This episode is part of our in-depth coverage of the Healthcare Infection Transmission Systems Consortium (HITS) 2018 conference in Nashville, TN that took place September 18-20th. Check out all our HITS 2018 episodes here, and look for more throughout the month of October.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures a patient’s satisfaction with the quality of their care during their stay at the hospital. It measures things like staff communication and attentiveness, discharge information, food service, and the hospital environment. These are important measures and every hospital should strive for excellence in each of them (we talked about this in our last episode). However, and as is often the case in healthcare, the HCAHPS survey can have unintended consequences.

Typically, the Environmental Services Department (EVS) is given responsibility for the hospital environment portion of the score. And this too makes sense. They’re the ones cleaning the rooms, emptying the trash, and ensuring that the patient has a comfortable environment to heal in. However, the most important responsibility for EVS is to ensure the environment is safe and HCAHPS does nothing to measure that. There is no measure that grades the EVS staff on how well they prevent the spread of pathogens through the hospital. This becomes a problem when pressures mount to improve HCAHPS scores. It creates an environment where EVS staff are forced to focus on the perception issues, and with shrinking staff sizes, it often comes at the expense of doing their most important work.

On this episode, we talk with Christine Greene, MPH, Ph.D., Principal Research Investigator at NSF International and President of HITS and Maurits Hughes, Director of Logistics and Support Services at Michigan Medicine about how to deal with the patient satisfaction vs. patient safety conundrum. It’s a challenge that requires proper education for staff and leadership about the importance of EVS’ role in the hospital and the alignment of EVS and other critical teams like Infection Control. It also requires a new attitude towards EVS staff. They aren’t just custodians or housekeepers… they are Infection Prevention Technicians. We can do a lot for patients by elevating the stature of and support for the EVS team.

HCAHPS and the Patient Safety vs. Patient Satisfaction Conundrum

1:46 Measuring Environmental Services (EVS) with HCAHPS: What sounds good on paper doesn’t always work in practice.

2:40 The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures a patient’s satisfaction with the quality of their care during their stay at the hospital. The problem with tying patient perception of cleanliness to reimbursement is that it creates the conundrum of patient satisfaction vs patient safety. Contamination removal does not increase patient satisfaction.

4:55 Environmental Services (EVS) at Michigan Health are closely aligned with Infection Prevention (IP). In the 30 minutes a day EVS is in a patient room, staff must make the room look clean, remove the clutter of medical supplies, ensure trash doesn’t get too full, all while trying to stay as quiet as possible to improve HCAHPS scores.

6:20 HCAHPS has nothing to do with patient safety. It sounds good on paper but doesn’t really measure if the patient is actually safe.

7:30 EVS must partner with IP and use tools to help them measure if the staff is cleaning to necessary levels. Cut-backs on staff and resources mean each staff member is being expected to do more in a given day. The culture of cleaning excellence is compromised by not respecting the folks who do the cleaning. If these frontline employees are, “the tip of the spear against pathogens” how do we make sure they’re treated, compensated, trained and supplied like it?

10:20 Remind employees that they are Infection Prevention Technicians (as opposed to custodians or housekeepers) and their role is to prevent the spread of infections and save lives. All services are hospital services.

12:22 The industry has not made investments in training for EVS. Getting the lab and IP staff to help educate the C-Suite would be huge.

13:20 How do you quantify the value that EVS brings to the organization? Michigan Health uses ATP testing, microbial swab testing, gel marking and special procedures in ED and other high priority areas to track EVS effectiveness. We share the results with leadership.

14:45 A “Bundled” approach to accountability. EVS, IP, and nursing staff are all responsible for taking action if a patient has an infection. Tests that determine if a surface has been wiped vs. decontaminated can help you better prioritize which processes need improvement.

17:30 A Quality Assurance program that uses the latest technology can help validate who infection control committees should focus on.

19:30 How do you get people to see EVS as a protector of ROI and prioritize cleaning at the level needed?

22:50 HCAHPS doesn’t align with the goals of infection prevention and that’s a huge disservice to patient safety. It leads to EVS focusing on the perception of cleanliness and quiet first, and safety second. The smell of the chemicals might be bad but we’re not cleaning a fast-food restaurant, we’re cleaning to save lives. To improve HCAHPS scores we need adequate levels of staff, training of staff, access to facilities and a team approach to preparing patients for a safe environment.

25:00 This issue won’t manifest itself immediately and requires a long-term strategic prioritization or eventually it will prevent you from doing other things you’re trying to accomplish.

On the HITS Consortium and HITS Conference:

“I think change will occur by getting more EVS and IP leaders involved in this sort of initiative but it is going to require us to change the paradigm and change the model of how EVS is perceived and managed throughout the healthcare facilities.” – Maurits Hughes


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This episode was recorded on site at the HITS 2018 conference in Nashville, TN. Check out all our HITS 2018 episodes here, and look for more throughout the month of October.

Thank you to HITS, Christine Greene of NSF International, Kelly Reynolds of the University of Arizona and Michael Diamond of The Infection Prevention Strategy for working with us on this conference coverage. It was a great event, in a great city, attended by true heroes of Infection Prevention and Control from all over the world.

Be sure to check out the next HITS conference in August 2019 in Buffalo, NY!

About The HITS 2018 Conference

The HITS 2018 Conference was held on September 18-20th in Nashville, TN.   HITS 2018 offers a unique forum for the exchange of knowledge and experience in the prevention of healthcare-associated infections and promoting “hospital health”.  The 2018 HITS “Catalyst for Change” Conference is a working conference, bringing together research scientists, industry and healthcare professionals for an interdisciplinary and dynamic approach. We work together to understand and prevent the transmission of pathogens throughout the hospital facility through a collaborative effort that includes engaging in applied research.  The conference is accredited as a provider for continuing education units (CEUs) through National Environmental Health Association (NEHA) and National Board of Public Health Examiners (NBPHE). Join us for this one-of-a-kind, multimodal event where researchers and experts from across disciplines will work toward identifying research gaps and applying data-driven methods in the field. Meet, greet and share ideas with the individuals and organizations who are growing and sustaining the industry as we explore creative and innovative solutions to this global problem. The full 2018 schedule can be found at

The HITS organizing committee has assembled world experts and key opinion leaders to share their knowledge and expertise. We host a research poster session to hear from those in healthcare about the research being conducted in their facilities.  We also incorporate workshop breakout sessions each day in order to provide a unique forum through which everyone can interact and be innovative as we work to identify potential solutions to key barriers and develop an agenda for change moving forward into the next year.  After the conference, members have the opportunity to become involved in one of the many research workgroups conducting research around pathogen transmission in healthcare.

Check out highlights from the HITS 2017 conference:

For media inquiries:

For more information, please visit the HITS Consortium website: or email us:

Check out our conference preview episode: HITS 2018 A Catalyst for Change in Infection Control – Episode 67 w/ Dr. Christine Greene and Dr. Kelly Reynolds.

About Christine Greene, MPH, PhD 

Principal Research Investigator at NSF International

Dr. Greene is the Principal Research Investigator for the Sanitation and Contamination Control unit of the Applied Research Center at NSF International.  She has over 10 years of experience in epidemiological and laboratory research.   She holds a Ph.D. in Environmental Health Sciences and an MPH in Hospital and Molecular Epidemiology from the University of Michigan, Ann Arbor. Her academic research focus has been on healthcare pathogen transmission, pathogen environmental survival, hand hygiene, disinfection and biofilms which has led to multiple publications. At NSF International, Dr. Greene has been making strides to improve public health in the areas of infectious disease prevention and control in clinical, dental and community settings. Her work serves to improve the accuracy of environmental mediated infectious disease transmission modeling, strengthens current guidelines to control healthcare-associated infections and provides new insights that will stimulate innovative approaches to reduce the risk of biofilm-related infections, pathogen transmission and curtail the environmental persistence and transmission of infectious agents. Dr. Greene is a member of the NSF International 444 Joint Committee Standard – Prevention of Injury and Disease Associated with Building Water Systems and serves on the ISO TC 304 working group 3 as the project leader for the healthcare hand hygiene performance and compliance standard.  She serves as a board member for The Infection Prevention Strategy.  Dr. Greene is a co-founder of the Healthcare Infection Transmission Systems (HITS) Consortium – an organization that strives to break down silos in healthcare using a cross-disciplinary, systems approach to addressing the pressing issues around infection control.

Email at

About Maurits Hughes

Maurits Hughes is the Director of Logistics and Support Services at Michigan Medicine. He’s a dedicated executive with over 20 years of management experience in clinicaland non-clinical environments

Maurits Hughes

Maurits Hughes on LinkedIn

About the Healthcare Infection Transmission Systems (HITS) Consortium

The Healthcare Infection Transmission System Consortium is a not-for-profit organization serving the field of infection control and prevention. HITS takes a holistic perspective to targeting healthcare associated infections by including multiple disciplines in the conversation, including infection prevention, environmental services, construction and renovation, facilities management and engineering along with research scientists and industry experts. HITS focuses on the major avenues for pathogen transmission in hospitals:  hands, surfaces, water and air.  HITS provides the necessary, cross-disciplinary platform to share knowledge and engage in research regarding the prevention of healthcare-associated infections and promotion of overall hospital health.

@HITSConsortium on Twitter

HITS Consortium on LinkedIn

Related and/or Mentioned on the Show

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Check out all the #HCBiz Show! Infection Prevention and Control coverage.

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