One of Osler’s strategic directions is that we “Continue to deliver exemplary care in the eyes of our patients and peer”.  In order to align with this strategic direction, Osler’s environmental services department implemented a two tiered audit system for measuring hospital cleanliness. The Cleanliness Compliance Audit is a Board reported performance measure that is reported on a quarterly basis.

The Cleanliness Compliance Audit consists of the following two audits:
1)  Quarterly, unannounced, independent 3rd party cleanliness audits that are conducted facility wide for both the Brampton Civic Hospital (BCH) and Etobicoke General Hospital (EGH). The audit measures cleanliness based on definitions from the Provincial Infectious Diseases Advisory Committee (PIDAC). During each audit, approximately 125 rooms at BCH and 85 rooms at EGH are randomly evaluated. 75% of the rooms that are audited are classified as high risk based on patient and facility usage. High risk rooms include:  Operating Room, Emergency Department, Critical Care units and inpatient rooms. The outcome of the cleanliness audit represents 50% of the value of the Cleanliness Compliance Audit measure.

2) The second audit type is a weekly, random audit during the third month. This audit measures the cleaning effectiveness of high transmission risk touch point items via the application of a Fluorescent Marker. Osler’s Coordinator of Quality Management, Support Services independently applies the marker to touch points in selected areas. After a complete 24 hour cleaning cycle, the Quality Coordinator and a member of the site’s housekeeping management/supervisory team review the points where the marker has been applied to identify if those touch points were cleaned in the 24 hour period.

During the audit period 600+ high touch points at BCH and 450+ high touch points at EGH are measured. Audit areas include the Operating Room, Day Surgery, rooms of discharged patient, Dialysis, Diagnostic Imaging and various clinics. The outcome of the Fluorescent Marker audit represents 50% of the value of the Cleanliness Compliance Audit measure. The two tiered auditing practice is in addition to the self-measured and joint auditing conducted by the Quality Manager and all Environmental Services supervisors for each site.

This audit system allows for consistent measurement and the development of operational action plans focused on improvements while keeping up to date with the challenges and successes at both sites. The audit standards within this program are compatible with the PIDAC and BC PICNET Best Practice for Environmental Cleaning standards. The BC PICNET Best Practice for Environmental Cleaning standards uses a weighted scoring system and 19 inspection elements and puts more emphasis on items such as beds, over-bed tables, toilet, etc. These items have a higher chance of contact by hand (Critical Touch Point), thus increasing the potential risk of spreading infection and microorganisms. This practice ensures that Critical Touch Points are the main focus during routine cleaning activities. The results from the 3rd party independent audits are used to improve performance, inform decision making and goal setting for the environmental services teams.

Osler’s housekeeping supervisors have been trained by Westech and conduct internal audits using consistent guidelines. Results are utilized and reported to highlight areas that require more focus for follow up.  Data from the quality program is used to support training and in-services for front line employees to further improve quality outcomes.

Contact Information:

Title: Quality Management Coordinator

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