About this series

This series of tutorial articles is a joint project of the Association for the Healthcare Environment and Health Facilities Management.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS scores are included among the measures to calculate value-based incentive payments in the hospital value-based purchasing program. The survey's goals include producing data about patients' perceptions of their care as well as creating new incentives for hospitals to improve quality care through public reporting.


To understand the nurse's perspective on improving the patient satisfaction scores that relate to the care of the environment, it is important for hospital environmental services (ES) professionals to be aware of the foundation from which the nursing delivery model of health care has been formed as well as the role that the environment has on the overall healing aspects of patient care. Understanding that cleanliness of the environment is a patient care function that originally was part of the nurse's role and now includes ES staff and infection control professionals will help collaboration efforts to improve patient satisfaction scores.

But the first and foremost goal of nurses isn't to increase a patient score related to perception. Instead, it is to provide the safest, best care possible for patients with the resources at hand. Once this has been accomplished, the nurses' second goal is to help the patients realize that the first goal has been met.

So, obviously, nurses cannot begin by reviewing HCAHPS scores nor develop strategies for changing how they provide patient care based solely on rankings and percentiles of patient perceptions. Instead, it begins with making sure they are providing the safest and best care for their patients and then using the patient perspective scores as one means among many to measure overall care when looking for improvement opportunities.

Back in time

What if ES professionals could forget for a moment the quest for achieving perfect HCAHPS scores, forget the pressure from administrators to achieve higher "top box" results on what may be a handful of patient comments, forget the push to create the "illusion of excellence" when given the resources for "status quo" and move back in time to when the foundation of the professionalism in nursing was born?

Tremendous changes have come to health care regarding the responsibilities placed upon the nursing staff. These changes have resulted in many duties that were once part of the professional nurse's role being delegated to staff, such as infection prevention and control, or to technical staff such as nursing assistants, patient transport and the ES staff. Even though these responsibilities are being shared with other members in the organization, they are still part of the overall patient care picture that is shared by the team, which is led by the registered nurse.

When it comes to environmental cleaning in patient care areas, it is impossible to separate the roles of nursing, infection prevention and control, and ES. All staff members are working together for the good of the patient and this area of their care requires the overlap of these specialists.

This overlap has evolved over the past 150 years. By the mid-1850s, the world of health care was no better than the centuries before. But in several parts of the world at nearly the same time, many changes and discoveries were taking place.

One of these places was in Europe. The Crimean War was raging and the human cost was immense. With a death toll estimate of 25,000 British, 100,000 French and up to a million Russians, almost all were caused by disease and deplorable care. In fact, the health care that anyone received was deplorable during those days and it was a well-known fact that the wealthy did not frequent the hospitals, only those too poor to pay for care in their homes would be found in such squalor. The chance of surviving childbirth during these times was much less for a woman who delivered in a hospital than a woman delivering outside the hospital.

Florence Nightingale was a young woman at this time. Born into an affluent family in England, she attended the best schools and was well-traveled for her years. She felt a strong calling to be a nurse, but this was much against her parent's wishes. Eventually, though, her perseverance won and, despite her family's wishes, she and other nurses joined the troops during the Crimean War. The conditions were deplorable for these injured soldiers and Florence began making changes that included training staff and demanding supplies to care for the injured. She began a journey that would forever change the way health care would be delivered.

During her service in the war, Nightingale conducted surveillance studies on diseases, wounds and deaths. She used her statistical skills to compile epidemiologically sound data that showed that most of the casualties were due to bad or nonexistent sanitation in the barracks. She made her data simple and tangible using a special graphic representation known as "Nightingale's Coxcomb." The graph effectively demonstrated the root causes of deaths. This was the beginning of the change in nursing and health care that would spread around the world.

It is very important to remember that there wasn't an understanding of how germs and communicable diseases spread or how to treat or prevent infections. Nightingale developed theories about how things occurred and, over time, published them, making her the first nursing theorist in history.

In fact, she is considered the founder of educated and scientific nursing. She was the first hospital epidemiologist, using sound statistical methods, pie charts and graphs to drive practice change and support her theories. These theories still are studied today in the nursing education programs around the world, with many of the principles still in place.

Nightingale's theory

Her "Environmental Theory," which incorporated the restoration of the usual health status of the nurse's clients into the delivery of health care, is still applicable today, not only to the nursing profession, but to the ES profession in health care along with the infection prevention and control discipline.

Nightingale wrote that the "environment could be altered to improve conditions so that the natural laws would allow healing to occur." She wrote about this theory on "Environmental Factors" in her book Notes on Nursing: What it is, What it is Not (1860).

These 13 canons of theory became the backbone of the training for her nurses and continue to be used today as the training foundation for professional nurses throughout the world. They include the following:

Ventilation. The interventions for this canon include keeping the patient in a room that is well-ventilated and odor-free.

Warmth. This includes the interventions needed to maintain a warm environment for the patient.

Health of houses. This includes providing pure air, water, efficient drainage and cleanliness in the patient's environment of care.

Light. This promotes light in the patient's room that is adequate to help healing.

Noise. The interventions for this canon include avoiding sudden noises and disturbances that startle or awaken patients and keeping noise in general to a minimum.

Cleanliness of room and walls. These interventions focus on keeping the environment clean and include specifics on how this can be accomplished.

Bed and bedding. These interventions include comfort measures related to keeping the bed dry and linen wrinkle-free to promote healing and prevent complications.

Personal cleanliness. This canon promotes keeping the patients clean and dry.

Variety. This canon refers to an attempt at incorporating variety in a patient's room to avoid boredom and depression.

Chattering hopes and advices. This refers to refraining from gossip or discussing patient care with those who did not need to know. It includes not handing out advice that is without fact.

Taking food. This canon includes the documentation of the amount of food and liquids the patient ingests, and includes asking the patient for input into their food selection by asking their food preferences.

Petty management. This canon involves the continuity of patient care when the nurse is absent so the patient does not experience variance in the standard of care when a specific nurse is not on duty.

Observation. This includes instructions related to observing the patient objectively and documentation of these observations by the nurse.

The environmental factors posed great significance during Nightingale's time. Health care institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to patient needs.

Communicating care

It is reassuring to understand that HCAHPS questions for patients are based on such basic fundamental aspects of providing safe, effective care that promotes healing. But what are nurses, ES staff or infection preventionists doing to help patients understand that we are accomplishing these things to ensure a safe and clean environment?

This is where collaboration comes into play. This most often will include nursing care providers, infection prevention and control, ES, patient transport, facilities engineers and others who provide an extension of the basic nursing care that involves the patient care environment.

ES professionals should take advantage of the synergy that comes from working together. They can demonstrate to patients that the entire team is working to provide them with the safest, best care always, which includes the cleanliness and safety of the environment.

By working together to provide the safest care possible and helping the patient to realize this, a health care organization can see HCAHPS indicators reflect patient perceptions over time. By first having the health care team review the outcome and process measures to assure that the safest, best care possible is being provided, the care team can then work together to help patients realize how well they are cared for each time they come for their health needs.

Debbie Hurst, R.N., CIC, works as the program manager of the infection control department at Asante Rogue Regional Medical Center in Medford, Ore., as well as a private health care consultant. She can be contacted at debrashurst@aol.com.