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Book Review
December 2015

Cutting costs, growing problems: hospital issues in the United States and Canada

Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients. By Dan Zuberi, Ithaca, NY: ILR Press, 182 pp., $62.95 hardcover, $19.95 paperback.

Every day, lives depend on the performance of hospital staff. Most people credit doctors and nurses for providing essential care to hospital patients, but hospitals are complex businesses with a diverse supporting staff. Perhaps the most underappreciated hospital staff members are the cleaning workers, who help prevent the spread of disease through sanitizing the facilities and equipment, and food service workers, who provide meals to patients. In recent years, hospitals throughout the United States and Canada have attempted to cut costs by outsourcing these services to independent companies, leading to cleaning and cafeteria employees being overworked, underpaid, and undertrained. The result is a dangerous situation for both hospital patients and hospital workers.

Examining the role of hospital workers is crucial to understanding the shortcomings of the healthcare system. Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients, by Dan Zuberi, is a compelling book about the drawbacks of outsourcing hospital cleaning and food preparation services. In seven chapters, Zuberi evaluates the shortcomings of the healthcare system, conducts interviews with hospital employees, and offers recommendations for policy changes. This structure provides a multifaceted view of issues related to hospital outsourcing.

Zuberi opens the book with the story of a hospital worker who is not given enough time to perform her cleaning duties. The worker’s story is immediately followed by the story of a Philadelphia grandmother whose minor surgery resulted in her contracting a healthcare-associated infection that ultimately led to her death. Zuberi emphasizes that such infections have become common and are a growing problem: “According to the World Health Organization (WHO), hundreds of millions of patients get infected annually” and “According to the U.S. Centers for Disease Control (CDC), healthcare-associated infections are a top-ten cause of death of Americans.” Although unsanitary conditions in hospitals result from inadequate cleaning, hospital cleaners, argues Zuberi, are not at fault but instead are victims of the flawed healthcare system.

Through outsourcing, hospitals seek to cut costs and maximize profits. In the next section, Zuberi explores the negative consequences of this approach on hospital cleaning and cafeteria staff: support staff are undertrained, are not provided with clean equipment such as uniforms and mops, and are expected to perform their job quickly instead of effectively. Essentially, they are overworked and underpaid. An additional issue is that outsourced support staff managers work remotely, so they are unable to communicate in person with hospital workers. Any problems that arise must go through the third-party staffing company, instead of being addressed directly by hospital staff. According to Zuberi, this aspect of outsourcing has broken the hospital team, further demoralizing workers.

To give the reader firsthand information about the hardships suffered by hospital support staff, Zuberi interviews a handful of hospital cleaners and cafeteria workers. They candidly discuss with him the physical and mental hardships they face in their jobs. Most of them make the minimum wage in their locality, a wage impossible to live on in most areas of Canada and the United States. Many are forced to take additional jobs to support their families and, as a result, end up exhausted at work. Often, they receive little or no vacation. Zuberi stresses the physical difficulties of working at a hospital: hospital staff work with dangerous chemicals, lift heavy objects, and are exposed to a multitude of diseases. The emotional interviews with these employees support Zuberi’s point that hospital workers are not given the ability to perform their jobs properly.

These interviews lead to the final section of the volume, in which Zuberi makes policy proposals to improve the healthcare system. He describes how cleanliness protocols, such as the requirement for staff to wash their hands, can halt the spread of disease and save lives. In addition to requiring hand washing, hospitals, says Zuberi, should monitor infections more aggressively. He then returns to the issue of hospital workers, suggesting that they be paid a “living wage.” He concludes by reiterating that a hospital is a complex organization which requires the support staff to have specific skills and teamwork, and outsourcing severs these crucial building blocks of hospital staff.

Zuberi does a solid job of breaking down very complex healthcare issues, laying out the book in such a way that it describes the decline of healthcare in a highly structured manner: he first introduces hospital cleanliness issues, then discusses hospital-acquired infections, proceeds with interviews of hospital support staff, and concludes with policy recommendations. Cleaning Up appeals to the reader’s emotions with captivating stories of both hospital patients and workers, effectively demonstrating the stark reality of the healthcare system.

Zuberi’s opening story, about the Philadelphia grandmother who acquires an infection after a simple surgery, could have been a story about any of our grandmothers. But what makes it especially effective is that he goes beyond the mere telling of a story: he explains how hospital-acquired infections are a growing problem, with the potential to affect anyone who visits a hospital. We rely on hospitals for so many services in our lives, and they should be considered places of healing. Unfortunately, they are not; instead, hospitals are becoming places where infection has the opportunity to run rampant, putting thousands of lives in danger every day. Zuberi’s readers share a common interest: because most have been to a hospital at some point in their lives, they are motivated to improve the system. Zuberi explains what is wrong with the system, providing plenty of examples and statistical support, and suggests policy improvements that should be taken seriously.

Although each of the book’s sections explores its issues thoroughly, the most poignant section is the one with the interviews with the hospital workers. It is heartbreaking to learn how the system fails the many support staff workers who want to do a good job. Working in a hospital is physically and mentally grueling, even with the proper amount of training and resources. Without them, a grueling job becomes impossible. These staff members contribute so much to the system as a whole by performing functions critical to the well-being of patients; the reader is both shocked and horrified by their unfortunate situation. The interviewees trust Zuberi, as is evidenced by the personal nature of the interviews, which reveal how deeply invested the author is in the issues of these workers.

Cleaning Up affords its readers crucial insight into the healthcare industry, closely examining the social and economic costs of profit-driven healthcare. Healthcare policy affects so many people: workers, patients, and all of their families. Zuberi succeeds in proving his point: it is time to take action to improve our healthcare system.

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About the Reviewer

Michelle A. Dressner

Michelle A. Dressner is an economist in the Office of Employment and Unemployment Statistics, U.S. Bureau of Labor Statistics.

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