Blood and Marrow Transplant Environmental Cleaning (BMTEC) Project


  • To ascertain the methods by which units are cleaned (e.g. frequency and process), resourcing, training, and education of environmental service personnel and clinical governance;
  • To facilitate compliance with the Environmental Cleaning Policy NSW (PD2012_061) in regard to external auditing.
  • To measure and benchmark the level of cleanliness of the transplant wards of the BMT Network.
  • To inform quality improvements in environmental cleaning standards in BMT/Haematology units (an extreme-risk functional area).
  • To assess sustainability of improvements made.


With the support of the BMT Network Council and ACI, the BMTEC project provides the following benefits:

(i.) Enhanced compliance with the Environmental Cleaning Policy NSW (PD2012_061).

The categorisation of risk in the Policy provides a basis for recommendations of frequency and minimum cleaning standards for each functional area. Additionally, the policy outlines measures to evaluate cleaning outcomes and the acceptable levels of quality that should be achieved for a given category of risk. The BMTEC’s external cleaning audits provide feedback on the adequacy of environmental cleaning and areas for improvement, as measured against the Environmental Cleaning Policy.

(ii.) Support activities toward National Safety and Quality Health Service Standards (NSQHS) and Hospital Accreditation.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has developed 8 NSQHS standards to promote the quality and safety of health service provision in Australia. The governance of cleaning services, gauging consumer expectations, and the implementation of cleaning standards of environmental hygiene make environmental cleaning an issue that cuts across multiple NSQHS standards. The BMTEC project addresses these three critical areas of the NSQHS standards.

(iii.) Respond to concerns brought to the Health Care Complaints Commission (HCCC) regarding complaints about the hospital environment and management of facilities

The BMTEC project will support improvements in environmental cleaning, with a goal of reducing patient complaints.

(iv.) Help minimise health care costs and hospital-associated infections (HAIs).

Measures to contain or eradicate HAIs cannot be fully effective without attention to environmental cleaning, as many HAIs persist in environmental reservoirs.



The Blood and Marrow Transplant Network and the Agency for Clinical Innovation (ACI) recognise that hospital cleanliness serves many purposes. A clean environment is a key strategy to minimise hospital-associated infections (HAIs), provides a safe environment for staff, patients and visitors and reflects the philosophy of the hospital’s care and concern.

This initiative has the full support of LHD Chief Executives and has the portability across other high-risk areas such as Burns, ICU and Renal.

The BMT Network of the Agency for Clinical Innovation has collaborated with Health Care Association Infections, Clinical Excellence Commission (CEC) throughout the BMTEC project. In 2018 the BMT Network will work with CEC to review the environmental cleaning audit tool and the NSW Environmental Cleaning Policy (PD061_2012). It is anticipated the audit tool will be available electronically via the CEC Quality Audit Reporting System.


Key Dates

August 2013

1st Round External Audits of Cleaning Practice - All BMT Units in NSW.

Locations: 15

May 2014

2nd Round External Audits of Cleaning Practice - All BMT Units in NSW

Locations: 15

August 2014

3rd Round External Audits of Cleaning Practice - All BMT Units in NSW

Locations: 15

August 2014


Environmental Cleaning Internal Auditor Training 

Follow-up external audits of cleaning practice

Locations: 15

August 2015

4th round external audits.

Pilot Sites

Implementation Sites

All LHDs with BMT Units (15 in total) participating in the external audits of cleaning practice:

Central Coast Local Health DistrictGosford Hospital
Hunter New England Local Health DistrictCalvary Mater Newcastle
John Hunter Children's Hospital
Illawarra Shoalhaven Local Health DistrictWollongong Hospital
Nepean Blue Mountains Local Health DistrictNepean Hospital
Northern Sydney Local Health DistrictRoyal North Shore Hospital
South Eastern Sydney Local Health DistrictPrince of Wales Hospital
St George Hospital
South Western Sydney Local Health DistrictLiverpool Hospital
Sydney Children's Hospital NetworkThe Children's Hospital at Westmead
Sydney Children's Hospital
Sydney Local Health DistrictConcord Repatriation General Hospital
Royal Prince Alfred Hospital
Western Sydney Local Health DistrictWestmead Hospital


The project has spanned over 5 years and demonstrated sustained improvement to unit cleanliness across the BMT Network. A survey of the directors of clinical governance, nurse unit managers and environmental cleaning managers is planned in 2018 to assess the change of practice since the initiation of the project. In addition a sixth round of external audits will be conducted.

Related Initiatives

Further Details

Clinical Excellence Commission Environmental Cleaning Standard Operating Procedures and Audit tool


  1. NSW Health CEC. Environmental Cleaning Policy, PD2012_061. 2012
  2. Care ACoSaQiH. National Safety and Quality Health Service Standards. 2017
  3. Commission HCC. Protecting the Health and Safety of the Public. Annual report 2011–12.


Richard Makin
BMT Network and Quality Manager
02 9464 4628

Monique Tovo
BMT Network Project Officer
02 9412 8215

Page Top | Added: 8 November 2013 | Last modified: 20 April 2018

Richard Makin
BMT Network and Quality Manager
02 9464 4628