Considerations for Reducing Risk: Surfaces in Healthcare Facilities

Key points

  • Hospitals must maintain a clean environment and reduce germ exposure to keep patients, visitors and healthcare personnel safe.
  • There are six Core Components to creating and sustaining a clean, safe environment.

Core Components of environmental cleaning and disinfection

  1. Integrate environmental services into the hospital's safety culture.
  2. Educate and train all personnel responsible for cleaning and disinfecting patient care areas.
  3. Select appropriate cleaning and disinfection technologies and products.
  4. Standardize setting-specific cleaning and disinfection protocols.
  5. Monitor effectiveness and adherence to cleaning and disinfection protocols.
  6. Provide feedback on the adequacy and effectiveness of cleaning and disinfection to staff and stakeholders.


These Core Components are for noncritical surfaces that come in contact with only intact skin such as:

  • Beds
  • Handrails
  • Over-bed tables
  • General housekeeping surfaces such as:
    • Floors
    • Walls
    • Tables

These Core Components are intended for acute care hospitals. However, all healthcare settings, such as long-term care and outpatient facilities, could apply these with additional special considerations such as patient population.

Core Components

  • Establish a defined management structure with multidisciplinary participation and oversight such as:
    • Hospital leadership
    • Quality
    • Nursing
    • Purchasing
    • Facility management
    • Infection prevention and control (IPC)
    • Environmental Service (EVS) departments

This management structure should hold regular meetings to review practices and quality measures and establish or review facility goals:

  • Define program responsibilities, including but not limited to:
    • Implementing the Core Components described in this document.
    • Evaluating effectiveness of the program using data from clinical surveillance, the environmental monitoring program and the environmental cleaning and disinfection monitoring strategy (See Monitoring section below).
  • Establish and maintain a clear reporting and accountability structure for EVS personnel.
  • Develop a performance evaluation and career advancement structure for EVS personnel and management.
  • Incorporate considerations for effective cleaning and disinfection in the design, structure and layout of patient care areas.

All personnel who clean and disinfect reusable patient care equipment and environmental surfaces in patient care areas must understand their roles and responsibilities.

Administrators can provide education and training on:

  • Hospital cleaning and disinfection policies and following them (i.e., a trainer observes correct practices).
  • Basic concepts of transmission and infection control and patient safety impact.
  • Proper use of personal protective equipment (PPE), Safe use of chemicals, cleaning technologies and more.
  • Infection control risks and other aspects of worker safety.
  • Identify and address IPC gaps using facility infection rate data.

Administrators can ensure training is sustainable and regularly occurring by:

  • Training all EVS personnel upon hire, at least annually and when introducing new equipment or protocols. If contracted services provide the training, make sure that it meets facility requirements.
  • Keeping a record of competency for all personnel responsible for disinfecting patient care areas and reusable equipment.
  • Re-training personnel to address weaknesses discovered during routine monitoring activities or audits (see monitoring section below).
  • Accounting for variables like:
    • Staff turnover.
    • Education levels.
    • Language and cultural barriers.
    • Multiple learning styles.

  • Tailor and standardize cleaning and disinfection technologies and products to the setting as much as possible.
  • Use a systematic process to select technologies and products, including advanced technologies like no-touch disinfection devices for patient care areas.
  • Convene all stakeholders, including the facility cleaning and disinfection program, EVS management, IPC, Materials Management, and other relevant healthcare personnel (HCP) in the decision-making process for factors such as:
    • Compatibility with device manufacturer's instructions for use
    • Contact time.
    • Possible health risks.
    • Acceptability to HCP and patients.
    • Effectiveness in decontaminating a surface.
    • Impact on overall cleaning efficiency.
    • Required expertise and training.
    • Effect on surfaces or devices of repeated exposure to a product.

Identify standardized, setting-specific protocols for cleaning and disinfection, including use of technologies and products

  • Emphasize that surfaces, including high-touch surfaces, must be cleaned effectively, accounting for differences in room layout, equipment, and patient risk.
  • Clearly define responsibilities for the cleaning and disinfection of noncritical equipment, shared medical equipment, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile workstations, code carts, airway boxes).
    • Make sure that staff involved in cleaning and disinfection are aware of their responsibilities and are appropriately trained to fulfill them.
    • Make sure that cleaning and disinfection supplies are easily accessible (e.g., cleaning cart and patient care areas are adequately stocked).
  • Develop standardized protocols for routine (e.g., daily) and discharge/transfer (also known as terminal) cleaning and disinfection for each major patient care room type (i.e., intensive care unit or ward) or area type (i.e., operating room, emergency department, radiology suite).
    • Make sure that the protocols are readily available (e.g., posted online or available in hard copy) for review by staff.
  • Include in the protocols:
    • Appropriate PPE for EVS personnel.
    • Processes for routine and discharge/transfer cleaning and disinfection for specific pathogens (e.g., difficile, Candida auris, norovirus, multidrug-resistant organisms (MDROs)) and other patient-level factors (e.g., wounds, diarrhea).
    • Facility-specific cleaning and disinfection technologies, products, and methods.
    • Processes for easy identification of equipment and rooms that have been properly cleaned and disinfected and are ready for patient use (e.g., tagging system, placement in dedicated clean area).
  • Develop policies and procedures for storage of patient and visitor personal items, which can make it difficult to properly clean a room.
  • Make sure that the EVS team can identify which patient rooms are under transmission-based precautions, variations in cleaning and disinfection protocols that may be required and necessary PPE.
  • Establish the minimal cleaning time (MCT) for routine and discharge/transfer cleaning for each major patient care room type or area.
    • Define a process to establish MCTs, for example by observing standardized cleaning protocols performed by experienced personnel.
    • Align MCTs with staffing plans to ensure that effective cleaning and disinfection can be completed and sustained.
    • Disseminate MCTs so that others who are responsible for patient flow, such as bed control and nursing, are aware of them for each patient care area.
    • Enforce MCTs and empower EVS staff to require adherence to MCTs.
    • Track cleaning times to: identify factors that influence them; and assess the need for mitigating those factors or revising the MCT.

An environmental cleaning and disinfection monitoring strategy allows EVS personnel, other relevant HCP and the facility cleaning and disinfection program to understand the current state of facility cleanliness and to identify areas for improvement.

  • Develop and implement a monitoring strategy for adherence to, and effectiveness of, cleaning and disinfection procedures.
  • Include in the protocols for monitoring:
    • Who should do the monitoring.
    • What type of monitoring will be used (e.g., direct observation, fluorescent gel, adenoside triphosphate (ATP).
    • How frequently the monitoring will occur.
    • How monitoring data will be validated.
    • Which rooms will be monitored.
    • Which surfaces will be assessed.
  • Incorporate methods for monitoring cleaning adherence and effectiveness in addition to direct observation (e.g., fluorescent markers, ATP assays).
  • Perform routine audits of adherence to cleaning and disinfection procedures.

  • Share cleaning and disinfection monitoring data with EVS personnel.
  • Highlight the importance of shared accountability for consistent and successful adherence to protocols for staff including:
    • EVS personnel
    • Management
    • Facility leadership
    • Clinical personnel
  • Present monitoring data to leadership to identify, validate the effectiveness and troubleshoot active issues with the cleaning strategy.


EVS personnel are responsible for cleaning and disinfection of reusable patient care equipment and environmental surfaces in patient care areas. They can be directly employed by the healthcare facility, a contractor, or another management structure. Additional HCP are also often responsible for cleaning and disinfection in patient care areas.

The safety culture of an organization is the individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to health and safety management.

Noncritical environmental surfaces come into contact with intact skin, but not mucous membranes. They include:

  • environmental surfaces (e.g., bed rails, bedside tables, countertops, patient furniture, and floors)
  • patient care items and equipment (e.g., bedpans, blood pressure cuffs, IV poles, crutches, and computers)

Reusable patient care equipment are devices that HCP can reuse to diagnose and treat multiple patients (e.g., surgical forceps, endoscopes and stethoscopes).

Routine cleaning is the regular cleaning (and disinfection, when indicated) when the room is occupied to remove organic material, reduce microbial contamination, and provide a visually clean environment. Emphasis is on surfaces within the patient zone.

Critical patient care equipment are equipment and devices that enter sterile tissue or the vascular system, such as surgical instruments, cardiac and urinary catheters. They are not in the scope of this document.

Semi-critical patient care equipment are equipment, such as endoscopes, respiratory and anesthesia equipment, and vaginal ultrasound probes, that comes into contact with mucus membranes. They are not in the scope of this document.

Terminal (discharge/transfer) cleaning is cleaning and disinfection that is performed after the patient is discharged or transferred. Includes the removal of organic material and significant reduction and elimination of microbial contamination.