Specifications for cleanliness in hospitals: PAS 5748

In June 2011 the British Standards Institution (BSI) published the Publicly Available Specification (PAS) 5748:2011, a specification for the planning, application and measurement of cleanliness services in hospitals. The PAS is for the use of healthcare organisations in England and may additionally prove to be of value to healthcare organisations across Europe and worldwide.

The specification was sponsored by the Department of Health (DH) and the National Patient Safety Agency (NPSA) in England.

The PAS was written by an independent consultancy, headed by David Griffiths, specialising in assisting healthcare organisations to improve the provision of cleanliness and other facilities, including management services. However, leading organisations involved in healthcare cleanliness have also contributed valuable inputs to the specification alongside David Griffiths, the DH and the NPSA.

These include:

• Association of Healthcare Cleaning Professionals (AHCP)
• British Institute of Cleaning Science (BICS)
• Health Estates and Facilities Management Association (Hefma)
• Infection Prevention Society (IPS)
• National Patient Safety Agency (NPSA)
• A total of 14 National Health Service Trusts, including both mental health and acute trusts.

Dr Liz Jones, Head of Patient Environment at the Department of Health, launched the PAS at the annual conference of the Association of Healthcare Cleaning Professionals and said: “PAS 5748 is a major milestone along the road to clean, safe hospitals and healthcare environments. It represents the culmination of a process to identify and standardise healthcare cleaning processes and procedures which started a decade ago.” 

Obviously then, this is intended as a landmark document for the NHS in England, and its very number commemorates the founding of the National Health Service on 5 July 1948 (5/7/48). 

This article looks at the aims of this new system, the rationale behind its development, what challenges its implementation will create for healthcare organisations and how its principles might be employed beyond England.

PAS 5748 seeks to provide healthcare organisations with a risk-based system with which to critically evaluate, plan, apply and measure cleanliness provision.

All healthcare organisations will always need to provide a clean and safe environment in which clinical activity can take place. In recent years, the main driver for doing so has been the contribution that a clean environment can make towards the control of infection. While this is clearly very important, it should not be forgotten that a visibly clean environment, especially in publicly accessible areas, is vital to the promotion of public, staff and, crucially, patient confidence.

In a genuinely innovative development, the PAS recognises and prescribes a system for weighting these very different risk factors and includes control of infection risk and public/patient confidence risk. This innovation will be discussed in more depth later.

The PAS further seeks to be a widely-recognised standard that will demonstrate that complying organisations recognise cleanliness as a key priority and have a systematic and auditable approach to its achievement. It is expected that compliance with PAS 5748 will be used by purchasers and users of healthcare services to help inform their choice of which organisation to use.

It is important to stress that PAS 5748 has not arrived ‘out of the blue’. It is, rather, the culmination of many years of work in this challenging area. Specifically, it builds on the experience and content of the NPSA’s ‘National Specifications for Cleanliness in the NHS’ (NSC), the most recent version of which was published in April 2007. Healthcare organisations will remain free to continue to use the NSC, although it will no longer be updated by either the NPSA or DH. 

The new PAS is expected to be used in conjunction with May 2009’s ‘Revised Healthcare Cleaning Manual.’

The PAS also draws on work from the management of cleanliness performed outside of a specifically healthcare setting and is consistent with the existing British Standard for the measurement of the quality of cleaning services (BS EN 13549:2001).

So what exactly does PAS 5748 do? Essentially, it provides a detailed methodology for:

• the governance of cleanliness provision
• the assessment of cleanliness risk
• the planning and provision of the performance of cleaning tasks
• the measurement of cleanliness
• the implementation of corrective actions
• the analysis of performance and the implementation of systematic improvements to cleanliness provision
• the reporting of cleanliness performance.

So, for example, with regard to governance, PAS 5748 clearly describes the way in which a healthcare organisation wishing to conform to the specification must document:

• its cleanliness policy
• the accountability of named persons for cleanliness within each ward or department
• the accountability of named persons for the provision of cleaning services performed by a group of staff, such as nurses, cleaners and estates personnel
• cleaning method statements, work schedules and pro formas.

As mentioned earlier, the innovative approach of PAS to the assessment of cleanliness risk is perhaps the clause likely to attract the most attention. The PAS describes, in detail, the required risk assessment methodology. In a breakthrough synthesis of previous practice, the framework gives equal value to infection control risk on the one hand and public, patient and staff risk on the other. Moreover, the framework is subtle enough to recognise that an element (any item which needs to be cleaned) may carry a different risk rating dependent on where it is located.

The expectation is that this will arm healthcare organisations with a standard, state-of-the-art risk assessment tool that will permit it to make an accurate assessment of the actual cleanliness risk which exists in each area of each organisation and to use this information to make informed and detailed decisions about frequencies for the performance of cleaning tasks and for monitoring of cleanliness outcomes. 

Clearly a major driver was to give healthcare organisations a tool that would allow them to make an informed decision about the allocation of resources required in their particular hospitals to mitigate the cleaning risk identified there. The aim is to move away from the ‘one-size-fits-all’ centrally-imposed directive that was a characteristic of previous English specifications for cleanliness, culminating in the NPSA’s publication of 2007.

Those specifications sought to generally drive up cleanliness standards. While they did not impose precise standards as such, they included what were styled ‘indicative aims.’ We are now witnessing a development in approach. This recognises that a more detailed and location-specific approach is needed, recognising that each healthcare organisation is itself best placed to assess its own particular risks and to decide how most effectively to mitigate them.

In light of this, it is expected that PAS 5748 will be particularly attractive to healthcare organisations that want to sculpt service delivery in a way that is appropriate to their own local requirements within a widely-recognised framework.

Moreover, it is highly likely that patients making an informed choice about which healthcare organisation to use will use cleanliness as part of their decision-making process. The new specification, which carries with it the prestige of the BSI and of the sponsoring and contributing bodies, is likely to assist healthcare organisations compliant with the PAS in giving confidence to and attracting potential patients.

Representatives of the DH, NPSA and BSI identified a potential need for an unambiguous specification carrying the weight and prestige of each body.

A series of study days was set up to which a huge variety of stakeholder organisations were invited. From these initial study days, the basic outline of the new specification was developed. A steering group was then set up, comprising the DH, NPSA and BSI representatives of key stakeholder organisations and the technical author, and, from here, a series of drafts were developed.

These early drafts were governed by clear principles set by the steering group. One such principle was to retain the best elements of the existing specifications and where changes did prove necessary, to keep them to a minimum. So, for example, the familiar basket of 49 representative measured elements (items whose cleanliness is measured) was kept at a similar level, increasing to 50, and the composition of the elements was amended slightly to ensure that the new standard would be appropriate for use in mental health and continuing care as well as in acute settings. The result is that a familiar and recognisable concept has been retained but refined and improved upon.

Once the first round of drafting was complete a public consultation was conducted, and this drew in several hundred comments from a large range of stakeholders. In addition, an important series of trial implementations at the 14 participating NHS trusts was undertaken. Both processes fed into the content of the development of the document and led to a number of simplifications designed to make compliance with the specification easier to achieve. 

Finally, the draft was put through a further round of revision and designed to ensure total compliance with the BSI style and the ruthless removal of any potential ambiguity.

The systematic avoidance of ambiguity has clearly been an absolutely key priority throughout and, as stated earlier, was certainly one of the major factors which led the sponsors to seek to work with BSI at the commencement of the project.

This has a particular relevance for the auditing of cleaning. In just one example, the PAS makes it quite clear that ‘the cleanliness of each scored element shall be assessed as it appears on first inspection. If the element does not conform to the cleanliness criterion, it shall be scored 0, irrespective of whether it is immediately cleaned thereafter.’

Moving to the more tightly specified process set out in the PAS will provide trust boards with the challenge of agreeing a cleanliness performance level for the organisation. So that patients and the public can be assured that high standards are being maintained, the PAS also requires that information about the achievement (or otherwise) of that level be made available on request. This will pose one of several challenges to implementation.

What other issues will impact on implementation? 

As we have seen, the specification is very clear, so interpretation and ambiguity should not be a problem. However, the process of implementation will require a root and branch review of current cleaning service delivery, and the governance, risk assessment and documentation processes will require commitment and input at senior and operational level within organisations. It is anticipated that implementation of the provision of this PAS will be entrusted to appropriately qualified and experienced people.

The PAS 5748 will, in all likelihood, be used by the majority of healthcare organisations in England in due course. But what is its future elsewhere? Right now, it is difficult to say, but the launch has already created considerable interest well beyond England. It seems likely that the PAS will be of the greatest immediate interest to healthcare organisations in Europe, and it is probable that many will wish to use this without necessarily complying with the full governance requirements. Other European healthcare organisations may, however, wish to follow requirements more fully. Either approach would be warmly welcomed by the creators of the PAS.