Document Type

Capstone Experience

Graduation Date


Degree Name

Master of Public Health


Environmental, Agricultural & Occupational Health

First Committee Member

Terry Stentz

Second Committee Member

Elizabeth Beam

Third Committee Member

Kelli Kopocis


This Tribal health clinic is located on reservation land and serves a community of approximately 1,550 members located over 64,000 acres located in Nevada and California. The clinic offers general health practice and podiatry at its central clinic with satellite offices located off-reservation offering dentistry, optometry, and behavioral health. The clinic is operated by Tribal staff and partners with the Indian Health Service (IHS) for environmental survey on an annual basis for compliance with Accreditation Association for Ambulatory Health Care (AAAHC) standards. While this clinic only offers outpatient services, the disinfection and cleaning protocols are an important step in limiting cross transmission of illnesses (Protano et al., 2019). Centers for Disease Control and Prevention (CDC) reported about 15% increase in methicillin-resistant Staphylococcus aureus (MRSA) infections in acute care facilities between 2019 and 2020 alone (CDC, 2020), which illustrates the need to evaluate cleaning procedures where possible.

Cleaning within the clinic is contracted to a third party for nightly services and is to be carried out during the day by clinic staff. Seen as a deficiency, the clinic was lacking documented cleaning and disinfection procedures and policies. Without documented procedures the clinic needed a way to verify disinfection activities were being performed and that the activities were being completed consistently. It was hypothesized that staff was not correctly disinfecting areas or not disinfecting areas at all, allowing bacterial load to build to harmful levels. Surface testing to determine activities and effectiveness of current cleaning activities was determined to be the best evaluation measure available. Methods for testing included a baseline Adenosine triphosphate (ATP) analysis to measure initial bacterial loads on surfaces. ATP has been shown as a positive correlation to bacterial load based upon plate growth studies (UKUKU et al., 2001). Development of formal disinfection procedures, a training for both medical and housekeeping staff, and periodic ATP testing to verify activities followed the initial baseline measures. The process was originally planned to be a four-month project, but was completed in 7 months, starting in April 2022 and completing in October 2022.

Utilization of the ATP testing did identify in the baseline results a problem of insufficient disinfection with a passing rate of only an average of 32% of surfaces. Testing was completed at two separate times and were unannounced to staff. The purpose of the separate times was to compare the disinfection results of the night-time “terminal” cleaning staff and the medical staff between patient cleaning.

Training on proper disinfection techniques, universal product adoption, mechanical interventions, and checklists for staff in patient rooms showed progressive improvement throughout the test period with the final week’s ATP swab results returned a passing rate of 89% of surfaces.

Included in

Public Health Commons