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Monitoring the patient environment

Dr Liz Jones, previously head of patient environment at the Department of Health, and Professor Keith Derbyshire, who was the chief analyst and chief economic adviser, argue that the costs of a dirty NHS are enormous and we need a monitoring system that combines quality and cost.

The headlines were clear. ‘Your Business is in Danger!’ they screamed, warning of a bug with the capacity to ‘wreak havoc’. The BBC reported that one woman had moved her whole family to a remote house in Scotland, with an independent water supply from a well.

 The catastrophe on our doorstep? The Millennium Bug. Depending on your view, this glitch in the world’s computers was going to bring planes crashing from the sky and set the internet ablaze, or alternatively might mean nothing at all. 

Those people with specific Millennium Bug responsibilities spent the New Year at their desks, anxiously awaiting 00.01. By 00.02, most of them had breathed a sigh of relief and were wishing they were back home with their families. I [Dr Jones] was high up in the Lancashire hills, watching other people’s fireworks displays for free and having a rare old time. 

Back in the office a few days later, we were more worried about a very different bug: MRSA. Rates of MRSA septicaemia were rising and it was becoming clear that this was a problem that was going to take some very heavy lifting indeed. The headlines were equally disturbing and even more graphic: “Bug ‘ate’ OAP’s leg” said the Sun, whilst other papers wrote about the “war on RSA” and talked about an “uncontrollable epidemic”. 

Seventeen years ago, we had relatively little hard evidence about the importance of a clean environment in preventing Healthcare Associated Infections (HCAIs). We had to learn the hard way that we can bring down rates of infection, but only by taking actions on many fronts. We also now understand much better that antibiotic resistance has seriously weakened one of those fronts, and that the others must take more strain. A clean NHS has never been more important.

When the NHS Plan was published in 2000, hospital cleanliness was a major concern. The Plan announced a new inspection process for cleanliness and the first Patient Environment Action Teams (PEAT) were set up. That year, around one-third of the hospitals we inspected were either ‘poor’ or ‘unacceptable’. It was time for the great clean-up to begin. 

PLACE 

Since then, standards of cleanliness have risen and risen. The revised assessment process (Patient-Led Assessments of the Care Environment – PLACE) recognised this in 2012, by resetting the bar to push for still higher standards. Again, the NHS responded and scores rose once more. Job done… except, of course, we all know that it isn’t. 

We have to continue to monitor the healthcare environment and – even more importantly – to respond to what we find. This is the aspect of PLACE that receives least attention from the media, yet it is the central plank of the process. Hospitals are expected to use their PLACE scores to develop an improvement plan that sees tangible, measurable changes year-on-year, responding to the problems that patients deem most important. 

With increased pressure on budgets, and a drive to find efficiency savings from every aspect of hospital performance, managers face a massive challenge to improve quality and reduce or, at best, contain costs. Cleaners are relatively low-paid and staff costs account for almost all the budget for cleaning services. The reality is that the only way to cut cleaning costs is to increase productivity or reduce standards. The public won’t stand for the latter, so we need to act on the former. This means we not only need to rigorously measure quality as well as finances, but share that information with the cleaning staff and get their ideas for ‘working smarter’ while encouraging retention and developing an ethos of team working. 

Of course the NHS has to break even. But the costs of a dirty NHS are enormous in infection, length of stay, mortality rates, patient satisfaction and public perception. If all we measure is the input cost, we will miss the opportunity to raise quality standards at the same time as we reduce spending. What is needed is a monitoring system that combines quality and cost in a way that allows individual hospitals to understand their improvement challenges and opportunities. 

The monitoring system needs to be able to do two contradictory things. It needs to be sufficiently sophisticated to separate avoidable from unavoidable cost differences. But it also needs to be sufficiently transparent for managers to understand and trust it. And, crucially, for staff to do the same and ‘own the problem’. Facilitated workshops of cleaning staff can then be used to get their wisdom on what the opportunities and barriers to improvement are. 

An honest and informed engagement process with staff will not only identify barriers managers are unaware of — it will allow them to propose solutions. The process in itself will also help reduce  psychological barriers to changed ways of working. Most staff in the NHS want to do a good job. As taxpayers, they also want to deliver good value. Monitoring cost and quality together is the only way to show them that they can deliver both.

FOR MORE INFORMATION

W: www.bettercareenvironments.org

W: www.york.ac.uk/che/staff/research/keith-derbyshire

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