A lack of oversight of environmental cleaning and cleaners by IPC staff at hospitals was noted, as well as a lack of relationship (e.g., coordination, collaboration) between clinical staff and cleaners at the unit/ward level. In Nigeria and Vietnam, lack of oversight (outsourced in both settings) was described as a barrier to making improvements. In Nigeria, the IPC team did not have input into the contract terms, which prevented any influence on the training required for cleaners as well as any ability to provide recommendations on the type and quality of cleaning products, supplies and equipment in use. In Vietnam, while overall there was more engagement by the hospitals’ IPC teams in the cleaning contract process (e.g., the hospital cleaning policy was used to inform the bidding process), there were gaps identified in the quality of routine monitoring which was led by the vendor with no role for the IPC team.

A disconnect of clinical staff from the environmental cleaning process and workforce was also identified. In Nigeria, Cambodia and Tanzania, some of the clinical staff participating in the project reported that, prior to the project, they had under-appreciated that environmental cleaning and cleaners played a role in patient safety within their departments. Lack of clarity on roles and responsibilities between cleaners and clinical staff and the impact on performance was also highlighted. At one hospital in Vietnam, while vendor-provided cleaners had been previously trained, the project team helped identify that the clinical staff on the unit with equipment cleaning responsibilities had not received any standard training on these duties. In the hospitals in Cambodia and Tanzania, there was a similar barrier encountered in terms of ambiguity around who cleans what, between clinical staff and cleaners.

To address the disconnect between IPC and environmental cleaning, an important facilitator was hospital leadership engagement. In Vietnam and Nigeria, leadership and administration supported IPC teams to either develop or update existing environmental cleaning policies and committed to aligning cleaning service contracts with these policies moving forward. In Vietnam, leadership also supported the IPC department to collaborate with the vendor to refine monitoring requirements and develop systems for sharing monitoring results between the vendor and the hospital IPC department. This new connection also allowed the IPC department to train the vendor on monitoring methods to improve the quality of the data collected. In Nigeria, leadership support of the project even extended to participation in the large training initiative, wherein the Chairman Medical Advisory Committee addressed trainees. Clinical staff, including nurses and unit leadership, also participated in the training in Nigeria, which helped improve awareness and engagement of these staff in environmental cleaning and the workforce. In Tanzania and Cambodia, leadership support was also critical, particularly in supporting clinical staff to take on the role of linking IPC and environmental cleaning—becoming so-called “champions”. These individuals were the first to be trained and then trained the cleaners at their hospitals. Crucially these champions also provided continuous supportive supervision with tools such as observation checklists, florescent gel monitoring and updated cleaning schedules. In Tanzania, the inclusion of nurses/midwives in the training at each hospital also helped to achieve a common understanding of cleaning standards and fostered better relations with the cleaning staff. Additionally, in Tanzania, for example, during feedback of results to Ministry of Health stakeholders, the importance of integration with the “five-star quality improvement system” was highlighted (Yahya & Mohamed, 2018).