At the Experience Convention and Trade Show in Las Vegas, Dr. Gavin Macgregor-Skinner, Senior Director of ISSA, and RJ Patel, founder of PCT Clean and PCT Janitorial in Atlanta, described how a four-stage exploration, preparation, implementation and sustainment (EPIS) framework outlines stages of evidence-based cleaning procedures that helped a children’s hospital in Suva, Fiji, significantly improve how they clean. The hospital, which conducts open-heart surgery, went from using old bed sheets as cleaning rags to completing nearly 500 surgeries without a single infection.

The hospital treats children with congenital heart disease from across the Pacific islands at no cost, supported by a nonprofit with which Macgregor-Skinner and Patel work. When the two first visited in 2023, the facility had no formal cleaning protocols.

“We didn’t comment. We listened,” Patel said of that first visit. At the time, the staff was doing the best they knew how with what they had, and the team’s first job was to understand that before suggesting anything different.

The EPIS framework is an implementation-science model that helps organizations move an evidence-based practice from a promising idea to a lasting part of everyday operations. Its four phases are:

• Exploration: when an organization identifies a need and considers possible solutions
• Preparation: when leaders and front-line staff plan resources, responsibilities and local adaptations
• Implementation: when the practice is introduced, monitored and refined
• Sustainment: when the organization works to maintain and improve it over time

EPIS also recognizes that success depends on internal factors such as leadership, staffing and organizational culture, as well as external factors such as funding, regulations and community needs. The phases are not always linear, and teams may return to an earlier phase as new information reveals what is—and is not—working.

Starting with what nobody notices

Rather than handing the hospital a manual on day one, Macgregor-Skinner and Patel picked a low-profile starting point: bed rails. The two began by using an ATP meter. This device helps verify cleanliness in real time by measuring adenosine triphosphate, a universal energy molecule found in all living things and organic residues. The hospital cleaning staff did an ATP swab test on a bed rail before cleaning. The reading came back at 9,158 relative light units (RLU), far above the generally accepted safe threshold of 500 RLU for this particular ATP meter. A staff member then cleaned the same rail with a dry 300 grams per square meter (GSM) microfiber cloth under the team’s guidance. The retest came back at 30 RLUs, a 99.67% decrease.

“If you don’t have a structured framework, then all you’re doing is making stuff up,” Macgregor-Skinner said. “What we want to do is give people a framework so they can defend the decisions they make. To make real changes in how you clean, the EPIS framework provides a process to determine what works and what doesn’t.”

Turning numbers into buy-in

With hospital staff now seeing the difference cleaning with microfiber made and using an ATP meter before and after cleaning to show how effective their cleaning was, the team moved into preparation. They mapped out how many microfiber cloths each hospital zone would need and priced it out so leadership could weigh the cost against their budget before committing.

They also introduced a color-coded system borrowed from infection-prevention programs already used in the hospital, but not for cleaning: red, amber and green zones marking high-risk surfaces and equipment in rooms throughout the hospital. The hospital’s infection-control team already tracked those zones using colors to identify different risk levels. However, cleaning hadn’t used the same system, and, during the EPIS Preparation phase, the team adapted an intervention already in use in the hospital. On subsequent visits, the team evaluated the EPIS implementation and sustainment stages. On a follow-up visit, the hospital cleaning team identified laundry problems with their microfiber cloths. The group then engaged senior management on how to wash and care for microfiber, and the hospital stopped combining different colored cleaning cloths in a single laundry load, since separating equipment by zone does little good if it all gets washed together. The new laundry process was: Do not wash all the colors together, and do not sort microfiber cloths only by color. Sort them by for what they were used.

A menu the staff wrote themselves

For implementation, the hospital built its own cleaning menu around the color-coded, traffic-light system rather than having one handed to them. Staff began testing many additional surfaces with the ATP meter on their own; this is the EPIS exploration stage. They watched readings drop from an initial 5,351 RLU before cleaning to below the 500 RLU threshold after cleaning and beyond as they refined their process.

The testing also surfaced problems the team hadn’t set out to find: The hospital used more chemicals and water than necessary and used cleaning products and disinfectants in ways that added risk for patients. Staff started using printed, visual job aids and checklists on the cleaning carts so cleaning steps didn’t rely on memory, and the team introduced other tools, such as ultraviolet flashlights, so staff could inspect surfaces themselves and adjust cleaning frequency as needed.

What the numbers eventually showed

The contrast became clear during one of the team’s visits, when a local newspaper reported a superbug multi-drug-resistant bacteria outbreak at another nearby hospital. When one hospital has a problem, it could put others in the area at risk. The children’s hospital increased its vigilance, maintained its cleaning processes and tested surfaces before and after cleaning as an early-detection surveillance system. Since 2023, the children’s hospital has completed nearly 500 life-saving heart surgeries at no cost to the patients from Fiji and neighboring Pacific island nations such as Samoa, Tuvalu, Tonga, Vanuatu, Kiribati, and the Solomon Islands.

“EPIS is an evidence-based framework for making real, sustainable changes in the cleaning industry, saving lives, cutting costs and increasing return on investment,” Macgregor-Skinner said.

Beyond one hospital

The pair said the same four-stage approach has been applied well outside health care, from hotels and supermarkets to schools, universities and airports. The bigger shift, they said, is less about products and more about treating custodial staff as informed decision-makers rather than people told what to do. Details on the hospital’s improvement work, along with a related research article on evidence-based cleaning, are available through ISSA.