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Karl Rinas, 61, who was treated for a bleeding ulcer at a Leamington, Ont., hospital last February, says he ended up wiping down the bathroom himself after his complaints about the dried liquid waste he found on the floor and toilet seat failed to get a reaction, but he worried about older, less mobile patients.

Despite all her efforts, Martin says she has no doubt that the antibiotic-resistant superbug Clostridium difficile infection her mother contracted soon after surgery was related to the hospital's level of cleanliness.

"I know everybody nowadays has to work more with less, but to me, a hospital should be absolutely clean," she said.

Of the respondents who wrote into the fifth estate's survey about being harmed in hospital, most said the harm was a hospital-acquired infection such as MRSA and C. difficile.

Unlike in the food industry, there are no standardized inspections for cleanliness in hospitals.

A World Health Organization report that compared Canada's infection data with that of 12 other wealthy countries found that Canada had the second-highest prevalence (11.6 per cent) of hospital-acquired infections after New Zealand — much higher than that of Germany (3.6 per cent) or France (4.4 per cent).

Is outsourcing to blame?Those who work in hospitals have pointed to the increased outsourcing of housekeeping in recent years as one reason behind the decline in hospital cleanliness that patients and hospital workers have observed

"There's no question there's been an impact on the quality of cleaning, and you can see that throughout the years as various hospitals have struggled with very high-profile superbug outbreaks," said Margi Blamey, spokesperson for the Hospital Employees' Union (HEU), which represents 41,000 hospital cleaning and support staff in B.C.

But health authorities in other countries are moving away from private cleaning services. Four years ago, Scotland reversed its decision to allow outsourcing of cleaning and catering services because it felt private contractors were not doing a good enough job keeping the spread of infections in check.

Blamey says as long as housekeeping is done on a for-profit basis, employers will reduce the number of staff and cut corners on staff training and cleaning supplies.

The Canadian Nosocomial Infection Surveillance Program is the closest thing to a federal overview that Canada has, but it relies on voluntary reporting by only 54 hospitals in 10 provinces, most of them teaching facilities, which, according to infection control experts, generally have higher infection rates than other acute care hospitals because they tend to see more seriously ill patients.

Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto's University Health Network, agrees that hospitals have fewer resources for housekeeping these days and have to concentrate cleaning on areas that are most likely to transmit bacteria — primarily the surfaces that multiple patients touch.

"I probably get more emails about dust bunnies in the stairwells than anything else in the hospital, and yet, we've done that for a reason. You're not going to catch anything from a stairwell, but you're going to catch it from your bed rails," Gardam said.

About two-thirds of hospital-acquired infections are preventable, Gardam said, but making a direct link between cleanliness and infection is not as straightforward as it might seem. Some hospital-acquired infections such as ventilator-associated pneumonia or central line-associated bloodstream infections have little to do with the hospital environment and can be controlled through proper protocols around equipment use. But a superbug like C. difficile is a lot trickier because it is hard to pinpoint its source.

Increasing cleaning staff on nights and weekends could also help. A typical medium-sized B.C. hospital that contracts out cleaning services has 24 cleaners by day but only four at night, says Blamey, and workers are often not backfilled when ill or on vacation.

"Bacteria don't care what time it is," said Gardam.

The infection expert says it doesn’t matter whether a private or public entity oversees cleaning; both have had problems with cleanliness. The bottom line is that hospitals generally undervalue the importance of cleaning staff, Gardam said.

"People don't really think of them as part of the team, but if you think about how infections are spread in hospitals, they're actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room."

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. It also wants fair wages and benefits for cleaning and food services staff to ensure against high turnover and gaps in training. The union also stated lay-offs and staff reductions would be a poor way to balance the budget.

"The cost associated with treating hospital-acquired infections, managing public relations fiascoes and defending lawsuits would defeat any possible savings while destroying the public trust." The Province of New Brunswick expects to have completed talks with a private contractor for the management of health-care cleaning and food services before the end of the year.

Bruce McFarlane, Health Minister Victor Boudreau's director of communications, said Friday that the province is "still in current discussions with the preferred proponent and we hope to have completed the process sometime this fall." McFarlane sent The Daily Gleaner an email statement Friday afternoon after the New Brunswick Council of Hospital Unions CUPE local 1252 released a 20-page document critical of the government's plan to privatize housekeeping, food services and porter services at hospitals. "We want to clarify that we are only outsourcing the management of the services," said McFarlane, who added that the ministry had not yet received the document.

"CUPE staff will remain in their union and will continue to be employees of the Province of New Brunswick." Norma Robinson, president of CUPE Local 1252, said she is "very concerned that the Liberal government is negotiating with a private firm to take over the management of food and cleaning services in the province's hospitals." Robinson said she's worried the move could lead to further privatization. In an interview with Brunswick News in April, Boudreau said the government wants to give the private sector a greater role in the province's health-care system.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. Calls made to Sodexo, Aramark and Compass were not returned by press time.

Those in charge of infection control need to examine what the situation is in their own hospitals and make the necessary changes to ensure standards are met and maintained. Canadians are fully justified in expecting hospitals to clean up their acts.

"They made decisions around staffing levels," Eoin Callan of the Service Employees International Union told CBC News. "They made decisions around what was cleaned, what was not cleaned — how frequently things were cleaned. And they also had an incentive to use cheaper diluted cleaning chemicals that were not as effective because it allowed them to pad their profit margins."

About one-third of hospitals in Ontario outsource their janitorial services, CBC News has learned, and that figure is higher in British Columbia and some other provinces.

VIHA says the new contract with Crothall raises cleaning standards, increases staffing levels, creates a specialist outbreak cleaning team, enhances monitoring processes and introduces more patient and staff satisfaction surveys.

Mike Old, spokesman for the Hospital Employees' Union, said the union supports the decision of the health authority to retain the experienced workers who currently clean the facilities."Our concerns about crushing workloads for cleaning staff have been recognized through a commitment to higher staffing levels in this contract," Old said.

Improper cleaning methods and insufficient cleaner strength had a significant effect in an 11-month C-Difficile outbreak at Nanaimo Regional General Hospital that infected 94 people and killed five which started in 2008.

Compass employees lacked proper training to use toxic chemicals that caused hair loss, nose inflammation, respiratory problems and skin irritation, according to two failed WorkSafe B.C. inspections issued in 2008 and 2009.

Workers used ineffective cleaners. Staff over-diluted bleach cleaner and later needed to switch to a soil-lifting detergent that would remove the virus from surfaces.

If the housekeeping fails on any of the new measures during monitoring, financial penalties will be applied.

In April last year, VIHA said it was getting rid of Compass and signing a new contract with Marquise to provide housekeeping and food services at residential care facilities on the south Island - Glengarry, Mount Tolmie, Aberdeen, Gorge Road and Priory Hospital - as well as Queen Alexandra Centre for Children's Health and Saanich Peninsula Hospital. But before the ink on the contract was dry, Marquise was bought by Compass.

Compass has three of its divisions working in VIHA's contracted sites: Crothall Services, providing housekeeping services; Morrison, providing food services; and Marquise Group, providing both food and housekeeping services in residential care facilities.

The Tories issued a request for proposals to take over the management of cleaning, hospital porters and food services. Opposition leader Bruce Fitch said Friday the Tories did not proceed any further than signing a request for proposals for the privatization idea. "We are looking for the details like everyone else as to how they will go forward with this," Fitch said. Until a deal is final, Boudreau will not reveal the name of the company the government is negotiating with, but CUPE, which represents cleaning and food staff, said it was told that food and facilities management giants Sodexo, Aramark and Compass Group are involved in the bidding process.

CUPE spokeswoman Norma Robinson said the union was told the government is seeking a 10-year contract and is negotiating with Sodexo to reach a deal in the next three to six months. If unsuccessful, it will then approach Aramark and Compass, according to Robinson. Boudreau was asked about an issue involving one of the companies when its contract was cancelled a couple of years ago at the Niagara Health System in Ontario. The contract with Aramark ended following a deadly C. difficile outbreak.

"I can't comment on a particular case," Boudreau said when asked about Niagara. "What we see is that based on the various models they (the private companies) bring forward, they demonstrate there are savings that can be found. There are issues now with cleanliness in our hospitals, and I hope this would address that." Aramark and Compass Group did not provide comment on Friday. Sodexo confirmed on Thursday that it did bid on the New Brunswick food and cleaning services contract, although said it hasn't been in talks with government recently.

A surging rat population in the hospital's cafeteria and food preparation area has prompted management to step up rodent control efforts in recent weeks. Inspectors believe that despite the increase, the rodents do not pose an imminent health risk to the hospital's patients, visitors or staff, said Richard Taki, regional director of health protection for Vancouver Coastal Health. But the results of last month's inspection highlight the hospital's ongoing challenges dealing with vermin, a situation hospital management and health inspectors say has been exacerbated by demolition and construction work in recent months. Inspection reports from 2013 show Vancouver Coastal Health had previously identified issues with rats and mice in the hospital cafeteria and more recently, last month's inspection found signs the problem had worsened.

"I don't think it's any different from any restaurant that has a rodent problem. They have rodents, they're under control, they've got a company looking after it. They're working toward resolving a problem, but you know, we live in a city that has rats everywhere." Nurses have seen the pest problem worsen, along with general cleanliness, said Claudette Jut, regional chair of the B.C. Nurses Union council. The Hospital Employees Union has identified the issue of short staffed cleaning and food service in the hospital and raised it "on several occasions" with the private contractor who employs the workers, said HEU spokesman Mike Old. "It's hard for us to tell what exactly has contributed to the rat infestation," said Old. "But it's a problem, I think, that the delivery of services is so badly fragmented because of privatization."

Frank Levenheck, director of facilities management for B.C. Women's and Children's Hospital, said demolition and construction on the hospital campus has contributed to the cafeteria's rodent issue. Over the past three weeks, hospital management has increased its efforts, Levenheck said, which includes working to seal holes in the building that act as entry points for vermin, more frequent cleaning and more frequent visits from the pest control company. Demolition for the hospital redevelopment began last May. Excavation began in August and is scheduled to be complete in February. Eight months before demolition began, hospital management had been directed to improve rodent control, records show. A VCH inspection on Sept. 3, 2013 found issues with "Inadequate Insect/Rodent Control," noting: "Areas have not been cleaned and Manager not aware if Pest Control has been in to specifically address these new sightings. Communication between services found to be poor and lacking in followup."

A week later, a followup reinspection report dated Sept. 10, 2013, noted: "Rat droppings still to be THOROUGHLY cleaned from underneath the heater vents in the production area. Noted mouse droppings in warehouse areas have not been cleaned up." The next Inspection Report, from July 2014, does not specify whether the rodent situation had improved or worsened since the problems noted in the report from the September before. The July 2014 report was the most recent posted to the Vancouver Coastal Health website until Postmedia News contacted the health authority this month to ask about inspections. Taki acknowledged the Dec. 22 inspection and provided Postmedia with a copy of the report, which was subsequently uploaded to the health authority's website.

Kristy Anderson, a spokeswoman from the provincial Ministry of Health, said if an inspector finds a food service establishment is not responsive to food safety notices or orders, the establishment "could be fined or ultimately be required to shut down until the situation is remedied. To our knowledge this has never occurred in a hospital or health authority-run facility."

Eight months before demolition, management at B.C. Women's and Children's Hospital had been directed to improve rodent control, records show.

"The goal is to introduce new technologies and inventive management practices, while achieving significant savings throughout the health-care system by standardizing the processes around managing these services, coordinating their planning and improving operational efficiency," Boudreau said. "Close to 1,800 people work to deliver food and cleaning services in New Brunswick hospitals. These employees are a vital part of our delivery of health care and the vast majority of them will continue to be government employees and CUPE members." But union officials said they don't believe it. They see the food service privatization as the tip of a much bigger iceberg that will lead to more cuts to jobs and, eventually, a lower level of service for New Brunswick taxpayers. Norma Robinson, president of CUPE Local 1252, said the union represents over 1,200 hospital support staff, paramedics, licensed practical nurses, patient care attendants and others. She said the Gallant government is trying to pick up on a plan that was started by the Alward Conservatives.

Robinson says union officials were called into a meeting last Thursday and told about the privatization plan. "This is not just about the jobs, it's about the service," Robinson said after her speech to the city hall rally. "We're talking about taking a publicly owned service and putting it in the hands of a private-for-profit corporation. It's not going to cost less, it's going to cost more because they are going to want to make a profit. That's our point, we don't want private companies coming in and taking over any public service in this province," Robinson said. "This is the tip of the iceberg. There are several areas they could look at to privatize. They are not being transparent with their information. They are doing a review of all services in the province, not just in hospitals. It's looking at all levels of government." Robinson called on taxpayers and voters to voice their anger at potential reductions in service as a result of cost-cutting and privatization. "We want answers. We want this stopped. We don't want privatization to come into this province, so we are going to try to stop this before this disease spreads and completely engulfs New Brunswick," Robinson said.

Patrick Colford, president of the New Brunswick Federation of Labour, was another speaker at the rally who said it was time for workers in the province to rise up against the government and fight cost-cutting that results in service reductions. "It's a taxpayer issue and where do taxpayers want their money spent?" he said after his speech. "Whether you are unionized or not, you are still a taxpayer. Is this about protecting jobs? Yes it might be but that's not the whole picture by any means. It's about protecting services that we depend on every day. "Talk to anybody who's ever been on EI and how frustrating it gets trying to talk to a human being to get answers, or somebody who goes to Service New Brunswick and has to take a number and sit there and wait. Or when you go to the emergency room and sit there and wait. All these cuts do is divide the population. Nobody wants to cut services and when the government comes in and says they are going to cut these public services and save X amount of dollars, people don't see the whole picture. The people who do are being vocal about it."

Saher said the province's hand hygiene strategy is working, but compliance only grew marginally from 50% in 2011 to 56% most recently. Other provinces such as Ontario and B.C. can claim over 70%, he said.

"New Brunswickers have been very clear - change is necessary and government needs to get its fiscal house in order," Macfarlane said. "We can no longer continue with the status quo. "We are undergoing a strategic program review to look for efficiencies and to uncover programs or services that could be changed or discontinued as well as find sources for revenue." McGarry said in a speech to the Rotary Club of Saint John in the Port City on Monday that a needed ideological shift in health care should see even greater use of private health-care firms.

"I think there are opportunities for the private sector to get more involved in our system in the things that we don't do as well as we should," he said. "Publicly paid, but privately delivered, contracted. "Do some of the services we provide under a public system really belong in the public system?" McGarry specifically cited outpatient services. "If you look at hospitals these days, you find so many ambulatory care services that are in the hospital system," he said. "Sometimes there is a private provider out in the community.

We have physio, there is private physio. We have audiologists, there are private audiologists. We have dietitians, there are private dietitians. You start to say, 'How did we ever get into this?' "As we start to shrink our infrastructure, these are the things that pop out." McGarry said the health authority is now at the beginning of five-year plan to redirect $48 million currently being spent on hospital infrastructure.

Meanwhile, the government has declined to reveal the prospective proponent of the food and cleaning services contract until a deal is finalized. But CUPE spokeswoman Norma Robinson says the Department of Health has informed the union that food and facilities management giants Sodexo, Aramark and Compass Group are involved in the bidding process. She said the union was told that the government is seeking a 10-year contract, first negotiating with Sodexo, to hammer down a deal within the next three to six months.

Sodexo has previously confirmed its interest in the contract to the Telegraph-Journal. Robinson said on Tuesday that questions remain as to what the impact of any deal will be on current public sector workers. "We don't know what this contract is going to look like from the union perspective," she said. "They are saying it's just the management today, but what does that look like when Sodexo gets in here? "What does that look like for the employees of the system."

Robinson added: "John McGarry has a five-year health plan that he is rolling out. The government says it's on a fiscal cliff saying there is money to be saved in health care. I think this is the first step to the privatization of health care."

"We are committed to the health and well-being of Ontarians living in long-term care homes and firmly believe in public accountability and transparency," said ministry spokesman David Jensen. Today, the Star profiles the story of former nursing home residents Fatemeh Hajimoradi, who has a serious pressure ulcer on her buttock, and Dorothy Benson, who died from problems related to gaping bedsores on her leg and foot.

Hajimoradi is now in Credit Valley Hospital, thanks to her family's advocacy. But the complaint filed by her granddaughter, Trinos, with the ministry got no results. Trinos emailed those photographs, with a complaint, to the ministry last spring. The ministry inspector didn't visit the home until Aug. 25 - two months after Hajimoradi was permanently moved to the hospital. Without interviewing the family, the investigator discounted the complaint and told Trinos the photos were not accepted because they could be edited or photo-shopped.

"I feel like I'm helpless now," Trinos said, after ending her call with the ministry. "They aren't going to send anyone else in there. They just go in, close the book and that's it." Jensen, the ministry spokesman, said inspectors do accept photos and must interview families in their investigation. Asked why that didn't happen in this case, he said the inspector used notes and photos from Trinos' original complaint with an intake worker. Now Trinos and her mother, Mehdizadeh, want their story made public as a warning to other families: watch closely, speak up and remember that a bedsore isn't a benign skin condition - it's a toxic threat that requires the most vigilant care.

In January 2013, Mehdizadeh entrusted her mother, Hajimoradi, to the Erin Mills Lodge. Hajimoradi has Parkinson's disease and dementia. She isn't able to move on her own and - like a growing number of long-term care residents - requires help with regular repositioning so that pressure from sitting or lying in the same spot does not create bedsores. Mehdizadeh said she understood skin breakdown was a risk but expected the staff to provide intensive care - including proper nutrition and hydration - so as to prevent the agony of serious infections and open wounds.

"My mother is suffering, suffering. We are all suffering," Mehdizadeh said. "I'm speaking out about this for all people in the older generation. Nursing homes are supposed to give them a safe journey home. But where are their rights to proper care?" Two years later, in May 2015, Trinos' notes said a worker at Erin Mills Lodge privately told the family about a serious and smelly bedsore on Hajimoradi's bottom.

Trinos and her mother said they didn't recognize the significance of the sore, nor did they see it, because the dressings that covered it were changed before their visits. "Come at a different time than you usually do, come and surprise (staff)," they recalled the worker telling them. The next day, Trinos' mother, Mehdizadeh, visited in the morning instead of the late afternoon. She told the nurse to open the dressing on her mother's bottom. The pressure ulcer was partially black and smelled like rotting flesh. Horrified, she took the first of many pictures. Several days later, her mother wasn't eating and was shaking with fever and nausea. Mehdizadeh demanded that the home call 911 and took her mother to hospital.

Mehdizadeh said her mother was admitted to hospital with two infections: sepsis, from the bedsore, and a urinary tract infection. In the hospital, Mehdizadeh and Trinos watched as nurses treated the pressure wound with sanitary cleaning kits. They were impressed. When Hajimoradi returned to the nursing home 10 days later, Trinos took photos and notes to document the difference in wound care. She said staff didn't follow the specific instructions sent by the hospital and didn't have the same cleaning kits. She said staff didn't offer pain medication before using undiluted iodine on the open wound "while my grandma was crying and screaming." Unlike the careful cleaning process used in the hospital, where nurses changed their gloves twice, Trinos photographed a worker cleaning the infected sore with one gloved and one bare hand.

On June 21, Trinos and her mother noticed that the dressing for a pressure wound on her hand was missing and the air mattress to help with the bedsore on her grandmother's buttocks was deflated. Eventually, Trinos called 911 and Hajimoradi was returned to Credit Valley Hospital, where she remains. This time, she was admitted with a dark red early-stage ulcer on her tailbone and a deeper ulcer on her buttock.

Erin Mills Lodge was sold by Sifton Properties to Schlegel Villages on July 10 - after Hajimoradi left. Schlegel spokeswoman Rose Lamb said the former operators tried to work with Hajimoradi's family but said the family insisted on taking her to the hospital. Lamb also said a subsequent meeting between Erin Mills workers and hospital staff concluded there had been no neglect. Lamb said the home's current internal monthly data shows that four out of 86 residents have "worsening" pressure ulcers.

She also cited the most recent report from the Canadian Institute for Health Information, which shows the incidence of worsening pressure ulcers at the home declined in 2013-14. That year, Erin Mills' incidence rates dropped to 1.1 per cent from 3.9 per cent the prior year. The Ontario average for 2013-14 was 3.9 per cent. Hajimoradi developed problems with ulcers in the spring of 2015, a period that is not included in the report.

While Hamilton Health Sciences was named by the Ministry of Health Friday to be one of 10 hospitals in the province to treat Ebola cases, it was recently found to have fallen short in protecting its cleaning staff against the potentially deadly virus.

"We're upset our members were put in this situation," said Dave Murphy president of CUPE 7,800. "They felt they were at risk."

Analysis of the swabs taken in the study found most of the bugs were benign. But that might not always be the case, said senior author Dr. Donald Redelmeier.

While elevator buttons are certainly among the surfaces hospital cleaners target, they are touched so often, by so many people, that it's a bit of a losing battle.

"They can't be cleaned again and again and again, every second of the day," Redelmeier said. "Once they're clean, they don't stay clean very long."

Studies have found bacterial contamination on neckties worn by male doctors, lab coats, stethoscopes, curtains separating beds in multiple-bed rooms, computer keyboards as well as smart phones and digital tablets health-care workers use to enter and check patient data.

For the study, swabs were taken from 120 different elevator buttons and 96 toilet surfaces in three different hospitals in Toronto. Swabbing was done on weekdays and weekends, and a variety of elevator buttons were tested. As well, the public washrooms closest to the elevators were also tested, with swabs taken of the door handles on the inside and outside of the main door, the latch used to close cubicle doors and the toilet flush handle or button.

Redelmeier said people should consider using an elbow, a pen or some other item to push elevator buttons in hospitals, or make sure they use hand sanitizer after exiting an elevator. He suggested hospitals should put sanitizer dispensers in elevators.

"Often when people use a hand cleanser, they're very good at washing their palms, but not their fingertips. And yet most of the transmission does not occur in the middle of the hand, it occurs at the periphery of the hand."

Guelph University microbiologist Keith Warriner conducted the tests for Marketplace and found alarming results. “I wasn’t expecting [bacteria] to be so prolific,”

Comforters were the most consistently contaminated spot, rating a "fail" in 23 out of 51 tests

faucets in hotel rooms were quite dirty themselves, with 16 fails out of 54

Over 70 per cent of remote controls tested were rated a caution or fail.

Other major hot spots included bed throws, bathroom sinks, toilet bases and telephones.

a pillow with so much bacteria it has “its own life story.”

Overburdened hotel staff is the main reason that many rooms are so filthy

Canada’s hotel union tries to enforce a cap 15 to 16 rooms cleaned per shift, giving staff approximately 30 minutes per room. Ruiz says that isn’t enough.

many housekeepers work unpaid overtime to reach their daily targets, but many still use time-saving “shortcuts” like not dusting or vacuuming.

In response to the 2011 C. difficile outbreak in the Niagara Health System, Mehra said they are "trying to find out the details of the cleaning contracts and whether the private companies were allowed to dramatically reduce the number of cleaners. "These are things that intrinsically affect patient care."