PAS 5748:2011, Specification for the planning, application and measurement of cleanliness services in hospitals

BSI, the Department of Health and the National Patient Safety Agency have developed a new specification for cleanliness in healthcare facilities. Publicly Available Specification (PAS) 5748 provides a framework for the planning, application and measurement of cleanliness in hospitals. In particular, PAS 5748 specifies requirements for: Governance of cleanliness services Assessing the risk of a lack of cleanliness both for infection and damage to patient, public or staff confidence Providing cleaning tasks Measuring cleanliness on the basis of visual inspection – including setting agreed performance levels Taking corrective action Conducting performance analysis and implementing improvement actions Providing a continuous service improvement plan Reporting cleanliness outcomes. This document is available for free download to NHS staff in England Who does PAS 5748 apply to? Although this PAS has been developed for use in acute, community and mental health hospitals, it has been developed in such a way as to enable future revisions to accommodate other types of healthcare facility, whether NHS or independent providers. Who would benefit from using PAS 5748? PAS 5748 is intended to be endorsed at board level, and implemented by anyone responsible for maintaining cleanliness in hospitals Who is PAS 5748 for? This PAS is intended for those whose responsibilities directly or indirectly include the provision of a clean, safe, environment for patient care The regulatory context pf PAS 5748 The provision of a clean and safe environment for healthcare must be a key priority for all healthcare organizations. It is a foundation for infection prevention and control and promotes patient, public and staff confidence. The Health and Social Care Act 2008 established the Care Quality Commission (CQC) and set out an overall framework for the regulation of health and social care activities. Regulations made under the Act describe the activities that may be carried out by providers that are registered with CQC and set the registration requirements that these providers must meet to become, and stay, registered. National Health Service (NHS) bodies in England that provide regulated activities have been required to comply with the full set of registration requirements since 1 April 2010. Independent healthcare and adult social care providers of regulated activities were required to comply with them from 1 October 2010. Section 21 of the Health and Social Care 2008 enables the Secretary of State to issue a Code of Practice about the prevention and control of infections. The Code contains guidance about demonstrating compliance with the registration requirements for cleanliness and infection control set out in regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The law states that the Code must be taken into account by the CQC when it makes decisions about registration against the cleanliness and infection control requirement. The regulations also say that providers must have regard to the Code when deciding how they will comply with registration requirements. So, by following the Code, registered providers will be able to show that they meet the regulation on cleanliness and infection control. However, they do not by law have to comply with the Code. A registered provider may be able to demonstrate that it meets the registration requirement regulation on cleanliness and infection control in a different way (equivalent or better) from that described in the Code. The CQC is responsible for judging compliance with the registration requirements set out in regulations. When doing this for the cleanliness and infection control requirement, it will take account of the Code and how registered providers are doing what the Code says. It will do this in a way that is proportionate to the risk of infection. How does PAS 5748 fit into the regulatory framework? The PAS provides a process through which providers can demonstrate how they plan, apply and measure the effectiveness of cleaning services. It does so in a manner that can provide sound documentary evidence to the CQC that there are proper policies and procedures in place to support the provision of a clean safe environment for care. However, there is no requirement that providers must adopt PAS 5748. The existing national specifications for cleanliness (NSC), which to date have been the means by which the majority of trusts have demonstrated compliance with CQC registration, will remain in place. However, it should be noted that there are no plans for their further review or updating. Contents of PAS 5748 include: Scope Terms and definitions Governance Policy Accountability Documentation Risk assessment Responsibility Identification of functional areas and elements Risk assessment of elements Risk assessment of functional areas Overall risk assessment of each element in a functional area Cleaning tasks Responsibilities Identification Risk assessment of cleaning tasks Method statements Frequencies Work schedules Competence Contingency Measurement Cleanliness criterion Agreed cleanliness performance level Technical audit Managerial audit Board assurance visit System audit Corrective action Performance analysis and improvement action Continuous service improvement Reporting Functional areas Hospital Board Scored elements Risk assessment of cleaning tasks Example of a technical audit sheet template Bibliography