AHE Blog

Baby boomers are retiring in large numbers, and qualified candidates often aren’t being groomed to step into these positions. Filling leadership positions has become more challenging as the role has evolved and become more complex. Along with cleaning, infection control and technical skills, evironmental services managers oversee large, diverse groups of employees and work closely with patients.

For that reason, managers need to make a strong case to ensure that qualified leaders and front-line professionals are available to step into those roles from a position of strength, leaders say. To excel at succession planning, leaders must:

Mentor and prepare management teams to be leaders and front-line teams to focus on excellence in services, technical skills and core knowledge.
Provide a career ladder with corresponding educational opportunities to develop employees.
Establish charge leads, senior floor leads, supervisors and managers to facilitate that career ladder.
Work closely with the human resource professionals in your organization to ensure that the right people are selected for open positions.
Senior leaders should encourage current and upcoming leaders to constantly improve their skills and knowledge through training, education and networking as well as earning certificates, certifications and fellowships.

The following professionals from AHE’s advisory council contributed to this sidebar:

Marci Butts, CHESP, director of ancillary and support services, The Jewish Hospital

Eddie Gomez, director of plant operations, HealthSouth Northern Kentucky Rehabilitation Hospital

April Huggler, T-CHEST, quality assurance and training manager, Oregon Health & Science University,

Rock Jensen, senior consultant, Soriant Healthcare

Nazar Masry, CHESP, T-CHEST, vice president of health care and laundry operations, Job Options Inc.

James Odom Jr., CHESP, T-CHEST, assistant director II of environmental services at Crothall Healthcare–Compass Group One

Georgie Shockey, principal of Ruck-Shockey Associates Inc.

As the millennial generation enters the workforce and becomes increasingly responsible for buying and accessing health care, organizations are gearing up for a new “regime.” What will this generation — which grew up with technology and the internet at its fingertips — demand and need from a system with mature institutions and complex structures? I have personal experience with this question (as a mother of a 27-year-old working professional) and have watched for responses with great interest.

In 2014, Price Waterhouse Coopers’ Health Research Institute conducted its annual survey of 1,000 consumers and industry experts to identify the top health industry issues for the coming year. One of its key findings was that millennials define “benefits” more broadly — emphasizing work-life balance over simple health benefits — than do members of previous generations. This expectation means that insurers and health care organizations need to work more closely with millennials to support and enhance their well-being and need to look at new mobile technologies that can create personalized, real-time support and feedback.

With that insight as background, I set out to understand how health care organizations might think about approaches, strategies, tactics and tools to cater to this growing segment of the population, generally considered to be people in their teens, 20s and early 30s. I also chose to look “upstream” at how a large public university (where many of these young folks have spent many of their millennial years) is addressing these unique needs, what it has learned and how these lessons may be transferable to health care organizations.

A student health service adapts

Claudia Covello, executive director of University Health Services at the University of California, Berkeley helped me understand the challenges and opportunities of serving almost 28,000 students who fall into the millennial age range with a full array of services including medical care, mental health care, urgent care, lab, optometry, immunizations, radiology, pharmacy and social services. The students face their own set of challenges, with almost 40 percent of them on Pell Grants (i.e., they come from low-income homes). For more than half of them, English is a second language. These are similar to the challenges faced by many health care organizations in the U.S.

Covello was reluctant to make generalizations about millennials but tentatively offered a few for our consideration:

“Different from prior generations, they want us to continue to stay in the parental role,” she says. “While they don’t want to be treated like children, they want to be guided.”

“Don’t assume anything,” she also says, “even how to make an appointment, how to choose a doctor or when to seek counselling.

“We have learned that talking about seeking health care is probably the most boring topic for students, so we engage them by talking about what they want to talk about. When talking about topics like sexual assault, alcohol abuse or stress, we weave in the health services that can support them.”

Even though all services are within a few blocks’ radius of campus, the students tend to ask questions about how they will they get to them. “They want high levels of customized care and immediacy,” Covello says. “Self-directed” services, where students can pick up standard prescriptions, manage pre-existing conditions or go in for routine care have been a huge help to them.

Mental health is one of the major issues on campus and keeps growing in importance. Since mental health is still somewhat stigmatized, the university’s health services has placed a psychologist and social worker in academic departments with drop-in hours. “Creating easy access in a nonthreatening and nonstigmatizing venue has proven to be wildly successful,” Covello says.

“Another major initiative we are adopting is an integrated care or collaborative care model,” she says. “Much like what hospitals and health systems are trying to do, we have added clinical psychologists, social workers and health educators and are piloting adding a clinical social worker.” For example, a student may make an appointment with a physician for a bodily ailment; but after listening to his or her history, the physician might prescribe some short-term meds and also do a warm hand-off to a psychologist. “Students love this approach — particularly having access to all providers in one visit.”

When I asked for Covello’s advice to hospitals, she gave me three tips:

Millennials should be invited to offer feedback on a provider’s website and encouraged to comment on its ease of use and interactivity.
Providers need to learn a new way of communicating. While these younger patients may be smart and well-informed, they need more follow-up and specific instructions than others. “Don’t take anything for granted,” she says.
To learn more about the millennial generation, conduct satisfaction surveys and ask open-ended questions.

To that end, leaders at many health care organizations have been working to understand and serve the unique needs of millennials. I spoke to three leading health systems in California: Kaiser Permanente, Sharp HealthCare and Sutter Health. Some common themes emerged about listening and learning; expanding digital solutions; improving access and convenience; delighting the customer; and communicating and connecting.

Listening and learning

Asking questions of this group and understanding its needs is crucial. In a Kaiser survey of millennials, the system found that health care coverage was important to them — “and they were willing to make trade-offs for this,” says Christine Paige, senior vice president for marketing and digital services. They also describe what “being healthy” means in terms similar to those of older Kaiser members — that is, “eating right,” “not being sick or injured” and “being at a desired weight.”

“Decision-making should follow based on your patients’ needs and not staff or provider demands, although it is easier said than done,” says Steven Green, M.D., chief medical officer for Sharp Rees-Stealy Medical Group. “Old traditions and norms are hard to break. Something as simple as reading survey comments can provide you with valuable ideas you may not have thought of.”

Expanding digital solutions

Understanding that access and convenience are top of mind not only to millennials but to all of its members, Kaiser has been working to improve access through email and telephone visits. In fact, email and telephone together make up more than 56 percent of all “touches,” says Paige. The health system is moving aggressively on this front and adding more video visit options. (See my “Three Approaches to Virtual Office Visits” from the July 16, 2015, H&HN Daily.)

At Sharp HealthCare, the patient portal MySharp launched in 2010 for similar reasons. “Instead of having to call, leave a message for your doctor and wait for a reply, patients can email us with detailed questions (rather than playing phone tag) — and get a much quicker response,” says Green. Much like Kaiser's electronic health record, lab results are available online to patients, along with educational information about normal ranges and other factors. “Not only is this more convenient,” says Green, “but it offers greater privacy — not having to talk to your doctor’s office from your cubicle or classroom.”

“Mobile is really the way to go,” says Kelly Faley, vice president of digital marketing for Sharp, “and if you aren’t there yet, this is where you need to focus. As we well know, health care tends to be behind the curve in technology, and we need to catch up.”

Improving access and convenience

“It’s our experience that millennials place special emphasis on convenience, customer service and cost,” says Sutter Health spokeswoman Karen Garner. The system has established Sutter Walk-In Care clinics that are open seven days a week, from 8 a.m. to 8 p.m., and offer amenities including charging stations, free Wi-Fi and complimentary refreshments. Fees stay consistent, so visitors know what charge to expect every timel. Walk-In Care locations are also stand-alone storefronts in shopping centers, which means they are a part of the neighborhood landscape and next to businesses like the local grocery store or dry cleaner.

While Sharp also offers extended hours, it has same-day appointments, early morning and evening hours and weekend appointments to accommodate all schedules. Kaiser, too, has been trying some fresh approaches and is piloting in-store clinics at Target stores in Southern California.

Delighting the customer

For decades, The Walt Disney Co., The Ritz Carlton Hotel Co. and Nordstrom have been talking about going beyond mere service to delighting the customer. Unfortunately, “service” and “customer” (or consumer) have been concepts adopted by health care with some difficulty. The introduction of more self-directed health care purchase options has made customer delight all the more important today.

“Millennials expect an Amazon experience, and we need to move to more modern ways of engaging with them" says Faley. "As avid users of Yelp and similar rating sites, millennials want quick and easy access to information about their doctor or hospital.”

In fact, Sharp is launching its “star ratings” based on Press Ganey surveys on doctor profiles, which will include patient comments. “We would much rather potential patients look at our own site for credible information based on our patient comments,” says Green. “We are proud of our physicians and want to share the robust information and ratings we have gathered.”

“At its core, health care is personal, so let’s get the administrative functions out of the way and let our caregivers focus on the care,” says Faley. “If we can check in for our flights and choose our hotel rooms on our phones, why can’t we make appointments, check in for our doctor’s appointment and pay our copay the same way?”

Communicating and connecting

Getting “eyeballs” with members of the millennial generation in their cluttered multimedia world can be challenging, to put it mildly. To that end, Sutter Health launched a digital partnership with Vice Media, a leading youth media company, to debut a health-focused channel named Tonic. The channel allows Sutter to reach this audience with its brand while offering a new, creative canvas for its clinical experts to be featured in original documentaries and other editorial content — in a place that millennials trust.

Sharp’s Faley says it has established a customer media room that monitors activity on Sharp's social media channels to look for problems and try to address them in a timely fashion. It also is trying to keep constituents engaged by pushing out at least two stories a day on social media, which it has found to be a success.

What I gleaned from all these conversations is that, while millennials may be at ease in the digital realm, they do want a personal relationship, support systems and someone taking an active interest in them. Their needs may be the impetus for pushing us a little harder to rethink our care and delivery systems — like creating new technologies or more convenient access. The outcomes of these adjustments, modifications and new approaches not only serve millennials but improve life for all of us. What could be better?

“The rewards and gratification of being a part of molding these young lives and setting them on a path to healthy living far outweighs any challenges,” says Covello.

And I certainly wish them every success.

Environmental services (ES) professionals recognize that labor expenses are a key component of all ES budgets. Labor costs typically comprise at least 90 percent of all ES expenses. Therefore, it is imperative that ES workforce budgets accurately reflect the labor required to accomplish the team's main goal — to provide a clean and safe environment.

Eight key steps

To accomplish this goal, there are eight key steps to take. By following and completing these steps, an ES professional can be assured that labor expenses accurately reflect what is needed to provide the facility with excellent results:

1. Meet with the users or owners of the room or area of care. It is important to fully understand the needs and expectations of end users. ES professionals should meet with each unit manager and review their expectations. Sample questions might include:

How often should the room or area be cleaned? Most rooms require only daily cleaning, but there are exceptions.
Is staffing required on one, two or three shifts? For example, operating room suites and emergency care units may require 24/7 staffing while office space usually only needs ES attention once a day, Monday through Friday.
What time of day can the room be cleaned? Having more rooms cleaned on the day shift can save ES professionals expense in shift differential pay.
What surfaces are expected to be cleaned by the ES staff? Is the ES employee expected to clean any of the medical equipment, computer screens, desktops or other special surfaces? ES professionals should be specific.
What are the expectations for refinishing floors, carpet cleaning and other non-daily restoration work completed by the ES staff?

It is imperative that the needs of the area as well as the capabilities of the ES department are met. ES professionals should not be tempted to promise more than can be delivered. Budgetary constraints invariably will come into play.

2. Review the room requirements. How large is the room? Room square footage can usually be collected through a hospital's facilities department. Using this available data will save ES professionals invaluable time. If this information is not available, they should measure the cleanable square footage, noting whether the floor covering is hard surface or carpeted.

ES professionals should then record the number and types of fixtures the ES staff are expected to clean, assigning a cleaning time to each fixture. If they are unsure, they should refer to Steps 4 and 5.

ES professionals also should ask if there are any special considerations that require the attention of the ES staff. For example, if the patient unit comprises immunosuppressed patients, additional cleaning time will be required for daily isolation gowning and cleaning.

3. Review industry cleaning time standards. The ISSA's Cleaning Industry Management Standard provides a comprehensive listing of cleaning times for most surfaces, items and procedures ES professionals will encounter. This provides a good starting point for determining cleaning times as well as verifying cleaning times already developed.

Today, ES professionals also have access to a number of software programs that can be used to determine room cleaning times.

4. Complete time studies. ES professionals should select staff members to complete time studies. Staff member selections should be based on whether they have demonstrated excellence in their performance. Final cleaning times should reflect the importance of adherence to high cleaning standards and high patient, visitor and staff satisfaction.

ES professionals should review the room cleaning expectations as determined from completing Steps 1 and 2 with the selected staff members.

A room should be cleaned by the selected ES staff members at least two times. However, there is no need to complete a time study for every room. For example, if there are 450 similar patient rooms in the facility, there is only a need to complete the time study in one patient room.

Similarly, ES professionals can extrapolate cleaning times for spaces that share common traits or usage. For example, complete time studies on a typical office space of 100 square feet. If the 100-square-foot office space requires five minutes to clean (or 20 feet per minute), it can be assumed that a similar space measuring 160 square feet will require eight minutes to clean.

The same process can be used for all types of rooms that require cleaning by the ES staff. ES professionals should determine cleaning time standards per 1,000 square feet cleaned for every type of room under the responsibility of the department. ES professionals should keep it simple: For each room, they should round up or down to the nearest full minute.

Finally, ES professionals should complete a formal room-cleaning inspection after each time-study cleaning. Ensure that the cleaning is complete and meets ES and facility cleaning standards. The goal is to have time studies that accurately reflect cleaning time requirements as well as high cleaning standards.

5. Identify work that is based on volume. Not all cleaning duties performed by the ES staff are based on square footage. Some are based on volume. When completing the time studies outlined in Step 4, ES professionals also should complete the time requirements for any volume-based assignments.

A common cleaning task based on volume is the number of discharged patient rooms that are expected to be cleaned each day. Annual discharge data typically can be obtained through a hospital’s bed management program or the finance department. This information can be used to determine the facility’s daily discharge activity.

It is important for ES professionals to gather this data for each day of the week because discharge patterns will vary from day to day. Higher discharges usually occur later in the week while weekend days usually have a lower number of discharges. Gathering and incorporating this information in the final workforce plan will ensure that daily staffing is correct.

Other volume-based tasks might include emergency department (ED) visits and the number of surgical cases performed each day, if the ES staff are responsible for cleaning the surgical suites between cases.

ES professionals should determine the hours required to complete project work including, but not limited to, refinishing hard floor surfaces, carpet and upholstery cleaning and window washing. Frequency of project work should be discussed when meeting the users and managers of the areas cleaned, as described in Step 1.

Some ES departments also are responsible for nontraditional tasks such as snow removal, landscaping and meeting setups. ES professionals also need to determine frequencies and time requirements for these tasks as part of the overall staffing model.

Finally, some areas require an ES presence that is not based on cleaning time or volume. A common example is the ED. This unit usually requires an ES presence 24/7 to ensure that clean rooms are always available for emergency patient arrivals.

Determining if one or more ES staff members are required will be dictated by the size of the ED and the number of emergency cases the unit typically intakes each day. ED visit data, by shift and day of the week, may be obtained from the hospital’s finance department. ES professionals should use this data in conjunction with communication with the ED staff to determine the required staffing. This process also can be used when determining the ES staffing required in the surgery department.

6. Compile the data collected to determine total staff requirements. ES professionals should determine the productivity standard for each type of space cleaned, compiling a summary list that denotes how much space can be cleaned per hour for each type of room and space. For example, if the total patient room square footage is 300,000 and the productivity standard for patient rooms is 1,200 square feet per hour, the work hours needed for patient room cleaning is 300,000 divided by 1,200, which equals 250 work hours per day. To calculate the weekly hours, it should be multiplied by seven for a total of 1,750 hours.

ES professionals must remember to take into account the hospital’s average daily census. If it is 80 percent, 1,750 should be multiplied by 80 percent. In this example, 1,400 hours are required to complete daily cleaning of the patient rooms.

ES professionals should complete the same process for cleaning all types of rooms and space that is based on square footage.

A similar process should also be completed for volume-based cleaning. For example, patient discharge room cleaning staffing requirements are based on the number of patient discharge rooms that must be cleaned each day. To determine the required ES staffing to complete daily discharges, ES professionals should obtain the hospital’s discharge data for the previous year. Assuming that no significant changes in patient activity occurred, this number will provide a good benchmark.

An annual discharge total of 10,950 denotes a daily discharge average of 30 (10,950 divided by 365 days equals 30). If a daily discharge requires 45 minutes to clean, the weekly hours that should be budgeted for discharge cleaning will be 30 discharges per day multiplied by 7 days per week (210) multiplied by 45 minutes (9,450) and divided by 60 minutes, or 157.5 hours.

A chart similar to the "Sample budget summary for required ES staffing" (above) will provide an accurate budget summary of the staffing required for the ES department. This is only a sampling of rooms, areas and tasks that might be included in a staffing summary. The total is derived by adding the “Weekly staffing” column and then dividing by 40 hours, or one full-time equivalent (FTE) staff member.

7. Determine ES relief staff required to cover for sick days, vacation days and open positions. ES staff earn paid time off to cover for sick leave days and vacation time. Staff will still be required to cover for this time. Sick-day usage usually can be obtained through a hospital’s payroll department. For instance, if the annual average sick-day usage for the ES department is 6,240 hours, three FTEs should be budgeted for sick-leave coverage. This is because one FTE equals 2,080 hours and 2,080 divided into 6,240 is three.

Typically, most ES staff also will earn vacation time. The amount of time off may vary based on years of service. The most accurate method to determine vacation coverage is to total the amount of vacation days each employee earns. For example, if the total vacation earned by the ES staff totals 390 days, then 1.5 FTEs will need to be budgeted for vacation coverage. This is derived by multiplying 390 by eight hours, then dividing the results (3,120) by 2,080.

Finally, ES professionals should work with the hospital’s human resources department to calculate the number of ES FTEs needed to cover vacant positions. It is rare for an ES department to have all positions filled at all times. If the ES department averages 1.25 vacant positions each day, then 1.25 FTEs should be budgeted. The required relief staff is then added to the ES department’s total staffing requirements, as illustrated in the chart "Sample relief request" (above).

Everything the environmental services department does impacts all customers within a health care organization in one form or another — patients, visitors and colleagues.

A positive customer service program starts with quality, and customers should perceive that quality as they enter the front door of the organization and continue through the entire facility.

How environmental services professionals do their jobs can affect a health care organization's HCAHPS scores. Consequently, customer service is vitally important and necessary for an environmental services leader to monitor and implement.

A positive environment

Providing a positive customer experience should be a top priority for any environmental services leader. This can be accomplished at the highest levels as well as with front-line colleagues.

Daily scripting is a starting point. This includes having the environmental services staff member ask permission to enter the patient’s room; entering the room with a calming presence and smiling; greeting the patient by name; introducing himself or herself and explaining his or her role in patient care; asking if assistance is needed and informing nursing if it is something they need to perform; escorting a patient or visitor to a desired location, if time allows; reporting any comments or concerns to related departments for immediate attention; performing all duties in a professional, detailed way; engaging in meaningful conversation; reviewing the work and inspecting the room for any concerns; and creating positive resolutions to any observed opportunities.

How the environmental services staff interacts with visitors, vendors and contractors when they see them in the hallways often can be just as important as the patients. In high-performing health care organizations, staff members are expected to smile and interact with individuals with whom they cross paths. This permeates the organization in such a way that it becomes a part of the culture.

The patient experience

The patient experience is shaped by past experiences, which may evoke fear, frustration, anxiety or excitement. The environmental services department’s goal is to embrace the patient or visitor, reduce anxiety, eliminate frustration and define a better experience that exceeds expectations. Environmental services, facilities, support services and the clinical staff are an integral team whose goal is to define the experience and make it as positive as possible.

When analyzing the patient experience, all aspects of the patient engagement must be evaluated, starting with the physical exterior. As the client enters the campus, what perception is formed? Are the grounds manicured and free of debris? Does landscaping invite a feeling of serenity? Is the entrance positively presented?

For example, Mercy Health Saint Mary’s, Grand Rapids, Mich., has a cathedral a short distance away. Because it is a Catholic hospital, it has dedicated resources to identify with the cathedral. This is seen in the walkway from the cathedral to the hospital’s main entrance. Work is underway to move this connection down the hospital’s main corridor to its “Mind, Body and Spirit” suite and also to its cafeteria to display wellness in a multifaceted way.

Additionally, it should be on the environmental services leader’s mind that entrances and exits are focal points and should be monitored routinely to remain clean and free of debris.

Moving further into the facility, a patient will notice whether the windows are clean. Are horizontal surfaces dust-free? Are the elevators clean? Are directions clear as the patient, visitor or staff person navigates throughout the facility? Cleanliness is evaluated at every point of interaction. Is the patient transporter friendly as the patient is moved to and from the radiology department? Presentation is vital to a patient’s perception and customer satisfaction is based on perception.

Once checked in, the patient observes other things. Did the dietary aide knock before entering the room? Does the transporter steer safely and engage in conversation? Does the environmental services technician have a badge that clearly displays his or her name? Does he or she explain his or her role in providing a clean and safe environment? Was the patient greeted by name?

Another move to improve the patient experience is having front-line staff notify the environmental services department leader when they have cleaned a room if the patient or resident was sleeping or out for testing. The leader then can notify the second-shift leader who visits the patient or family to see if the room was cleaned as expected, stating that the patient was sleeping or out of the room during the normal daily cleaning procedure.

A systematic approach of seeking continuous improvement allows the facility to exceed expectations of patients consistently. The environment and the culture of the facility can influence behaviors that will determine patient perceptions which, in turn, should align with the organization’s culture. Environmental services colleagues can be the ones to define the expectation and strive to exceed it in delivery and execution with each interaction.

Building relationships

Improving customer service must progress seamlessly from the C-suite through middle management to front-line employees. A clear and consistent message exemplified in the actions of all leaders is vital to sustaining the culture of the organization. Educating environmental services colleagues to understand the desired impact encourages them to internalize the behavior. An organized and systemic approach is formed as colleagues emulate the behavior.

Customer satisfaction is based on building better relationships through each opportunity for engagement. Interactions with colleagues, patients, vendors and multiple departments are critical to building an infrastructure that creates bonds and reinforces the “wow!” experience. Environmental colleagues should exemplify the organization’s culture. Strong relationships with internal and external customers also will build strong relationships within the community.

Building relationships is the overarching component of customer service excellence. When a facility is being cleaned, environmental services staff can fully engage internal and external customers. It is critical that they perform their duties efficiently. Technically, the environmental services staff members often spend more time in the patient room than any other team member.

If environmental services leaders operate under the premise that the patient is a guest in their workplace and that he or she is not feeling well, department personnel will approach their tasks in a quiet and efficient manner to minimize disruption to the patient. The patient appreciates a quiet entry, a calming presence, a coordinated outline of tasks and a prompt exit. Environmental colleagues should be encouraged to foster a quiet environment for healing. Compassionate communication with respectful presentation and a positive attitude will demonstrate customer service excellence to the patient.

Colleagues throughout the organization should be hired to maintain the culture and be educated with the essentials to motivate performance. The right staff members will elevate the patient experience by modeling positive behaviors.

Gathering feedback

Another, often overlooked, aspect of customer service is the visibility of environmental services leadership. One action is to have each leader visit the floors to talk with staff as well as nursing staff. The next level is visiting with patients or their family members. This is a largely proactive move for the leadership, but also is vitally important.

Another way of receiving feedback is by leaving tent cards in each room. These cards usually have on one side what the environmental services department does on a daily basis and an area with contact information for the department, if further service is needed. An area also is provided for the staff member to sign off on. Provide these tent cards after each daily cleaning and at discharge or terminal cleaning. Another way to receive feedback is to install signage in every public restroom informing who to call if it is not clean.

Additionally, formal and informal customer feedback can be obtained through phone calls and email; routine monitoring of the facility as outlined in the department’s quality assurance program; either phone or in-person contact with each medical center department manager on at least a quarterly basis to discuss the service delivery as well as satisfaction, suggestions for improvement and areas of strength; casual conversations, initiated with various customers on a random basis, to confirm satisfaction with service delivery or identify opportunities for improvement; using Survey Monkey's online survey software; and, of course, through the HCAHPS website.

Excellence at its best

Environmental services leaders and staff can provide a link to the necessary resources for the patient. They can assist by offering to make a call, inform the nurse of a dietary request or report a need to plant operations. As department employees build a relationship with the patient, he or she becomes more comfortable communicating with staff and may share information that requires intervention by another department. Follow-up ensures that the need was addressed.

As patients, visitors or family members engage with the staff, the ultimate goal is to achieve positive experiences. Positive body language and effective communication at all levels are important. Patients remember positive interactions more than they remember names. A positive resolution to all concerns should be the goal of every health care organization.

Environmental services staff should be empowered to connect with patients. They should feel motivated so that every interaction creates a positive patient experience. Allow staff who are ingrained in the culture to develop creative ways within the organizational framework to create innovations that foster patient satisfaction. This interaction brings fulfillment to the colleague, gives comfort to the patient and reinforces the positive culture of the facility.

From cleanliness and accessibility to heavy wear, wayfinding and promoting a healing environment, hospitals face a unique, stringent set of challenges. The flooring is no exception. It’s a crucial part of creating a quality care setting. Below, we discuss various factors to consider when choosing flooring for your healthcare facility and how to incorporate evidence-based design into a hospital flooring plan.

When discussing evidence-based design in hospital flooring, it’s a smart bet to lean heavily on the guidelines provided by The Center for Health Design (CHD), who in 2012 published a peer-reviewed guide to implementing evidence-based design (EBD) in the selection of healthcare flooring. The guide draws on EBD and original research, detailing industry best practices for flooring. This approach sees real results that help promote the wellbeing of those who walk through a healthcare facility’s doors. Here are some key considerations for weighing your healthcare flooring options.

1. Where the flooring is to be used

The entrance of a hospital and its corridors and clinical areas serve different purposes and will face different pressures. Entrances, for instance, are the first area patients, families and visitors see in your hospital. They also experience some of the heaviest foot traffic. You’ll want a durable, welcoming floor that promotes your design vision and makes a strong first impression for your patrons. Corridors also see heavy use, including foot traffic and heavy rolling loads, such as equipment carts, stretchers, med carts and wheelchairs. Clinical areas are at the highest risk of accumulating pathogens and other potentially harmful germs. Accordingly, no one flooring type will serve as a catch-all for each area within your hospital. Deciding whether to use sheet vinyl, LVT, tile or rubber flooring relies on many factors specific to the location within the facility in which it will be used.

2. Minimizing fall risk

Choosing the right flooring can minimize the risk of patients sustaining falls, so hospital flooring should be slip-resistant, impermeable and easily cleaned. That’s all easy enough. But other EBD standards are not as obvious, such as recommendations for finishes. The finishing on hospital flooring should have a low reflectance value as to prevent glare and joints and seams should be few and far between in order to prevent tripping.

3. Texture and noise absorption

Texture affects many aspects of a flooring’s performance, ranging from noise absorbance to reducing injuries relating to falling. Preventing falls is important, but they will inevitably happen, and floors that have energy-absorbent properties will minimize injuries of staff or patients who fall. This can also be achieved through underlays that will increase cushioning. Underlays and finishes can also be used for noise absorbance, reducing noise from rolling carts or heavy foot traffic.

4. Reducing staff fatigue

Nurses, doctors and other healthcare facility personnel work long shifts. And, for much of those shifts, they’re on their feet. Cushioned flooring or mats can reduce staff fatigue, saving their feet and their sanity. However, the CHD recommends that cushioning be combined with roller mobility, so that equipment can still be transferred easily.

5. Minimizing risk of healthcare-associated infections

HAIs are a healthcare facility’s nightmare. EBD can guide hospitals in choosing flooring that best mitigates the risk of HAI, while improving the overall patient experience. The CHD has a host of recommendations to this end. They recommend against using carpet, especially in burn units and operating rooms, where the risk for airborne pathogens is high. Rather, they suggest using easily cleaned, impermeable materials that can easily be cleaned.

6. Color and design

Color is crucial to simplifying wayfinding within the many corridors and wings inherent in many hospitals. Colors and patterns can aid in promoting a “non-institutional” atmosphere, while aiding in wayfinding. Of course, because some patrons of healthcare facilities have sensitive eyes, the CHD recommends using non-glare finishes.

7. Going green

LEED guidelines shouldn’t be ignored when choosing a flooring solution that works for you. In addition to allowing your facility to be in accordance with the U.S. Green Building Council’s standards, choosing the right floor coverings will also improve the indoor air quality of your facility. The LEED for Healthcare guide offers guidance on how to best accomplish this.

Additional resources to consult

• LEED for Healthcare — A flooring rating system developed by the U.S. Green Building Council (USGBC) that takes evidence-based design and indoor air quality into account

• Green Guide for Healthcare (GGHC) — a best-practices guide for healthy and sustainable design, construction and operations for healthcare facilities

• FloorScore — a rating system developed by the Resilient Floor Covering Institute (RFCI) in conjunction with Scientific Certification Systems (SCS) that evaluates flooring for VOC emission levels and compliance with other rating systems

• ecoScorecard — a composite tool showing flooring products that comply with the most popular rating systems

• Spectra Trends in Commercial Flooring Guide — the latest in flooring materials, design and decision-making frameworks so you can select the best floor for your facility

Using EBD to make your hospital flooring decisions boosts ROI in the long run. Flooring that maximizes safety and quality, while minimizing harm to patrons and staff, will ideally maximize ROI. Using a specialized contract flooring partner that understand the varying needs of healthcare facilities will go far in promoting the efficiency and safety of your hospital.

Developing a hospital floor cleaning program

Advice for environmental services professionals on daily, periodic and restorative maintenance

Rock Jensen

In hospitals and health care facilities, there are few cleaning techniques that can make an impression like a well-maintained floor. From the moment visitors walk into the facility and glance around, their first impressions of the overall cleanliness are made by how the floors are presented.

Walk-off mats, though not a part of the physical act of cleaning floors, are essential aspects of the floor-cleaning process. They do more than just protect people from slips and falls in wet environments. They are the first line of defense in removing and preventing dirt from coming into a facility.

Matting placement should effectively remove the dirt in a systematic way. An aggressive scraping mat placed outside of the entrance can remove up to 50 percent of the soil before it enters the building. Designed to collect the bulk of the dirt, the scraper should be at least 6 feet long and as wide as the doorway so it allows two steps with each foot.

Key components

Floor care in hospitals includes key steps that combine to make the floor care process more efficient, reduce wear and abrasion and extend the life of the floor. Skipping these steps will only mean more long-term labor and expense.

The inside of the door should be followed by 15 feet of a wiping-type matting to remove any dust or soil that might remain on the shoes. This will ensure three steps per foot for the cleaning process. Environmental services (ES) managers must remember to change matting when it is soiled. This may require daily changing when soiling is heavy.

Finally, safety is paramount when performing any floor care maintenance. ES managers should ensure the appropriate use of “Wet Floor” or “Caution” signs anytime a wet-cleaning process is to be performed. Managers should ensure that the sign or caution tape is placed so that it will alert someone before entering the work area. Staff should wear appropriate protective equipment such as safety glasses, gloves and nonslip footwear.

Any equipment that might be used should be inspected to ensure its safety. Likewise, ES managers should think about the chemicals that will be used and their hazardous-response procedures.

Maintenance intervals

Using the appropriate tools and chemicals for each part of the floor care process will avoid damage to the floor care surface. Using the wrong product will void the floor manufacturer’s warranty and could mean significant expense to replace any damaged flooring.

In general, floor care maintenance is divided into three frequencies. These processes specifically are for vinyl composition tile and vinyl flooring surfaces:

Daily maintenance. As the name suggests, this is a routine process of removing dry soiling such as dust and dirt through vacuuming, dust mopping and damp mopping. By following these simple processes frequently, the hospital can extend the time between more aggressive and costly processes.

The first step is to remove the dry dust and soil not removed by the matting. This is most efficiently accomplished by vacuuming carpeted surfaces and dust mopping, then damp-mopping hard floors. This should be performed daily at a minimum and more often when conditions require. The dirt removed at this point in the process doesn’t have to be removed later with more aggressive processes and expense.

This daily cleaning should be performed more frequently at all entrances and less frequently farther into the center of the facility. Microfiber products are effective when used dry or with water because microfiber cleans surfaces mechanically, not chemically, by scraping the surface with microscopic precision.

The best chemical for mopping most hard-surface floors is a neutral — pH between 6 and 7 — floor cleaner that has no strong alkaline ingredients that might remove polish. Outside of surgical and invasive practice areas, floors in patient areas are not typically considered sterile environments.

If a health care institution requires that disinfectants be used on floors, a quaternary product should be used, followed by a neutral floor cleaner to rinse the floor after the disinfectant has dried. ES managers should ensure proper dilutions of all chemicals to prevent excess chemical residue on the dried floor.

Periodic maintenance. This consists of more aggressive methods, which incorporate scrubbing, buffing and burnishing. Depending on the traffic volume or location of the particular floor, this could require daily maintenance or it might be performed weekly or semi-weekly.

Again, higher-frequency scrubbing is performed in locations closer to facility entrances and in high-traffic areas vs. locations toward the center. When creating floor-cleaning schedules, this methodology should be utilized to ensure that time is spent where needed.

All floors should be dust mopped prior to using a floor-scrubbing process to prevent excess dirt from accumulating on the scrubbing pads and equipment, and being sucked into the vacuum motor system or scrubbed into the floor finish. After placing safety or caution signs in the area, the floor is ready to be cleaned. The floor scrubber uses a process of placing water or cleaner on the floor, scrubbing with moderately abrasive nonwoven pads, and then removing the water with a vacuum. This is typically done in one continuous process as the machine passes over the floor.

A pH-neutral floor cleaner or similar product can be used in the floor scrubber. If there are individuals with respiratory sensitivity in the area, water can be used. The operator should make overlapping passes with the machine in the center of hallways and corridors where most traffic occurs, and only one pass near the walls where there is less traffic. If this is performed late in the evenings, nursing can be consulted to see if patient room doors can be closed to limit disturbances.

Burnishing restores a gloss or shine to a clean, dry floor. A soft, light-colored pad that is less abrasive is used on the bottom of the burnisher to move across the floor surface. Burnishing is when the pad levels out any light scratches that could catch dirt, heating up the floor finish and mildly reshaping it before finally smoothing out the top layers. Care must be taken in this process to ensure that the burnishing pad is constantly changing locations so as not to “burn” the floor finish.

Spray buffing is a process that uses a specially formulated solution that is sprayed on the floor and then immediately buffed with the machine until dry. This process levels and fills scratches and reduces the need for more aggressive floor care maintenance, plus it enhances the floor’s glossy look. This process is more time-consuming than burnishing, but can be useful in high-traffic areas.

Restorative maintenance. Stripping is the most aggressive aspect of floor care and is performed when the finish has become degraded and cannot be maintained with scrubbing and burnishing to provide the desired shine and protection.

The restorative process consists of removing the remaining old finish from the floor surface and applying new layers of finish. Stripping solutions are aggressive and caustic. Care should be taken to protect skin, eyes and clothing from splashes. Nonslip protective shoe coverings should be used because the floor surface will become slippery during this process. The stripper’s pH should be between 8 and 9, but not exceed 10 to prevent damage to the floor surface.

The process consists of spreading the stripper onto the floor surface. The floor must remain wet the entire time ES professionals are working with the stripper so they should not spread out more stripper than they can work with in a few minutes. After applying the stripper, it should sit for a few minutes to start dissolving the remaining floor finish. While the floor is wet with stripper, ES professionals use a floor machine with an aggressive black pad on the bottom to scrub and remove the finish.

A putty knife or scraper also is useful in removing floor finish in corners, along walls or in tight locations. Before the stripper dries, it should be rewetted with additional stripper to continue working or removed with floor vacuums. The floor should be rinsed completely with water when stripping is complete.

Applying new floor finish is the most critical aspect of the entire process. Though floor finish application can change from different manufacturers, some aspects are the same. The first coat should be applied thinly. A flat-finish mop is good for this purpose. If the first layer is too thick, the finish can adhere or cure improperly, ruining the other coats.

The typical application process is to outline the room with finish, then work back and forth across the floor. ES professionals should allow time for the finish to dry completely before applying the next thin coat in the same manner. Six coats should be sufficient. Areas with less traffic require fewer coats.

Rock Jensen is senior consultant for Soriant Healthcare in Milton, Ga. He can be reached at Rock.Jensen@sorianthealthcare.com.

How does your Quality Management Program Stack Up?

Top Eight Quality Checks for Your EVS Quality Management System

In today’s healthcare landscape, the emphasis on quality metrics, quality outcomes and performance improvement processes has exploded as healthcare reimbursement policies become more focused on quality and patient satisfaction. Building a successful Quality Management System for Environmental Services is not only required for regulatory compliance but also essential to realize patient safety and satisfaction outcomes. Healthcare Environmental Services leaders must have a comprehensive quality management program which measures and improves outcomes for the variety of EVS tasks provided in multiple buildings and room types on all shifts.

So, how does your Quality Management System measure up? Check your system against these eight leading edge characteristics of a great EVS quality management system.

Reputable

Is your QM system recognized by your internal customers as valuable to the organization? Your quality metrics, your quality measurement practices, and your quality improvement processes must be viewed as credible to nursing/perioperative leaders, ancillary departments, infection prevention and hospital administration. The outcomes you achieve with your QM program must match the vision of your internal customers in order for your quality reputation to be valid. So how do you develop a reputable quality management program? You must include your stakeholders in your QM design process and also in your annual review processes so that your metrics for tasks and frequencies consistently meet their expectations. Since your internal customers are your primary customers, they are also your primary reputation builders.

Rational

Are your QM metrics and criteria easily understood by everyone? Do they make sense to those in your organization? They must be clear and concise in order for everyone to understand them. Your descriptions of environmental services cleaning standards, waste management and textile services must create word pictures in the minds of your employees, your supervisors, and of course your internal customers. For example, a vertical wall surface “free of black marks, streaks, smudges and hand prints” creates a visual picture in the mind of the reader. A toilet seat “free of body fluid spots or debris” also creates a visual impression in the mind of the reader and a waste receptacle “less than ¾ filled” creates a visual photograph in the mind of the reader. The more rational the criterial, the better change of accomplishing the intended outcome.

Realistic

Are your QM metrics realistic given the number of FTE’s, patient volume and acuity in your facility? For example, if your metric for hard floor care is a continuous “wet look” floor appearance yet you have limited project staff to perform floor maintenance operations, then your metric is unattainable. If your metric is weekly floor machine scrubbing for each OR suite but you lack adequate staff you have unrealistic expectations in your quality management program. Your credibility is only as strong as your ability to keep the promises you make so realistic quality metrics are essential.

Rewardable

Is there a meaningful link between your recognition program and your quality management program? Are your employees recognized for years of service, birthdays and productivity more often than they are recognized for their quality outcomes? While length of service and productivity results are certainly worthy of recognition, EVS workers who are frequently recognized with “meaningful rewards” for excellent quality outcomes will more readily connect with quality management metrics and strive to achieve better results.

Random

Are your Quality Measurement activities random or predictable? Do they promote continual survey readiness? If your employees are able to predict your favorite inspection areas or your inspection days, their human nature help them unconsciously prepare for your survey according to your pattern. For example do you have “inspection shoes” or certain days when you have fewer meetings and more inspection time? If you are able to create a truly random system of quality inspections, your staff will have to learn to embrace continual readiness and your quality management results will improve facility wide.

Routine

Are your quality measurement activities a planned and routine part of your department operations? Or are quality surveys often cancelled by staff shortages, supervisory vacations or special projects? If your quality management activities are sporadic or performed only after all other activities are satisfied, then quality management may appear to be a low priority to your staff and internal customers. The volume of your quality management activities reflect your commitment to quality management as a top priority. This means your inspection volumes should be evenly distributed throughout the month and the year.

Regulatory

Does your quality management system reflect the regulatory surveys you expect for accreditation or licensing at your facility? Whether your surveyors are from TJC, DNV, CMS or DOH, they will each use a list of standards or guidelines during their survey process. Your quality management reviews should include all of those regulatory items. For example, if your local health department mandates that onsite biohazard waste storage be limited to 72 hours, then your QM program should include a review of biohazard waste storage time. If your accreditation survey guidelines require an annual competency certification for each of your staff members, then your quality management program should include monitoring of annual department competencies completion for each employee. If you are required to keep your clean linen products covered at all times, does your QM review include a check of clean line storage and transport practices. Matching your survey requirements with your QM program ensures continual readiness and better survey outcomes.

Reportable

Are your quality results summarized in electronic format such as graphs or dashboard? Are you able to present a one page summary of your quality management results at your QM/PI monthly meeting, your employee meetings or for your board reports? Does the manner in which you report your quality results inspire confidence in your Environmental Services technical expertise and leadership abilities? Are you able to drill down in your QM data to source information for ratings, by room or employee so that you can participate in tracer methodology survey processes with clinical departments? There are several automated QM systems designed for Environmental Services that you can use to capture and report your quality metrics and outcomes. Even for smaller facilities, the use of QM software tools will save you precious time and ensure that your QM system is comprehensive and your reports are professional.

For more information on EVS Quality Management Systems visit www.smartfacilitysoftware.com

Cindy E. Paget has worked in healthcare since 1986, leadership development and consulting for Environmental Services and Human Resources. Cindy is a member of AHE, CHESP and SPHR certified and serves as a convention speaker and writer for healthcare learning events. Cindy holds a dual degree BS in Business Administration /Information Systems and an MA in Organizational Leadership and lives in Sequim, WA. .

Staff Training and Development ~ Does it Really Matter?

Does sending your kids to college matter? And, if you are not a parent yet, why did your parents send you off to college? Most high school graduates can read, write, and even do basic math. So why the extra time, effort, and expenses when they can just get a job with a high school diploma? This question can be answered in one simple word - Knowledge… In this day and age, knowledge is power, and more knowledge equals more power. The same is true for staff training and development. The more you infuse your staff with knowledge, the more confidence they will have to perform their job at a high level. This in turn, makes you, the boss, look good and makes your operation run that much smoother. I would say that’s a significant benefit. Wouldn’t you? But, that’s just one “selfish” benefit…

One of my favorite ex-bosses used to refer to himself as “a Housekeeper in a tie”, and after 12 years in Healthcare I can say, “I disagree with you Jim!” It is not a secret that the word “trash” comes to mind whenever housekeeping or environmental services is mentioned in a conversation. Admit it or not, that’s at least the perception; we are just “trash collectors” or “housekeepers in a tie”, if you are in management. Personally, I prefer the term “life savers” because in essence, that is what we do. Let’s think about it for a minute…If an environmental services worker is properly trained to clean and disinfect an isolation room after a MRSA or C-Diff patient is discharged . . . couldn’t that possibly save the life of the next vulnerable patient who occupies that same room? Even if that means saving only one out of the 99,000 patients that die each year from acquiring an HAI in the US (according to the CDC). Isn’t that significant enough? You better believe it!

Besides being a confidence booster, and potentially saving lives, there are numerous other advantages to staff training and development. Let’s examine a few other benefits:

It gives your staff a sense of belonging which in turn will increase loyalty and decrease turnover.
It’s comforting to patients and customers alike knowing that your staff is fully trained and competent to address any of their needs.
Several training topics are mandated by local, state, and/or Federal laws, so non-compliance could translate into a loss on an organization’s P&L statement. That usually means trouble!
Greatly assists your organization in passing inspections or accreditations such as The Joint Commission, OSHA, or even in-house.
Training separates your organization from the competition.
It is the smart thing to do.

There are many benefits and advantages of training and staff development to an organization that outweigh the nuisance of implementation and up-keep. Best of all, it doesn’t have to be very costly, because all you really need is a classroom or a meeting space, commitment, and some creativity to make it happen. So does staff training and development really matter? I believe the answer is no secret!

The Calendar

Meetings, appointments, interviews, when to pick up the kids…these are all things we put on our calendars to help us plan our days and to help us remember where we have to be and when we have to be there.

At Wheaton Franciscan Healthcare, the Environmental Services Department uses their calendars to schedule weekly and monthly tasks and to help keep hot spots cooled down. Managers and Team Leads develop the tasks on the calendar by touring the buildings and reviewing complaint emails and calls.

The tasks are placed into a Microsoft Outlook calendar appointment which pops up the Managers and Team Lead’s calendars the first of each month. The appointment is editable so tasks can be added or deleted as time progresses. The Director of the department manages the list and checks items off as they are completed.

Each Manager, Team Lead and even the Director is assigned specific tasks to complete. For example, Mangers have a list of leaders in the facility to schedule rounds with and Team Leads have a list of tasks to accomplish before the month ends. Cleaning the trash cans outside of the entry ways, project work in larger areas and checking the eye wash stations are tasks scheduled for the team Leads. The Director is to tour and inspect completed tasks, encouraging the Managers and Team Leads to expand and improve the list.

The calendar has helped to teach the Team Leads and new Managers how to prioritize ongoing tasks and how to manage their time better in a hectic environment such as Environmental Services. None of the tasks are urgent, but they all need to be completed within the month.

The calendar has been in place for over a year and it has cooled off many of our nagging hot spots.

Antimicrobial Stewardship

Antimicrobial stewardship is one of the top priorities in the realm of infection prevention and control. The term antimicrobial primarily includes antibiotics that target bacteria, antivirals that target viruses, and antifungals that target fungi. The concepts of stewardship include selection of the right antimicrobial agent for the right purpose, the right dosage to treat or prevent the infection, the right route of administration, and given for the right duration. Inappropriate use of antimicrobials has been a major player in development of organisms that are now resistant to the antimicrobials once used against them. The organisms are smart, so we must be smarter in our approaches.

Many in infection prevention erroneously think that only the ordering healthcare provider, such as the physician or nurse practitioner, is responsible for stewardship when in fact we all have a role to play:

The ordering healthcare provider is responsible for selecting the right antimicrobial that targets the organism known or suspected to be causing the infection;
Often, the healthcare provider has to use an educated guess to forecast the causative organism because a culture has not yet identified the organism(s). For this forecast to be successful, information must be compiled by the microbiology laboratory in the form of an Antibiogram. This antibiogram provides the ordering healthcare provider with information about what types of organisms are seen in that particular facility and/or patient care area. Identifying the most likely culprits enables a more accurate initial choice of antimicrobial agent;
In order for the antibiogram to be accurate, healthcare personnel responsible for collection of culture specimen must do so in a way that prevents contamination. If a culture specimen is contaminated, the microbiology laboratory may not be able to accurately identify the organisms and their data used to develop the antibiogram may then be inaccurate. This prevents the ordering healthcare provider for being able to accurately forecast likely organisms causing illness in the patient;
If the ordering healthcare provider waits for culture results to select the right antimicrobial agent, the healthcare personnel collecting the specimen for culture must use excellent technique so the culture results are accurate;
Even when best practices have been used to select the right antimicrobial, collect the specimen for culture, perform the culturing process, and develop the antibiogram, resistance can still occur. When organisms are subjected to treatment with an antimicrobial agent, they develop abilities to withstand that impact by developing ways to “resist” the effect of the antimicrobial agent. Once organisms have learned how to “resist” the effect, they become classified as resistant organisms. If they are able to resist several different antimicrobial agents, they may be termed “multi-drug resistant”. This also means that their environment will now harbor these resistant organisms. Environmental services personnel are critical in the fight against drug resistance and they, too, have a role in antimicrobial stewardship. Their role involves reduction of the burden of the organsims in the patient and facility environment through attention to environmental hygiene.
Environmental Services personnel also take stewardship one step further through appropriate use of the chemical disinfectants and disinfectant procedures used during performance of their job responsibilities. Selection of the right disinfectant, proper dilution, proper application of the disinfectant, and enabling adequate contact time mirror the actions done by the ordering healthcare provider when they are selecting the right antimicrobial agent. It is easy to see that selecting the right agent to treat the environment is important, just like it is important to select the right agent to treat the patient.
Environmental Services leaders are vital to the success of infection prevention interventions. Environmental Services personnel must understand their job responsibilities and have knowledge as to why their work is important. They must be enabled to do their best work. For this to happen, leadership must continuously work with their staff so they recognize barriers to work performance. Systems must be agile enough so personnel can adjust work practices as changes in resistant organisms are identified. A simple example involves the ability to change disinfectants in the event an outbreak of C. difficile is identified. Environmental Services leaders must ask themselves if their workers have the abilities and the power to make changes that may arise outside of routine business hours, on weekends, or holidays. Are we enabling the workforce to use their knowledge and desire to improve patient outcomes? If not, this is a change that must start today.

This overview of antimicrobial stewardship shows how healthcare personnel at every level must work together and perform their job responsibilities consistently and at a high level of quality at all times. If there is a breakdown at any point in this complicated process, the patient is the one who suffers. Our responsibility is to do our best work, do what is right for our patients and our coworkers, and treat others like we want to be treated. Together, we can achieve the best for those who depend on us—our patients.

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