Improving HCAHPS Room Cleanliness Scores

Lauren Rodriguez, Zoe Raine, Madison Stith, Andrew Liesen, Lieyu Zhang
Abstract
Description of the Issue: Patient room cleanliness
is important for infection control and influences
that patient’s experience, which in turn can affect
outcome of care. The HCAHPS scores for room
cleanliness at Bon Secours St. Francis Medical
Center (SMFC) are at 67%, which is 9% lower than
the national average.
Data Analysis: Data was collected through an
interview with the environmental services manager
from SFMC and college library databases.
Root Cause: A lack of awareness on patient
perception of room cleanliness.
Proposed Solution: We propose using real time
surveys to address patient dissatisfaction before
leaving the hospital.
Conclusion: The information obtained will be
relayed back to the quality improvement team and
Per interview with T. Evans (2/17/2021)
changes will be implemented to improve overall
room cleanliness.
Introduction and
Bon Secours Memorial College of Nursing
Data and Analysis
● Patient perception of room cleanliness effects
clinical outcomes and financial reimbursement
(Krouss et al., 2020).
● A hospital's physical environment, including
cleanliness, was the third highest contributor to a
hospital's overall HCAHPS rating (McCaughey ,
Stalley, & Williams, 2013).
● “Patient as the best judge who accurately assesses
and provides inputs to help in the overall
improvement of quality health care provision
through the rectification of the system weaknesses”
● “Cleanliness is viewed as important both in terms of
elimination of bacteria that could lead to infection
and because it says something about the
competence and commitment of the hospital staff
as a whole. “ (Sofaer, et al., 2005)
● SFMC has up to 14 EVS staff per day
● High EVS staff turnover rates; low incentives
Many units have outdated features
●
AIM - Proposed Solution
Our goal is a 5% increase in HCAHPS score
regarding room cleanliness for patients hospital
wide within 6 months of starting the project.
Real time surveys given by volunteers will be used
to collect data on patient satisfaction and room
cleanliness to address any complaints patients may
have.
Logistics
● Recruiting volunteers
● Printing and distributing surveys
● Delegating volunteer assignments
● Survey responses verified by EVS or nursing
management
Stakeholders
Nursing and EVS management
●
Hospital management and administration
●
Conclusion
Patient’s perception of room cleanliness is a vital factor
in judging the quality of care they receive. The
information received through real-time surveying gives
staff a chance to correct issues immediately. This
eliminates any dissatisfaction based on cleanliness of
their room.
St. Francis Medical Center unit managers take the data
collected from the real time surveys and communicate
back to quality improvement team.
Our hope is that SFMC stakeholders take the outcomes
of our group work to implement change in
environmental services practices and optimize
management procedures in the organization.
Obtaining patient’s feelings and concerns of their room
cleanliness, promptly tending to their needs, and
adapting overall procedure is a proactive technique to
address this issue and will improve quality of care,

Lack of communication and teamwork between EVS

Description of the Issue
Macro Description: Hospital room cleanliness is not
only important for infection control but for patient
● QI team
patient’s overall experience and HCAHPS scores.
● ● Patients
and nursing staff. References
● EVS visits each room once per day.
Potential costs Asamrew, N., Endris, A., & Tadesse, M. (2020). Level of patient satisfaction with inpatient services
● $0.10 per page for survey paper and its determinants: a study of specialized hospital in ethiopia. Journal of Environmental

satisfaction as well. Patient experience affects the Root Cause ●

outcome of their care. Room cleanliness is part of the
HCAHPS domain. Lack of data on this topic proves that
further exploration is warranted.
“Room cleanliness” is a subjective term that is
interpreted differently by each patient. A lack of
awareness on patient perception of room cleanliness
has been identified as the root cause of low HCAHPS
●
5-10 minutes of volunteer time per patient survey
2 hours/ week for department supervisors to communicate with staff
and Public Health. https://doi.org/10.1155/2020/2473469
Centers for Medicare & Medicaid Services (CMS). (2020). HCAHPS: patients' perspectives of care
survey. Retrieved from
● 7-15 minutes/ room for staff to respond to identified issues
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospit
alQualityInits/HospitalHCAHPS
Krouss, M., Bedell, D., Solly, T., Phillips, G., Hermele, J., Ojo, A., Fasihuddin, F., Atreja, A., Dunn, A.,
Timeline & Cho, H. (2020). Project TOPS: team-based oversight of patient satisfaction through
real-time interdisciplinary feedback. The Joint Commission Journal on Quality and Patient
● Implemented by July 19, 2021 Safety, 46(7), 427-430. doi:10.1016/j.jcjq.2020.04.003

Micro Description: HCAHPS scores for room
cleanliness at St. Francis medical center (SFMC) are 9%
lower than the national average.
scores at St Francis.
Hypothesis: If we increase awareness of real time
patient experiences, we can improve HCAHPS scores
related to patient room cleanliness, therefore, we
propose using real time surveys to address patient
dissatisfaction before leaving hospital.
● Training for volunteers on site McCaughey , D., Stalley, S., & Williams, E. (2013). Examining the effect of EVS spending on
HCAHPS scores: A value optimization matrix for expense management. Journal of
● Evaluation at 3 month mark
● Outcomes of project evaluated at 6 month mark
healthcare management.
Sofaer, S., Crofton, C., Goldstein, E., Hoy, E. & Crabb, J. (2005). What do consumers want to know
about the quality of care in hospitals? Health Services Research, 40, 2018-2036.
https://doi.org/10.1111/j.1475-6773.2005.00473.x
Data Collection
● HCAHPS scores
● Real time surveys