Allegheny Valley Hospital
Pittsburgh, PA
Supporting Sustained HCAHPS Cleanliness Performance through Disciplined Execution
Allegheny Valley Hospital is a 147-bed full-service hospital serving the Allegheny and Kiski Valley communities, supported by 300+ physicians and 900+ employees. The hospital delivers comprehensive inpatient and outpatient care across a broad range of specialties, including emergency medicine, cardiovascular care, cancer services, rehabilitation, and behavioral health.
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77.58
Increase in HCAHPS cleanliness Top Box (2025 YTD)
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94
Reduction in reported employee injuries
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90
Employee engagement score
EVS scope includes approximately 400,692 square feet cleaned daily.
The ‘every patient, every day’ approach made the difference. Patients feel seen and supported, especially in the emergency department, and our teams have better visibility into concerns before they show up in survey results. That level of consistency has strengthened confidence in EVS performance across the hospital.
Christopher DeRubbo MBA Director of Operations, AVH
The Challenge
As patient experience expectations increased, Allegheny Valley Hospital (AVH) leadership needed EVS performance that was consistent, reliable, and defensible over time. While the program was established, slight month-to-month variation in HCAHPS cleanliness results made long-term trends harder to interpret with confidence.
Leadership priorities centered on predictability, not just improvement. The goal was ensuring cleanliness performance remained consistent in execution and improved over time across units, shifts, and survey cycles without added escalation. What mattered most was leadership confidence in consistent execution, fewer escalations, and patient experience outcomes that held steady month after month.
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Infection Control
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Patient Safety
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Operational Efficiency
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Employee Engagement
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Quality Assurance
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Employee Safety
Initiatives and Programs
- A Patient Ambassador supports an “every patient, every day” engagement model across units, shifts, and the emergency department. Daily patient interviews provided real-time visibility into cleanliness perception during
the stay, allowing concerns to be addressed proactively before discharge. In the emergency department, the ambassador supported comfort-focused engagement during extended waits with activity materials and basic amenities.
Digital workforce management tools supported consistent execution across shifts through streamlined workflows and realigned digital duty lists. QR codes gave patients and families a simple way to request support, improving responsiveness and service visibility..
- Implemented improvements with financial accountability. The patient ambassador role was budget neutral through staffing realignment. Floor care services were transitioned in-house to improve quality control and reduce reliance on third-party vendors.
- Implemented cycle maintenance floor care and transitioned to materials better suited for high traffic and frequent sanitization to reduce visible defects that affect perception of clean.
- Strengthened signature programs—Positive Impressions and High-Profile Cleaning—supported by leadership rounding, audits, and “teachable moments” that reinforced expectations consistently across units & shifts.
- Extended rounding and patient interviews beyond business hours through EVS leaders and evening managers, ensuring concerns were identified and resolved across all shifts.
- Aligned Patient Transport operations around measurable execution standards to support room readiness, discharge flow, and a more predictable patient journey.
Outcomes
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• 77.58% HHCAHPS Cleanliness Top Box: Cleanliness performance reached 77.58%, finishing 5% above the 2025 goal and reflecting sustained, predictable performance.
• 2,761/2,404 Patient Engagement and Quality Assurance Touchpoints: Daily rounding replaced delayed survey feedback with real-time insight, enabling earlier course correction across units and shifts.
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• 94% Reduction in Reported Employee Injuries: Reported injuries declined from 17 (2024) to 1 (2025), reflecting stronger safety focus and workforce stability.
• 90 Employee Engagement Score: Engagement reached 90, with 98% favorable sentiment, ranking 12 points above the company average.
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• 454/33/8% Consistent Daily Execution: Averaged 454 productive minutes per shift, 33 assigned tasks, and only 8% of tasks flagged for unusually fast completion – supporting reliable, repeatable execution.
• Over 28,000 Transport Tasks: Completing more than 28,000 transport tasks in 2025 with a 10-minute average trip time and 96.9% on-time performance, reinforcing reliable throughput and discharge flow.
Our strong partnership with the EVS team starts at the leadership level and extends all the way down to every employee. This ensures consistent quality and a shared commitment to our goals. We’ve experienced high visibility from their team, and their ‘can-do’ attitude is truly infectious, fostering strong employee engagement not just within EVS, but across our entire facility. This collaborative spirit has also directly impacted our operations, contributing to fast patient throughput, which, in turn, allows us to service more patients effectively.
Milissa Hammers, MSN, RN Chief Nursing Officer AVH
AVH Leadership gained confidence in a predictable, scalable EVS program aligned with patient experience and operational priorities—creating the foundation for expanded collaboration, including the recent approval to add valet services.