Table 1.

Challenges to patient room cleaning and HFE-informed intervention ideas for improving patient room cleaning.

Work system elements	Challenges to patient room cleaning	HFE-Informed intervention ideas
People	○ EVS associates  ○ Education, literacy and language barriers that are not addressed with current education tools  ○ Physical limitations (e.g., height, back pain) that hinder the cleaning of certain surfaces  ○ Lack of practical relevant information (e.g., when to change cleaning cloths, mop heads)  ○ Personal concerns about working in close proximity to bacteria  ○ Lack of skills to communicate with patients and families, particularly in areas such as psychiatry, labor and delivery, and intensive care ○ Patients and Families  ○ Lack of recognition of the role of EVS associates in keeping the near patient environment clean and their role in infection prevention	○ Training of EVS associates  ○ Redesigning training materials for patient room cleaning based on HFE analysis (e.g., physical ergonomic assessment, task analysis)  ○ Simulation-based communication training with role-plays and observations of EVS associate-patient interactions  ○ Creating a forum for EVS associates to ask questions and discuss anxieties  ○ Specific, easy to understand teaching about contact precaution rooms, droplet and airborne precautions, with a questions and answers forum ○ Patient and family education  ○ Developing education materials to enhance patient and family awareness as to the essential role of the EVS associates
Tasks	○ Patient Room Cleaning  ○ High workload with time pressure and interruptions  ○ Repetitive nature of patient room cleaning tasks intensifying feelings of boredom and fatigue  ○ Ambiguity about responsibility for patient room cleaning and medical equipment cleaning	○ Job redesign  ○ Redefining responsibilities and tasks of EVS associates using principles of job enrichment, job enlargement, and job rotation  ○ Balancing individual work and teamwork of EVS associates ○ Task redesign  ○ Redesigning patient room cleaning tasks based on physical ergonomics principles (e.g., work in neutral postures, reduce excessive force) and sociotechnical system principles (e.g., responsible autonomy, adaptability)
Tools and technologies	○ Cleaning tools and supplies  ○ Cleaning tools and supplies not supporting patient room cleaning tasks  ○ Complex instructions for using cleaning tools and supplies (e.g., mixing or dilution of solutions)  ○ Distributed storage of cleaning tools and supplies ○ Cleaning checklist  ○ Poorly designed, ineffective cleaning checklists  ○ Cleaning checklist not fitting with the workflow of EVS associates ○ Medical equipment  ○ Complex medical equipment (e.g., patient bed) that is difficult to clean	○ Redesign and rearrangement of cleaning tools and supplies  ○ Redesigning cleaning tools and supplies based on usability evaluation (e.g., heuristic evaluation, user testing)  ○ Redesigning instructions, labels and warnings using HFE principles (e.g. HFE principles for labeling)  ○ Limiting the number of cleaning tools and supplies used and centralizing the their storage ○ Redesign of cleaning checklist  ○ Using a participatory, user-centered design approach to redesign the cleaning checklist ○ Selection of medical equipment  ○ HFE and infection prevention professionals assessing medical equipment before making purchasing decisions to ensure adequate cleaning is feasible
Organization	○ Organizational culture  ○ Lack of appreciation that EVS associates contribute to patient safety ○ Organizational structure  ○ Hierarchy with power difference between frontline workers and leadership and between EVS associates and other healthcare professionals ○ Performance evaluation and promotion  ○ No long term recognition of good work of EVS associates  ○ No promotion pathway for EVS associates ○ Staffing and work schedule  ○ Conflicting pressures such as minding a child, who is sick and cannot go to school, or school is closed, that may prevent an EVS associate from coming to work.	○ Creation of safety culture  ○ Building a culture of safety by highlighting the importance of EVS associates in infection prevention  ○ Involving EVS associates in a unit-based forum for addressing safety-related issues ○ Change of organizational structure  ○ Building teams between EVS associates and other healthcare professionals ○ Change of evaluation and promotion system  ○ Providing certification programs with testing and qualifications to EVS associates  ○ Developing clear promotion pathway for EVS associates ○ Staffing and work schedule  ○ Flexibility of hours  ○ Inexpensive daycare options  ○ Backup system whereby if an EVS associate is unable to come to work their tasks are covered.
Internal environment	○ Patient Room  ○ Patient room cluttered with patient belongings  ○ Patient room with dim light	○ Patient room layout  ○ Providing specific areas (e.g., labeled shelving and closet space) for patients and families to hold their belongings  ○ Color-coding high touch surfaces to alert EVS associates

EVS Environmental Services

HFE Human Factors Engineering