As a key strategy in preventing healthcare-associated infections (HAIs), environmental cleaning in healthcare facilities not only enhances patient safety by reducing the presence of pathogens in patients’ surroundings but also significantly impacts other important healthcare outcomes, such as patient satisfaction and healthcare cost.

However, it is increasingly evident that many cleaning practices act as a double-edged sword by producing unintended harmful effects on human health, as well as the environment.

Cleaning chemicals may cause human health effects, such as asthma and dermatitis, and contribute to environmental pollution and ecosystem deterioration. In addition, cleaning staff also may suffer from musculoskeletal disorders associated with certain cleaning procedures (Markkanen, Quinn, Galligan, & Bello, 2009).

Green cleaning—A systematic approach
A growing number of health organizations are increasingly engaged in green cleaning or sustainable cleaning, a new interdisciplinary and systematic approach to cleaning in healthcare. This systematic approach involves the integration of a variety of cleaning methods, including the selection of green benign cleaners and other green products, optimizations in building design, and improvements in operations (see Figure 1 in the file attachments at the bottom of this page).

The aim of green cleaning is at least three-fold: (1) to maintain environmental cleanliness and prevent HAIs; (2) to protect patients and staff from potential harmful health effects of certain cleaning products and procedures; and (3) to reduce environmental impact and enhance sustainability.

The implementation of green cleaning at a particular healthcare organization is influenced or shaped by external and internal factors, such as federal or state regulations and hospital infection prevention culture. The success or effectiveness of green cleaning should be measured against its multiple goals.

HHI green cleaning project
With the development of green cleaning, it is increasingly urgent to examine current common practices of green cleaning and evaluate the effectiveness of these practices based on empirical data. In order to promote research in this area, The Center for Health Design (CHD) engaged with Health Care Without Harm (HCWH) and the Healthier Hospitals Initiative (HHI) to launch a Pebble research project.

Under the guidance of an advisory committee comprised of industry experts, the CHD research team conducted interviews with five major hospitals across the country to examine the components, implementation, and effects of their green cleaning programs. The team also conducted an online questionnaire survey to gather opinions regarding high-priority research questions on green cleaning.

The case study and questionnaire protocols were developed based on the conceptual framework of green cleaning, as shown in Figure 1 (found in the file attachments at the bottom of this page), and were tested and modified according to feedback from the advisory committee.

Case studies
Five hospitals voluntarily participated in the case study interviews. The facilities included:

Green cleaning practices
The five hospitals began to implement green cleaning at various points in time within the last 10 years. Eight green cleaning practices in three main categories—selection of cleaning products, operational changes, and building design—were implemented at the five facilities. As shown in Table 1 (found in the file attachments at the bottom of this page), some practices have been more commonly adopted than others. All facilities have engaged in a systematic approach by adopting practices in multiple categories.

Selection of green cleaning products
All five facilities sought to select and use certified green cleaners with a smaller amount of harmful ingredients. However, variations existed at different facilities in the percentage of cleaners used that were considered green. In some facilities, almost all cleaners used were certified as green cleaners. In other facilities, only one or two green cleaners were used.

Another widely adopted cleaning product was the microfiber mop that cleaned the floors more efficiently than traditional string mops, used less chemical and water, and helped reduce the risk of musculoskeletal injuries.

Less adopted but promising methods included several types of cleaning machines or devices using new technologies, such as electronically charged water. Only one facility made efforts to minimize the number of chemicals for the purpose of addressing hypersensitive issues and reducing long-term accumulative effects.

Operational changes
Three facilities recognized the potential risks involved in the use of harsh chemicals to over-clean areas, such as administration departments, where infection risks were low. Therefore, one important operational change at these facilities was the determination of appropriate levels of cleanliness in different clinical and service areas to avoid unnecessary overuse of strong chemicals.

Two facilities focused on optimizing methods of applying and dispensing cleaning chemicals (squeezing or pouring chemicals on cloth instead of spraying) to reduce indoor air pollution resulting from the aerosolization of chemicals. At one facility, innovations like fluorescent markers helped provide critical objective feedback to improve the performance of individual cleaning staff members.

Building design
All facilities endeavored to use appropriate surface finish materials, especially flooring materials, that were easy to clean and maintain so that chemical cleaning, stripping, and waxing could be minimized. Many facilities expressed interest in using and evaluating new, more desirable flooring materials but were hindered by the lack of research evidence to support decision-making.

Other building design methods of facilitating environmental cleaning as well as reducing unnecessary chemical use included the use of floor mat systems at building entrances, the reduction of horizontal surfaces, movable furniture, efficient ventilation and filtration systems, and layout design that facilitated environmental cleaning.


Implementation of green cleaning
Consistent with the systematic approach shown in Figure 1, the green cleaning efforts at one particular facility were typically led by a multidisciplinary team including representatives from infection prevention, environmental cleaning, purchasing, facilities management departments, and others. The success of a green cleaning program relied on the strong s
upport of hospital administrators as well as front-line staff members.

Sometimes staff’s resistance to moving away from the traditional approach posed a challenge to implementing certain green cleaning practices, such as microfiber mops. This challenge was effectively overcome through the combination of multiple methods, including the engagement of cleaning staff in focus group discussions with infection prevention personnel and vendors, removal of traditional mops from the work environment, and explanation of personal benefits.

Another challenge was the lack of publicly available research evidence regarding the effectiveness of the proposed green cleaning products and practices. Facilities often needed to conduct trials in small areas and obtain information from vendors in order to inform decision-making.


Evaluation of green cleaning
The empirical evaluation of different green cleaning practices is extremely important because of the lack of existing research. However, the case study facilities rarely conducted regular monitoring and evaluation of the effectiveness of the implemented green cleaning products and practices.

Although some relevant data, such as infection rates and patient satisfaction scores, was probably collected for other purposes, this data was not easily accessible and, therefore, not routinely used to evaluate the effectiveness of green cleaning.

Evaluation methods used to test new products or practices before implementation falls in several categories: methods directly measuring the effectiveness of cleaning, such as adenosine triphosphate testing, fluorescent markers, and culturing; the use of existing data, such as staff injuries; costs analysis; patient surveys; and so on.

Although reliable post-implementation data was lacking, anecdotal reports indicated that green cleaning was effective in saving water and chemical, reducing complaints about odors and health issues, and preventing HAIs.


Questionnaire survey
A total of 150 individuals responded to the online questionnaire survey, representing a wide range of stakeholders, including environmental service managers, physicians, nurses, other healthcare staff, sustainability consultants, manufacturers, and students.


Key components of green cleaning
The selection of cleaning products, operational changes, and building design were identified by respondents as the key components of green cleaning. However, operational changes and building design were only recognized by a very small portion of the respondents (16% and 2%, respectively).

Green cleaning was still largely perceived as a practice of selecting and using green cleaners or other cleaning products. The vast majority (93%) of respondents identified the reduction of toxicity and harm as a criterion in selecting cleaning products. Other criteria for selecting products included the effectiveness of HAI prevention and the amount of waste, recycling, and resource use. 


High-priority research topics
According to survey respondents, it is clear that research efforts should focus on the effectiveness of green cleaning in terms of infection prevention, environmental protection, and the reduction of harmful human health effects (see Figure 2).

The impact of green cleaning on preventing infections was by far the most important topic. In addition, the development of standard evaluation methods and a standard definition of green cleaning were identified as important research foci to enhance the quality of research in this area.

The balancing of multiple factors around green cleaning (e.g. infection prevention, environmental impact, health effects) for decision-making was recommended as a key focus area by the survey respondents. Sample research questions included: 

  • What are the most effective cleaners with the least toxicity for cleaning areas with high infectious potential?
  • Is [green cleaner] less expensive (including all materials needed to be used with it, e.g., reusable cloth, disposable cloth, reusable mop, disposable mop), but able to perform or outperform currently used cleansers?


Green cleaning is a systematic approach that integrates multiple methods—including selection of products, operational changes, and building design—to achieve the balanced optimization of patient, worker, and environmental safeties.

Healthcare facilities are increasingly adopting innovations in technology, design, and operations to make environmental cleaning more sustainable. There is an urgent need to systemically evaluate the effectiveness and efficiency of the green cleaning products and practices to inform decision-making. HCD

The paper was based on the material collected for a Pebble research project sponsored by the Healthier Hospitals Initiative. The full research report is available at:

We are grateful for the support from Health Care Without Harm and the Healthier Hospitals Initiative. We also would like to thank case study interviewees and questionnaire survey respondents, as well as the members of the advisory committee. Special thanks go to Janet Brown and Nancy DellaMattera for their help with online survey distribution.



Markkanen, P., Quinn, M., Galligan, C. & Bello, A. (2009). Cleaning in healthcare facilities: Reducing human health effects and environmental impacts. Health Care Research Collaborative Paper Series.

Lowell Center for Sustainable Production. Lowell, MA: University of Massachusetts.