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How Hospital Outsourcing Is Hurting

Workers and Endangering Patients

Dan Zuberi




To the memory of Helen Robinson, who loved a good book.



1. Stuff Gets Missed: An Introduction

to a Growing Health Care Crisis

2. Germs, Blood, and Cost-Cutting:

The Daily Struggle to Keep Hospitals Clean

3. Compromising Cleanliness: How Outsourcing

Keeps Hospital Workers from Doing Their Jobs

4. Untrained Workers, Unfit Managers

5. Breaking Up the Team

6. Down and Out in Vancouver: Struggling,

Stressed, and Exhausted Hospital Support Workers

7. Cleaning Up




I thank the many people who helped me complete the research behind this book and its publication. First and foremost, the interview participants, who remain anonymous, made this work possible by sharing their time, stories, and invaluable insights. While their stories, at times, broke my heart, I applaud their hard work, dedication, and commitment.

I also extend an extraordinary thank you to Melita Ptashnick, who began working on this project before returning to school to complete her MA degree and has worked for years helping collect, analyze, and disseminate data as a research assistant and coordinator on this and several other ongoing research projects. I have been fortunate to have the help of many research assistants for this study, including Tamara J. Ibrahim, Michael Halpin, Katherine McCallum, Geraldina Polanco, and Ariel Taylor.

I am especially appreciative of the Social Sciences and Humanities and Research Council of Canada for a Standard Research Grant, which supported this research. This research also benefited from a UBC Dean of Arts Undergraduate Research Award and a New Investigator Salary Award from the Canadian Institutes of Health Research (2011–2016).

This research would not have been possible had it not been for the help and support of several staff members at the Hospital Employees’ Union, especially Marcy Cohen, Chris Kincaid, Deborah Littman, and Jennifer Whiteside.

Throughout my career, I have been fortunate to benefit from the mentoring of many senior scholars who are leaders in their field. I thank my undergraduate honors advisor, Patricia Fernandez-Kelly and my MSc advisor at Oxford, George Smith. I am especially grateful for the ongoing support and mentorship of my PhD supervisor, Katherine S. Newman, dean of Arts and Sciences at Johns Hopkins University, and my supervisory committee members William J. Wilson and Mary C. Waters at Harvard University, as well as Jeffrey Reitz at the University of Toronto. I also thank my post-doctoral supervisor at the University of British Columbia (UBC), Clyde Hertzman, and my early career mentors: Neil Guppy at UBC and David Hulchanksi and Sheila Neysmith at the University of Toronto. I thank Faye Mishna, dean of the Factor-Inwentash Faculty of Social Work and Mark Stabile, director of the School of Public Policy & Governance at the University of Toronto for their support.

I have been fortunate to have had the support and encouragement of many people during this research project. I enjoyed the opportunity to spend part of a sabbatical at the Department of Sociology at the University of California, Berkeley, with the sponsorship of Peter Evans, who I thank for his encouragement. I also thank Irene Bloemraad and Kim Voss for their support.

I was especially fortunate to return to Harvard as the William Lyon Mackenzie King Research Fellow at the Weatherhead Center for International Affairs in 2011–2012 while revising the book manuscript. I am grateful to Canada program staff, including Steven B. Bloomfield, executive director; Helen Clayton, program coordinator; and Thomas C. Murphy, for their help. It was wonderful getting to know and work with Jim Dunn. I also thank Mary Jo Bane, Lisa Berkman, Kathryn Edin, Marshall Ganz, Peter Hall, Christopher Jencks, Michéle Lamont, Pamela Metz, Jim Quane, Beverly Silver, and Eddie Walker.

Over the course of this project, I have enjoyed the support and encouragement of many colleagues whom I thank, including Peter Adler, Joan Anderson, Rosemary Batt, Shyon Baumann, Sarah Brayne, Alex Colvin, Jennifer Chun, Adrienne Davidson, Julian Dierkes, Gary Evans, Richard Freeman, Ann Frost, Dan Hiebert, Nancy Gallini, Rebecca Givens, Anna Haley-Locke, Charles Hirschmann, Crawford Kilian, Seth Klein, Sarosh Kuruvilla, Robert Kuttner, Susan J. Lambert, Sean Lauer, Judith Lynam, Ruth Milkman, Peter Moskos, Dianne Newell, Aimee Nygaard, Winnie Poster, Patrick Sharkey, David Tindall, Chris Tilly, Lowell Turner, Danielle van Jaarsveld, Paul Watt, Rima Wilkes, Elvin Wyly, and Carrie Yodanis.

At Cornell University Press, it is always a pleasure to work with Fran Benson, who believed in and was enthusiastic about this research from its beginning. I have been inspired by the amazing work of Suzanne Gordon, author and co-editor of The Culture and Politics of Health Care Work series, and learned a great deal from her advice. I also appreciated the feedback from Siobhan Nelson, co-editor of the series, on the manuscript as well as the feedback from the anonymous reviewers. I appreciate the help of senior production editor Karen Laun, copy supervisor Susan Barnett, marketing director Mahinder Kingra, and copyeditor Julie Nemer. I thank Diana Hembree, health journalist, for her help and advice. I had the extremely good fortune to work with brilliant editor, Chris Woolston. I also appreciate the dedicated transcription work by Tara Neufeld.

I thank faculty at the following institutions for the opportunity to present the findings of this research: Harvard University; University of Washington, Seattle; Cornell University/ILR School; American University; Portland State University; San Diego State University; University of British Columbia; and University of Toronto.

Parts of chapters 1 and 6 appeared originally in the American Behavioral Scientist 55(7) (2011): 920–40. Those passages are reproduced here with permission from Sage Publications, Ltd., from Daniyal Zuberi, Contracting Out Hospital Support Jobs: The Effects of Poverty Wages, Excessive Workload and Job Insecurity on Work and Family Life, © Sage Publication, 2011.

The past several years have been full of adventures and travel from Vancouver to San Francisco, to Boston, and now to Toronto. I thank my friends, who have opened their homes to us over the years and whose company I’ve enjoyed over many dinners and outings: Alan Jacobs and Antje Ellermann, Tamara Smyth and Tommy Babbin, Shannon Daub and Ryan Blogg, Wendy Roth and Ian Tietjen, Anand Das and Shilpa Patel, Catherine Bischoff and Tom Zehetmeier, Kyle Horner and Kyla Tienhaara, Amy Hanser and Nathan Lauster, Mark Koehler and Linh, Jeremy Weinstein and Rachel Gibson, Joiwind and Amit Ronen, David and Sarah Pinto-Duschinsky, Molly and Ty Sterkel, Sam Jones and Pierre Koch, Veronique Sardi and John Parinello, Trish Winston, Jen Darrah-Okike and Kanu Okike, Judith and Hanno Steen, and Arjumand Siddiqi.

I have also been blessed to have the support of my wonderful family. My two daughters, Saskia and Naomi, bring unimaginable joy into my life. My spouse, Joanna, what can I say? I can’t thank her enough for her support and love, for believing in me and this book through it all, for reading and re-reading chapter revisions, and for reminding me why these stories are important to share and understanding why it’s just wrong that so many needlessly suffer. Keeping me grounded, giving me perspective, reminding me of what’s important, for being there. As anyone who has met her knows, she is simply amazing. I thank my mom, Lilly Zuberi, for being such a wonderful person and my father, Mo Zuberi for his support. I also thank my sisters Anita Zuberi (and her husband Steve Chase) and Sofia Zuberi (and her fiancé Jakob). I also am especially grateful to my father-in-law, Cam Robinson, who keeps me updated with the latest Scientific American articles on antibiotic resistance and has been so supportive and kind. My sister-in-law Michelle Robinson and family, Charles Lepoutre, Georges, and Élise have been the best hosts so many times. I thank Leslie Robinson, Kate and Graham, Toni and David Owen, and Jennifer Owen.

My family has been greatly saddened by the passing of Helen Robinson and Jean Vivian. With the passing of loved ones and births of new family members, we celebrate the joy and beauty of life so intricately and intimately connected to struggle and loss, remember how we can honor those before us, and work toward a more just, safer, and more sustainable future for the generations to come.



An Introduction to a Growing Health Care Crisis

Tracy Melucci cleans a hospital for a living.¹ Well, sometimes clean is a strong word. More realistically, she makes her hospital less dirty than it was before. Short on time, short on resources, and long on responsibilities, she cleans what she can. And she knows it’s not enough. Basically, you do the big stuff and then you start cutting corners, she says. You just cannot get it all done. And when I say ‘cutting corners’ that means bathrooms, offices, hallways. Stuff gets missed.

Stuff gets missed. Hospitals across the United States, Canada, and much of Europe have dramatically changed their approach to housekeeping and other support work in the last decade, and people are dying as a result. Disinvestment and outsourcing of hospital cleaning services have left hospitals less hygienic and more vulnerable to the spread of hospital-acquired infections.

A Philadelphia grandmother checked into a hospital for a minor knee operation. The operation should have greatly improved her mobility and quality of life; instead, it opened the door to an infection of methicillin-resistant Staphylococcus aureus, or MRSA. The infection—which most likely could have been prevented—burrowed into her joint and started devouring all the tissue it could reach. Doctors removed her knee and amputated her leg. But even after a total of twenty surgeries, the germ still prevailed. In spring 2010, she died from the infection at the age of seventy-seven.²

Drug-resistant germs let loose in less-than-spotless hospitals—it’s a scenario for disaster. According to the World Health Organization (WHO), hundreds of millions of patients get infected annually.³ Millions die as a result, and many others will be struggling to recover, often spending several extra days, weeks, or months in a hospital bed. The U.S. Centers for Disease Control reported a decline in MRSA cases in the United States from 2005 through 2010,⁴ but, C. difficile infections remain at historic high levels.⁵ Overall, the problem of hospital-acquired infections shows no signs of slowing down. In fact, many infection-control professionals and researchers fear it is going to get a whole lot worse.

That is the reality of today’s health care system: The very places patients go for treatment and healing can, instead, be a source of severe illness and even death. According to WHO, at least 1.4 million people are suffering from a health care–associated infection at any one time.⁶ This is not a problem confined to developing countries; many of the most serious cases are in the United States, Canada, and Europe.⁷ Despite differences in monitoring, measurement, and reporting across regions and countries, it remains clear that health care–associated infections are a leading cause of illness and death. According the U.S. Centers for Disease Control, 1.9 million people every year are infected in U.S. hospitals and 99,000 people die.⁸ Many of the survivors suffer long-term health consequences and even disability. The statistics are similarly dismal for Canada. Linda Raines, an infection-control nurse at a Vancouver hospital explains, hospital-acquired infections are the third or fourth leading cause of death in Canada. That is staggering to me. Over 220,000 Canadians are affected by hospital-acquired infection every year, and out of that approximately 8,000–12,000 actually pass away due to it.

Hospital infections are also incredibly expensive to treat. In the United States, one economic estimate put the cost at $6.7 billion per year.¹⁰ In Canada, direct treatment costs are estimated at approximately $1 billion per year.¹¹ These costs do not include financial settlements or damages awarded from the growing number of lawsuits and compensation claims filed by victims and their families as a result of health care–associated infections.¹² These estimates also do not take into account the loss of economic productivity or the pain and suffering of victims. The prevalence of health care–associated infection literally means that people risk their lives whenever they enter a health care setting or hospital to get treatment.

How high is this risk? A 2009 article published in the Canadian Medical Association Journal estimates that one in ten adult hospital patients contract an infection before being discharged, which is similar to estimates from other countries, ranging from the United Kingdom to New Zealand.¹³ In the United States, roughly 70 percent of hospital-acquired infections are resistant to one or more antibiotics.¹⁴ It’s frighteningly easy to pick up an infection during a hospital stay. Linda Raines, infection-control nurse, relates this story: We had a patient that was a cath lab nurse in a different hospital, and obviously as a nurse she was very aware of her surroundings and her hand hygiene. She was in the hospital three times and by the third admission she was MRSA positive. To me, she was the top of the top as far as doing everything right, and it just took three visits.

Catherine Noonan, another nurse and infection-control practitioner in Vancouver, explains, I don’t think that the average person knows enough about the organisms that they come with, the organisms that they encounter in the hospital, and how transmission occurs.

Veronica Sendal, an epidemiologist who consults on infection-control reform to U.S. hospitals, says that the general public has somehow managed to live in denial about the risk of hospital-acquired infections, even though most everyone knows someone who has been affected. And, she says, it’s not just the public that underestimates the risks: Health care workers have some knowledge of the frequency and severity of HAIs [hospital-acquired infections] but do not always realize the impact of their own actions nor do they necessarily prioritize prevention in day-to-day activities. We do not have a total understanding of the host, agent, and environmental factors that contribute to the incidence of infection nor do we know or have the technology, means, or commitment to safely prevent HAIs.

Getting infected in the hospital dramatically increases the likelihood that a patient will require extensive care or even die. The most dangerous cases of hospital-acquired infections result in pneumonia or infection of the bloodstream, gastrointestinal system, surgical sites, skin, or soft tissue.¹⁵ Getting an infection complicates care and requires extended treatment and even hospitalization. A report from the UK Health Protection Agency estimates that a patient with a health care–associated infection is 7.1 times more likely to die than a similar uninfected patient.¹⁶

It’s not a pleasant way to go. People with an infection of Clostridium diff icile—a superbug that’s on the rise in hospitals across the world—have likened it to swallowing shards of glass. Patients may suffer from unstoppable diarrhea for weeks before finally dying.¹⁷ Even if they survive and recover, they can suffer lasting health consequences. Louisa Appleton, an infection-control practitioner in Vancouver laments, "people don’t realize that their legs could be amputated or they can die from it or they end up losing their bowels when they get C. diff."

The problem is rapidly becoming even more serious.¹⁸ Overall, all kinds of infections are becoming more widespread, more difficult to treat, and more dangerous to patient health. According to the U.S. Centers for Disease Control (CDC), health care–associated infections are a top-ten cause of death of Americans.¹⁹ While this overall assessment may seem pretty grim, the on-the-ground reality is actually worse than the numbers suggest. Many infections and casualties of health care–associated infections are misattributed or simply not reported.

Whether they want to or not, hospitals are fighting a war against germs. Professor Arthur Sanders, a senior faculty member and leading expert on infectious disease, certainly feels like the germs are winning: I talk about hospitals as cesspools. Hospitals are an important vehicle for bad infections and resistant infections to go into the community, and then ultimately back to the hospital setting. So, pretty well in every way I can think of, they’re a significant issue, and perhaps what makes it more frustrating is that many of these are, in theory, preventable if healthcare providers and administrators did their jobs.

The situation is scary, but it is far from hopeless. In fact, hospitals in Scandinavia and the Netherlands have managed to greatly reduce the prevalence of hospital-acquired infections with a series of policy reforms—the types of reforms that could be implemented elsewhere but aren’t. The steps include incentives to increase hand-washing, prevent the overuse of antibiotics, increase careful monitoring, and, crucially, increase the training and professionalization of hospital cleaners and support workers.²⁰ Julia Drake, a medical lab microbiologist working in a British Columbia public health lab, explains, I think there are European cities that are very advanced in terms of infection control. I’ve been through hospitals in Germany where they actually sterilize the entire patient bed. That may be overkill but they basically sterilize every bed, and put it in plastic wrap, so you have a brand new bed that’s totally cleaned up, ready for the next patient. Well whether that’s necessary is debatable, but there’s full spectrum of the pendulum. . . . there are countries that pull out all their stops.

Globally, hospitals and health care systems have adopted a variety of approaches to prevent superbug outbreaks and reduce infection rates. The WHO, for example, is attempting to encourage hand-washing and other infection-control guidelines around the theme of Clean Care Is Safer Care.²¹ The good news is that many of these interventions have resulted in proven reductions in infection rates. They are all well worth the cost and investment required to implement, especially in light of the emergence of new deadly strains of antibiotic-resistant bacteria, such as C. difficile, vancomycin-resistant Enterococcus (VRE) and vancomycin-intermediate/resistant Staphylococcus (VISA/VRSA).²²

Yet the calls for increasing hand-washing and implementing safe-care checklists should be viewed only as a good start. Because of the urgency of the threat from hospital-acquired infections, the crisis must be attacked simultaneously from multiple fronts.²³ The good news is that multipronged approaches have been proven effective for quelling an outbreak or reducing overall infection rates. Here are some recent success stories:

• The University of Pittsburgh hospital reduced C. difficile infection rates by 50 percent through improved cleaning, antibiotic stewardship, and isolating infected patients.²⁴

• St. Michael’s Hospital in Toronto reduced MRSA infections by 60 percent through improved cleaning by 2006, and according to publically available hospital surveillance reports, reported fewer than ten new MRSA cases in 2011.²⁵

• In 2008, the United Kingdom completed a deep clean of 1,500 hospitals at a cost of £63 million. The UK National Audit office estimates that spending £120 million on cleaning (including the deep clean) saved between £143 million and £263 million in treatment expenses.²⁶

• An 2011 article in the New England Journal of Medicine describes how a multipronged approach, including surveillance, contact precautions, hand hygiene, and institutional cultural change to involve all staff in infection control, successfully reduced hospital-acquired infection rates at U.S. veterans’ hospitals.²⁷

The research evidence clearly points to the importance of environmental hygiene—or hospital cleanliness—for preventing the transmission of hospital-acquired infections. In a 2008 article in Lancet Infectious Diseases, Stephanie Dancer, microbiologist, notes that "cleaning has already been accepted as an important factor in the control of . . . hardy environmental pathogens such as Clostridium difficile, vancomycin-resistant enterococci, norovirus, and Acinetobacter spp."²⁸ Her article presents detailed evidence that hospital cleanliness is also a key factor for controlling transmission of MRSA. In another article published in BMC Medicine, Dancer and her colleagues reported the findings of a controlled experiment that found adding one extra cleaner to a ward resulted in a decline in measured microbial contamination detected on hand-touch sites, prevented many infections, and generated substantial savings.²⁹

Other research clearly shows that proper and thorough cleaning of high-touch surfaces and other germ hot spots in hospitals can reduce the rates of hospital-acquired infections. In their review of the literature, Philip C. Carling, director of epidemiology at Boston’s Carney Hospital, and Judene M. Bartley note that "five studies have recently shown that improved routine disinfection cleaning practice is associated with an average 40% decrease in transmission of VRE, MRSA, and A. baumannii."³⁰

Unlike typical housekeepers, hospital cleaners are supposed to completely disinfect all surfaces of the room to make it safe for the next patient. But they rarely meet this goal. Currently, patients who stay in a room where the previous occupant had an infection such as MRSA, C. difficile, VRE, and Acinetobacter baumannii have been found to have a 73 percent elevated risk of getting infected compared to other patients.³¹

It may seem obvious that the people who mop the floors and wipe off countertops—the people on the front lines of hospital hygiene—could play a key role in preventing the spread of hospital-acquired infections. But in most of the world, these workers are practically afterthoughts, if anyone bothers to think about them at all. Previous research on hospital support workers in the United States and Canada reveals that they feel devalued and ignored, despite the importance of the work they do.³² My research identifies the largely overlooked connection between deteriorating working conditions in hospitals and the increase in hospital-acquired infections. I argue that workplace reforms must play a key role in any attempt to control the spread of infections. To protect the patients, you first have to protect the workers.

Outsourced Workers, Unintended Consequences

Clean hospital environments are critical for reducing hospital-acquired infections. Yet hospitals in many parts of the world continue to slash the resources dedicated to support services. Indeed, many are now handing over cleaning and food service responsibilities to outside companies, mostly local franchises of multinational corporations. Think McDonalds but with housekeepers instead of hamburgers. This is a particularly pernicious example of franchise capitalism—by transferring these jobs to outside contractors, hospitals are not just hurting their support workers but also increasing the risks to their patients.

Unfortunately, hospitals are increasingly unwilling to spend the money to support the workers on the front lines of the fight against germs.³³ As recently reported in the Canadian Medical Association Journal, budget cuts and outsourcing have seen the proportion of hospital budgets devoted to support staff drop from 26% in 1976 to 16% in 2002.³⁴ These cuts mirror disinvestment in support services by U.S. hospitals, which are estimated to have reduced cleaning staff by at least 25 percent since 1995.³⁵ Pia Davis, a representative of the Chicago Service Employees International Union, says hospital cleaners are barely prepared to do their jobs. Hospitals hire people and say just go in there and clean, she says. They don’t show them what chemicals to use or not to use. We have report after report showing that rooms are not cleaned every day.³⁶

U.S. hospitals have gutted cleaning staff over the years, a dangerous response to financial crises that have pushed as many as one-third of U.S. hospitals to the brink of bankruptcy.³⁷ Approximately one-third of American hospitals have outsourced their cleaning services.³⁸ Disinvestment in cleaning has consequences: approximately 75 percent of U.S. hospitals have been cited and sanctioned for cleanliness and sanitation violations in that period.³⁹

While public health officials are sounding the alarm about the spread of infection in hospitals, the workers responsible for keeping hospitals clean continue to toil in obscurity. If anyone talks about them at all, it’s usually in a quest for a useful scapegoat. But the workers aren’t the villains in this story; they are some of the real victims.

Contracting out services can lower costs—at least in theory—but the savings come at a steep price. Housekeepers and dietary aides in hospitals are deeply aware of something that hospital administrators have refused to acknowledge. In many interviews, workers told me that outsourcing has led directly to dirtier, more dangerous hospitals. Hospital support staff require proper qualifications, training, equipment, and decent work conditions to do their jobs well, but outsourcing has undercut the workers and their mission at every level.⁴⁰