation;

5 Vol. 38 No. 5 Supplement 1 Carling an Bartley S45 Fig 4. Summary of the 5 methos use in evaluating environmental hygiene. incorporates ES staff eucation base on specific objectively evaluable expectations; facilitates the evelopment of a program that has a high potential for ientifying specific as well as systemic institutional programmatic issues that limit or aversely impact EC; allows for short cycle monitoring of ES staff performance with irect feeback to improve EC an ocuments the sustainability of improvements, once they have been achieve; has the potential for using positive performance achievement to reinforce goo performance an the value of such performance in the context of the institution s objectively efine patient safety goals; has the ability to objectively ientify an ocument iniviual EC oversights an the nee for remeial action; represents a system easily aaptable to establishe process improvement (PI) moalities such as the Plan-Do-Act (PDA) cycle, Positive Deviance, Six sigma, an others; facilitates compliance with TJC stanars; facilitates compliance with CMS CoP manates; provies objective performance information for internal an interinstitutional benchmarking; allows for use of the same monitoring systems for one-on-one an small group, hans-on, eucation; an facilitates the use of the same process improvement system over a range of practices an venues within the hospital an potentially other health care settings. It is beyon the scope of the current iscussion to provie a complete cost/benefit analysis of these programs, but, in light of current financial constraints, one aitional avantage worth noting is that, overall in a large stuy of 36 hospitals, the program appears to be resource neutral, with less than a 1% increase in ES resources. 26 Although enhance EC monitoring has a range of avantages, several limitations to its use have so far been ientifie (Fig 3), incluing the following: The nee to evelop an implement a new program often in a setting of limite IPs resources; the critical nee for aministrative support for successful implementation an maintenance of the ongoing program; the nee to maintain a positive, blameless, close working relationship between IP an ES leaership; complexities associate with the nee (or at least value) of covertly collecting a preintervention assessment of EC to optimize subsequent ata analysis an eucation; an potential monitoring tool issues. Whereas objective monitoring of practice has evolve as the cornerstone of enhance programs, the incorporation of patient survey results an problem-base interventions constitute important components of the overall program. ANALYSIS OF HYGIENIC PRACTICE MONITORING TOOLS Whereas the avantages of enhance EC monitoring in contrast to the limitations of conventional monitoring provie support for hospitals implementing programs to objectively monitor EC, the avantages an limitations of various monitoring approaches an tools must also be consiere. As summarize in Fig 4 an note below, there are currently 5 systems that may be potentially useful for enhance programmatic monitoring. Covert practice observation Covertly monitoring EC can provie an objective assessment of iniviual ES staff performance an

6 S46 Carling an Bartley American Journal of Infection Control June 2010 compliance with cleaning protocols. This approach has been use to evaluate an improve environmental hygiene relate to VRE transmission in one hospital. Hayen et al utilize a traine research observer to covertly monitor aily isinfection cleaning of 8 high-risk objects in an intensive care unit uring the 2-month baseline portion of the stuy. 11 Thoroughness of isinfection cleaning was then monitore following eucational interventions along with immeiate feeback uring cleaning by the research staff. As a result, the thoroughness of environmental cleaning improve from 48% to 87%, an VRE transmission ecrease significantly. Although clearly effective, logistical issues relate to maintaining such a program outsie a research setting coul limit aaptation of this form of EC monitoring as a process improvement intervention. Swab cultures As note previously, swab cultures of surfaces have been utilize in a range of clinical settings to stuy the environmental epiemiology of many HAPs as well as in the evaluation of outbreaks relate to specific organisms. Whereas several outbreak intervention stuies have attribute favorable outcomes to improve EC in association with ecrease environmental contamination by target organisms, none of the reports specifically note whether serial environmental culture results were actually use to provie EC practice feeback to the ES staff. In a single stuy evaluating the impact of various programmatic an eucational interventions to improve isinfection cleaning of intensive care unit keyboars, the confirmation of VRE contamination was use effectively to improve cleaning performance. 27 Broth-enriche swab cultures to quantify bacterial contamination of patient area surfaces have been use in a single stuy, along with Aeneinetriphosphate (ATP) results, to provie irect feeback to ES staff. 60 In this stuy, overall ATP scores improve following feeback, but the impact on actual bacterial contamination was not reporte. Although swab cultures are easy to use, the cost of processing, incluing isolate ientification (if neee), the elay in analyzing results, the nee to evelop baseline values for comparisons, an the limite feasibility of monitoring multiple surfaces in multiple patient rooms as part of an ongoing EC monitoring program in other than a research setting may be issues that coul limit the broa application of such a system for evaluating EC practice. Agar slie cultures Agar-coate glass slies with finger hols were evelope to simplify quantitative cultures of liquis. The slies have been aopte for use in environmental surface monitoring to assess the limitations of visual auits of EC. 58 Subsequently, several stuies have use agar-coate slie systems to evaluate cleaning practice as well as to compare cleaning regimens 61,62 by quantifying aerobic colony counts (ACCs) per square centimeter 61,63 as well as to compare cleaning regimens. 61,63 Although 2 stuies 61,64 measure ACCs before an after cleaning, no stuies to ate have evaluate the actual thoroughness of cleaning of the same objects to etermine whether objects with relatively high ACCs surfaces were either poorly cleane or actually overlooke by the ES staff. Although some ifficulties have been encountere in utilizing the agar contact culturing on other than large, flat surfaces, they potentially provie an easy metho for quantifying viable microbial surface contamination. There is a nee, similar to that note above for swab cultures, to evelop baseline values for accurate interpretation of stuy finings. Agar-coate slies an eicate incubation systems are commercially available. Fluorescent gel A monitoring system using an essentially invisible transparent gel that ries on surfaces following application an resists abrasion was evelope specifically to evaluate the thoroughness of environmental cleaning in health care settings. Following the ientification of opportunities to improve cleaning in 23 hospitals, 59 use of the system within a structure process improvement program le to the thoroughness of isinfection cleaning improving from 48% to 77% in 36 stuy hospitals. 26 The same system was subsequently use by Gooman et al to evaluate EC in 10 intensive care units in a single hospital. Following performance feeback, the thoroughness of cleaning improve from 44% to 71%. 22 Further analysis of this stuy has confirme that improve EC was associate with ecrease MRSA an VRE transmission. 15 Most recently, the same monitoring tool an PI system were use in coorination with group performance benchmarking an facilitate program analysis in 12 hospitals within a single health care system. 33 Average thoroughness of terminal room isinfection cleaning improve significantly with 11 of the 12 stuy hospitals achieving sustaine rates of improve cleaning to 85% or above. However, as note in Fig 4, the fluorescent gel system cannot be use to measure actual cleanliness of surfaces but only thoroughness of cleaning practice. For this reason, the system must be use in conjunction with environmental cultures for problem-oriente hygienic monitoring as iscusse previously. The system is commercially available for use in acute care hospitals on a subscription basis.

7 Vol. 38 No. 5 Supplement 1 ATP bioluminescence Carling an Bartley S47 The measurement of organic ATP on surfaces using a luciferase assay an luminometer has been use to evaluate cleanliness of foo preparation surfaces for more than 30 years. 65 A specialize swab is use to sample a stanarize surface area, which is then analyze using a portable hanhel luminometer. The amount of ATP, both microbial an nonmicrobial, is quantifie an expresse as relative light units (RLU). Although reaout scales vary more than 10-fol 66 an sensitivity varies between commercially available systems, 67 very low reaings are typically associate with low ACCs on foo preparation surfaces. 68 Very high RLU reaings may represent either the viable bioburen, organic ebris incluing ea bacteria, or a combination of both. Inee, a recent stuy has foun that ebris accounts for approximately 66% of ATP on surfaces. 58 The clinical relevance of this issue was clarifie by Griffith et al 69 as well as in a stuy of ambient contamination of surfaces potentially touche following hanwashing base on propose cleanliness stanars. 70 A mean ATP RLU reaing of 3707 was foun on the 618 surfaces teste, with 89% failing to meet the,500 RLU level in a propose stanar. In contrast, only 27% (168/618) of the same surfaces ha ACCs above the propose ACC cleanliness stanar of,2.5 (colony-forming units)/cm 2. In 2007, a stuy was unertaken by the National Health Service to evaluate the potential role the ATP tool in evaluating EC in hospitals. 54 While noting limitations in the ATP system, the authors conclue that the tool coul potentially be use effectively for eucation of ES staff, although an evaluation of such use was not part of the stuy esign. Although it is likely that part of the lack of correlation between ATP reaings an ACCs note in the preceing stuies relates to the fact that ATP systems measure organic ebris as well as viable bacterial counts, several stuies have note aitional environmental factors that may increase or ecrease ATP reaings, incluing resiual etergent an isinfectants that may either increase of ecrease RLU reaings, 71 plasticisers foun in microfiber cloths, 72 ammonium compouns foun in launry chemistries, 72 an surfaces in poor conition. 58 Aitional logistical limitations of the ATP tool inclue the nee to evelop baseline values, to evaluate a surface within a few minutes of cleaning, 70 an the inability to use the system when a bleach-base isinfectant is being use for cleaning. 60 Boyce et al 60 use preintervention ACCs along with ATP results in eucation of the ES. Subsequently, iniviual housekeepers were aske to clean a room that they were tol woul be monitore by the ATP system following cleaning. As a result of these interventions, the authors ocumente significant improvement in the aily cleaning Fig 5. The relationship between the number of high-risk objects evaluate an the ability to etect significant change in the thoroughness of cleaning. of 4 near-patient surfaces as measure by the ATP system. 60 Luminometers an specimen collection swabs are available from several commercial sources. Cleanliness versus cleaning practice When choosing an evaluation metho for use in an enhance program of EC monitoring, it is important to consier whether the cleaning process or the actual cleanliness of surfaces is to be monitore. Observation an fluorescent gel systems irectly evaluate the cleaning process, but the swab or slie culture as well as ATP bioluminescence systems measure cleanliness. Although the latter 3 systems coul be use to monitor hygienic cleaning practice, to o so necessitates monitoring the surface to be evaluate both before an after cleaning because a proportion of surfaces may actually be clean prior to monitoring as a result of their being cleane previously an not yet contaminate at the time of monitoring. 60,73 Furthermore, the intrinsically low concentration of most major HAPs on surfaces limits the use of pathogen-specific monitoring as a means for assessing actual practice. 62,73,74 Although it is conceptually possible to effectively monitor hygienic cleaning with the latter systems, efining the level of microbial contamination that actually correlates with goo or poor EC in a clinical setting has yet to be efine objectively. GENERAL ELEMENTS OF ENHANCED MONITORING PROGRAMS The most critical aspect of implementing an enhance hygienic monitoring program relates to the nee for the program to be evelope from its inception

8 S48 Carling an Bartley American Journal of Infection Control June 2010 as a joint blame-free unertaking between the infection prevention team an the ES leaership. The program must be base on the mutual unerstaning of the nee to optimize patient an health care personnel environmental pathogen/contaminant transmission safety through mutually evelope policies an proceures as well as structure, objective performance monitoring. Whereas the CMS stanar states that monitoring housekeeping activities represents a efine component of the responsibilities of infection control, 37 the evelopment of a mutually supportive approach to maximizing patient an health care personnel safety through optimize EC has been critical to programmatic success. 26,33 CMS sees infection prevention an control more programmatically, ie, it is everyone s responsibility. The program in this case nees ownership by major stakeholers, eg, environmental services an infection prevention specialists to be a continuous performance improvement process, with measures that can be appreciate by all participants. Logistical issues must also be consiere as part of planning for the implementation of an enhance program. Before a ecision has been mae to use one of the approaches to objectively monitor cleaning practice, it is important to etermine the number of ata points that must be monitore on a regular basis to accurately assess practice. Although it woul be ieal to be able to ientify small fluctuations in practice accurately, such an approach woul be highly labor intensive. As note in Fig 5, the sample size neee to accurately etect a 10% variation in cleaning practice within the range of baseline cleaning thoroughness foun by the Healthcare Environmental Hygiene Stuy Group hospitals (20%-80%) is quite substantial. 75 In contrast, monitoring of only 50 to 120 surfaces woul be neee to accurately etect a 20% change in practice. Given the range of patient zone objects monitore in the publishe reports of hygienic practice, which vary from 8 11 to 15, 22 a reasonably accurate etermination of thoroughness of cleaning practice coul be etermine by monitoring 10 to 15 representative patient rooms per evaluation cycle epening on the estimate overall thoroughness of cleaning anticipate. In aition, it is important, while consiering the benefits of enhance programmatic monitoring of EC, not to overlook the intrinsic importance of stanarizing an optimizing cleaning processes, equipment, an isinfectant/cleaning system use to realize the full benefits of more thorough cleaning of high-risk surfaces in the patient zone. SUMMARY Although basic monitoring of EC using visual assessment can ientify gross lapses in practice, it has recently become evient that opportunities to improve the thoroughness of patient zone surface cleaning exist within a range of health care settings with only 34% of surfaces in 8 ifferent health care settings being cleane accoring to policy. 68 In the context of careful epiemiologic stuies that have confirme a substantially increase risk of acquiring HAPs from prior room occupants an the clear ocumentation that thoroughness of environmental hygiene can be objectively evaluate an improve through structure interventions an that improve cleaning of high-risk surfaces both ecreases environmental contamination an patient acquisition of HAPs, it woul appear that there is clear support for hospitals an other health care facilities to consier the importance of optimizing EC in the patient zone. Although the implementation of the type of enhance hygienic monitoring program outline above will facilitate compliance with TJC an CMS stanars, it is also important to note that such programs meet the specifications of the Department of Health an Human Services Action Plan to Prevent Healthcare Associate Infections (June 2009), which states the following: Stanarize methos (ie, performance methos) that are feasible, vali, an reliable shoul be use for measuring an reporting compliance with broa-base HAI prevention practices that must be practice consistently by a large number of health care personnel. 76 Carrying out such a systematic program with measurable achievements an goals can receive eserve visibility by being inclue in the chief executive officer an Boar of Trustee s ashboar on a quarterly basis. Given the increase attention by Department of Health an Human Services to patient satisfaction surveys, now that reimbursement epens on such reporting, it is likely that future CMS reimbursement will epen on actual performance. Furthermore, in this context, patient perception of cleanliness takes on another imension an level of importance to organizations leaership. In view of the above consierations, it is highly likely that enhance environmental monitoring programs will enable the organization to provie measurable, objective ata to support their claims of proviing a clean an safe environment for patients, their families, an health care personnel. References 1. Silvestri L, Petros AJ, Sarginson RE, e la Ca MA, Murray AE, van Saene HKF. Hanwashing in the intensive care unit: a big measure with moest effects. J Hosp Infect 2005;59: Rupp ME, Fitzgeral T, Puumala S, Anerson JR. Prospective, controlle, cross-over trial of alcohol-base han gel in critical care units. 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