Green Cleaning in Healthcare: Current Practices and Questions for Future Research

By: Xiaobo Quan, Ph.D., Anjali Joseph, Ph.D., Matthew Jelen
Published by The Center for Health Design, September 2011
 

EXECUTIVE SUMMARY

Environmental cleaning plays a key role in preventing healthcare associated infections (HAIs). But many current cleaning practices in healthcare may negatively impact human health and the environment. Green cleaning is a new, promising approach to environmental cleaning that aims at reducing harm to human health and the environment while maintaining or improving the hygiene of the healthcare environment. While a growing number of healthcare facilities are adopting green cleaning practices, there are many essential questions around green cleaning that remain unanswered due to the lack of research in this area.

The objective of the Healthier Hospitals Initiative (HHI) Pebble Project is to promote and support development of green cleaning initiatives by better understanding current green cleaning practices and identifying future research topics of high priority. Under the guidance of an advisory group consisting of industry experts, the project team at the Center for Health Design (CHD) a) established a conceptual framework for green cleaning through literature review, b) conducted case study interviews with representatives from five major healthcare facilities, and c) conducted an online questionnaire survey of high-priority research questions around green cleaning.

The conceptual framework takes a systemic approach toward green cleaning. Factors around green cleaning generally fall into three groups: The healthcare hygiene system, external and internal factors impacting the healthcare hygiene system (e.g. regulations, sustainability movement, staff education and training), and outcomes influenced by healthcare cleaning and hygiene. The healthcare hygiene system is an integration of not only healthcare cleaning (including risk assessment and the selection, application, and disposal of cleaning agents) but building design (e.g. ventilation system, interior finish materials) and operational design (e.g. building maintenance, waste management). These components of the healthcare hygiene system interact with each other and other factors to influence multiple outcomes, including environmental cleanliness, risk of HAIs, health effects (e.g. asthma, dermatitis), environmental impact (e.g. bioaccumulation, waste, and energy consumption), patient and staff satisfaction, and cost-effectiveness.

Nine green cleaning practices were found in the five case study facilities. These practices generally fall into three main categories: 1) selection of cleaning products (including green cleaners, cleaning tools or equipment that use less water and chemicals, and minimal number of chemical types); 2) operational change (including cleaning for appropriate levels of cleanliness, application and dispensing methods, and use of fluorescent marker); and 3) building design (including interior design that reduces the need for cleaning or facilitates cleaning, and layout that makes housekeeping more efficient). Variations exist in green cleaning practices across different facilities. The selection of cleaning products that contain or use less harsh chemicals is the most commonly adopted method. Operational changes commonly implemented include the establishment of appropriate cleanliness levels in different areas based on infection risk estimation and optimal application and dispensing of cleaning chemicals (e.g. squeezing or pouring chemicals directly onto cleaning cloth instead of spraying). All case study facilities have made efforts to select flooring materials that require less cleaning and maintenance, but research evidence is lacking to support informed decision-making on this issue.

The implementation of green cleaning usually involves strong leadership from facility administration and internal multi-disciplinary sustainability teams, as well as staff acceptance and ownership. Almost all case study facilities conducted initial evaluation of new products and procedures before implementation, but rarely monitored or evaluated the performance of the products and procedures after adoption. Certain healthcare outcome data have been routinely collected for other business purposes (e.g. infection prevention), but typically were not utilized in the evaluation of green cleaning. Anecdotal evidence from the case studies suggests that green cleaning generally results in benefits such as reduced use of water and chemicals, fewer complaints from staff and patients, and lower levels of infection rates.

The 150 respondents to the survey were mostly healthcare staff, including environmental service managers, nurses, sustainability consultants and administrators. The majority of the respondents perceived green cleaning to be only a practice of selecting and using appropriate cleaning products, while other important aspects including operational changes and building design were largely ignored. The three most important research topics identified in the survey are 1) the effect of green cleaning on facility cleanliness and HAI prevention; 2) the effectiveness of green cleaning in protecting the environment; and 3) the health effects of green cleaning. Other important research topics identified include the cost-effectiveness of green cleaning and the development of standard methods to evaluate different green cleaning products and practices.

In conclusion, green cleaning is an interdisciplinary, systematic approach involving the selection and use of cleaning products as well as operational changes and building design. A variety of green cleaning products and practices have been implemented in healthcare facilities. However, one big challenge in implementing green cleaning is the limited evidence regarding the effectiveness of these products and practices. The actual effects of green cleaning are typically not routinely monitored and evaluated, even though certain relevant data may already be collected for other purposes in various health care departments. For the ongoing development of green cleaning initiatives, it is urgent to conduct research focusing on practical questions from real settings, for example:

• How do green cleaning products/practices effectively impact environmental cleanliness and HAI transmission?
• How do green cleaning products/practices effectively impact the environment?
• How do green cleaning products/practices effectively impact human health (e.g. asthma, dermatitis)?
• What are the standard tools and methods for the comparative evaluation of various green cleaning products/practices?
• How cost-effective and feasible are certain products/practices?
• What are the advantages and disadvantages of various flooring materials in regard to cleaning?