All indications are that COVID-19 survives for days on hard surfaces and possibly even soft ones. So, once doctors and nurses undertake their heroic work to save a patient’s life, someone has to mop the floor and wipe the room down, not missing a single drawer handle, light switch, or doorknob.
This responsibility falls to “environmental service” or EVS workers, the label that health care administrators apply to hospital cleaners. And, roughly one-quarter of EVS workers are employed not by the facilities in which they work, but by a contract cleaning agency. As others have reported, this has grave implications for the health of these workers. But actually, these seemingly mundane employment arrangements could make us all sicker.
My research, undertaken before the spread of the coronavirus, shows that hospitals that outsourced their cleaners reported nearly twice as many patients contracting one particularly deadly “superbug” called Clostridium difficile, or C. diff., during their hospital stay. That these differences remained even holding steady hospital and patient characteristics implies that hospitals with contracted cleaners were simply not kept as clean.
We know much more about C. diff. than we do about COVID-19, but we also know that, in some ways, they are very similar. Both linger, in the absence of proper cleaning, on surfaces, and can be deadly. For perspective, the president now concedes that 100,000 Americans could succumb to the coronavirus; according to the Alliance for Aging Research, 99,000 Americans die every year from C. diff. and other hospital-acquired infections like it.
In both cases, the best cure is prevention. For C. diff., that means sharing research-based best practices with cleaners and then providing them the recommended disinfectants to follow protocol. Soap is not enough.
So, why would outsourcing cleaners increase infections? We find that when hospitals outsource cleaning, they cede managerial control of EVS workers. This limits hospitals’ ability to comply with evidence-based infection control standards and requirements. It also hinders hospital administrators’ efforts to coordinate the complex work required to deliver safe, high-quality care.
Despite some hospitals’ efforts to make contractor-employed cleaners feel like employees, administrators often inadvertently exclude agency workers from formal and informal communication and training. That means that contracted cleaners are not kept apprised of frequently changing standards for sanitizing a COVID-19-infected room. They are also functionally and socially divorced from the rest of the care team, excluded, for example, from regular morning huddles.
In our research, the decision to outsource cleaning was driven by costs— not quality. The cleaning agencies selected are those that can somehow maintain a revolving army of cleaners despite paying bargain basement wages and depriving workers of fringe benefits — namely health insurance and paid sick days. This drives sky-high turnover, further discouraging investments in disinfection training. Rapid churn also ensures these workers have little sustained interest in unionizing.
So, contracted cleaners tend to be underpaid, undertrained, and detached from the core work hospitals must undertake during a pandemic. When they display COVID-19 symptoms, they cannot afford to take off from work. Even when they can access free testing, they cannot afford proper medical care — unless they are “lucky” enough to make so little that they qualify for Medicaid. Many do. But even Medicaid won’t pay for missed days of work.
Hospitals are not obligated to report the employment status of anyone working in their facilities. Consequently, under current rules, neither policymakers nor prospective patients can determine how many or which hospitals outsource cleaners, and thus, which hospitals are less likely to be properly sanitized.
These days, many hospital administrators probably regret having relinquished control of the EVS function. Accordingly, policymakers should seize the moment to mandate that all hospitals treating COVID-19 patients reassume the direct employment of those filling non-licensed roles in their facilities. Providing these workers the same protections as their co-workers not only protects an extremely vulnerable group of workers. It also promotes public health.
Once we conquer this pandemic, health care policymakers should reform payment systems to encourage “high-road” employment models and to make crystal clear that outsourcing’s apparent upfront savings are dwarfed by the social costs arising from poorer infection control. They can also reform employment policy in the sector by discouraging the use of third-party workers for non-licensed health care roles and protecting frontline workers’ rights to organize.
We probably all consider essential those on the frontlines charged with containing the spread of COVID-19 or caring for those already afflicted. But too often, our mental picture excludes jobs like those of cleaners and janitors. As it turns out, in times like this, we do so at our own peril.
Adam Seth Litwin is an associate professor of industrial and labor relations at Cornell University. He is the lead author of “Superbugs versus Outsourced Cleaners: Employment Arrangements and the Spread of Health Care–Associated Infections,” which appeared in the Industrial and Labor Relations Review. Follow him on Twitter @ProfASLitwin.