The 21st century has brought new and evolving drug-resistant strains that can be deadly to frail, immunodeficient and otherwise compromised patients. Preventing contact, airborne and waterborne microorganisms from infecting vulnerable patients has
become a formidable challenge for all health care providers.

In many respects, environmental services (ES) employees, frequently referred to as housekeeping staff in days gone by, are now recognized as a major defense factor against the spread of infections in hospitals. In fact, when it comes to patient safety, no single role is more important than that of the ES team.

"When our ES staff explain their roles, we want them to say that they prevent infections," says Dr. Dan Salinas, chief medical officer at Children's Healthcare of Atlanta (CHOA).

Thus, it is time the ES field be elevated to the stature of a profession. If patient survival rates and outcomes are to be improved, additional attention must be invested in ES staff ranging from enhanced education and training to cre­dentialing, certifications and resources.

Transforming the image

When reviewing hospital employee pay scales, one will discover ES personnel are often near the bottom. No secondary schooling or certifications are required, or encouraged. A physical exam, background check and a negative drug test will parlay an able-bodied, well-intended person into an ES job. To compound the problem, only minimal training historically has been imparted to them.

If ES employees are to realize the importance of their roles, several tangible changes are in order and, ultimately, environmental services must be embraced as a clinical profession.

For starters, instead of organizing the hospital-based department with a reporting relationship to ancillary support services, the department should report directly to safety or infection control. At CHOA, a safety division is being structured within the facilities management and support services department that will include
environmental services.

From a human resources perspective, ES position descriptions should be rewritten, retitled and regraded. To evoke a rebirth of ES employee pride, enact significant quality enhancements and help other health care workers acknowledge the evolution of the ES role, the department image must be elevated.

Zach Plaskon, ES manager and content expert at Children's Healthcare of Atlanta Hospital at Scottish Rite, suggests "environmental clinician" as a new title for selected members of his ES team. In fact, CHOA plans to recruit infection prevention clinicians into vacant ES management positions.

To instill new pride and emphasize this renaissance in the ES field, it will be necessary to provide different uniforms, perhaps with a more old-fashioned, clinical appearance. A white shirt or a dental smock with navy blue or gray slacks may provide such differentiation among the health care ranks; something perma-pressed and washable will be needed.

To professionalize the ES discipline, more emphasis should be placed on education and motivators for the team. Formal learning forums, town hall meetings with leaders and brainstorming sessions are recommended to capture innovative ideas and to gain buy-in. In addition, education for non-ES staff should enable co-workers to understand, appreciate and support ES employees.

Hospitalwide acknowledgments, celebrations and public awards are a must as ES staff achieve daily successes centered around the protection of human lives.

Operational model

A lot is expected of ES staff: A cheerful demeanor, a helpful attitude and professionalism are required whether the task at hand involves laundry management, floor waxing, toilet disinfecting, vacuuming, trash removal or testing for quality and for surface contaminants.

Moreover, after a patient room is cleaned, ES supervisors at CHOA test room surfaces for contaminants. If the test results are positive or inconclusive, additional cleaning must be undertaken without delay.

Collaboration between ES and infection control teams is fundamental. For example, the infection control team led by Renee Watson, R.N., CIC, manager of infection control at CHOA, developed and implemented an "ES bundles" concept that has proven successful.

Bundles, which are groups of scientifically validated processes, "have proven successful in eliminating bloodstream, ventilator and surgical infections," Watson says, "and the same concept has been applied to cleaning." In such a program, standardized cleaning processes such as a three-cloth, hands-free approach for different areas based on degree of disinfection required and threats present are evaluated daily through qualitative and quantitative measures.

Cleaning methods involving push carts, mop buckets with wringers, terry cloths with spray bottles, water pails, string mops and dust mops have been replaced with color-coded microfiber cloths (i.e., yellow for toilets, blue for patient rooms), single-use mops and cleaning stations.

Step-by-step cleaning processes that are adhered to daily were developed on a service-line basis. This approach hardwires the system, which is integral in sustaining improvements in patient safety. It makes the process easy and consistent.

Additionally, a hygiene policy was developed as part of the infection control process.

Frequently touched surfaces that were previously overlooked are now being cleaned and disinfected on a daily basis. Examples of surfaces that must be dis­infected to control contamination and prevent transmission of disease include doorknobs, telephones, light switches, clinical equipment, bedrails, over-bed tables, linen hampers, waste receptacles, window sills, IV poles, thermometers, monitors, computer keyboards, TV controls, nurse call buttons, call light deactivators, handrails, faucet hardware, toilet walls, shower benches and other high-touch areas. Surfaces are classified into critical and noncritical categories, dictating the cleaning protocols. More stringent procedures are observed for patient isolation rooms (i.e., contact, airborne or droplet isolation).

Now more than ever, job responsibilities must be carefully defined and communicated, particularly in areas where multiple departments have responsibilities for cleaning, such as in operating rooms where both the ES and surgical teams are responsible for rendering the rooms sterile. It takes approximately one hour and 45 minutes to terminally clean a single operating room at the end of each day. Additionally, there must be clearly defined roles regarding clinical responsibility versus ES responsibility. Meetings with all stakeholders are necessary to map out these plans.

New technologies, equipment and products are helping to meet the challenge. Computerized color-coded teletracking software now enables ES managers to track patient room vacancies and generate meaningful reports that monitor room turnaround times by individual ES full-time equivalents (FTEs) or the number of discharges per day or per unit.

For example, ES supervisors are now able to monitor performance quality through the use of computerized handheld personal digital assistants (PDAs) that enable rapid data input for accurate results and reporting.

New equipment, such as mechanized floor strippers that require only water, are enabling personnel to strip and wax an area in a single night. Other innovative cleaning devices, such as high-pressure "no-touch" cleaning equipment, also can prove useful in improving ES department efficiency.

Operations improvement

Regardless of the level of confidence in hospital ES quality and outcomes, a lean operations improvement activity should be embarked upon. When doing so, ES managers should bring selected members of the ES team into a room for a few days to discuss and examine the current ways of doing things, current processes and the barriers they may be facing.

Then, improved solutions should be identified: Conduct brainstorming sessions focused on ideas for correcting or improving quality, efficiency, cost containment and pride. Devise a work plan with timelines and accountabilities for implementing recommendations agreed to by the lean participants. Follow up, assess and continue to raise the bar each month to achieve continuous improvement.

It will be important to develop a dashboard or scorecard that includes ES performance metrics tied to infection prevention patient outcomes. The monthly dashboard for multidrug-resistant organism metrics and infectious disease should include key ES indicators associated with quality inspections, pathogen counts and the resulting microbiological presence.

While patient satisfaction surveys contain important feedback, quantitative data linked to infection control, patient safety and patient outcomes are needed for ES performance improvements. Validate that ES managers are invited to serve on any hospital-based or systemwide environmental safety management committees and attend the monthly meeting forums. They will bring great value to the discussion and are likely to benefit from the initiatives of other disciplines.

Finally, ES managers should encourage hospital administrators to get to know their ES staff. They may even change into one of their uniforms and undertake some workaday activities with them. Administrators are likely to receive invaluable ideas and new support in their mission to save lives and improve the quality of life for patients.

Revolutionizing ES

ES education, training, quality assurance, recognition and mechanisms of encouragement such as resources are all important if hospitals are to win the fight against infection.

It's time to revolutionize the traditional ES department and ensure that its practitioners are viewed as true professionals. It's time to make a difference.

Constance Nestor, FACHE, is vice president of facilities management and support services for Children's Healthcare of Atlanta. She can be reached at The opinions expressed are her own.

Sidebar - Tips for improving ES department performance

Improving environmental services (ES) department performance is key to enhancing the reputation of ES personnel. Following are some tips to help achieve such performance improvement:

• Don't base ES staffing on census. Daily discharge statistics don't include patient transfers required for isolation cases or roommate issues and the associated terminal cleaning requirements.

• Total cumulative surface areas should be computed when calculating the number of full-time equivalents (FTEs) required to clean a facility. Calculations shouldn't be based on square footages by floor alone. The American Society for Healthcare Environmental Services' Practice Guidance for Healthcare Environmental Cleaning, which can be found at, is one source for alternative staffing methodologies.

• Place potential discharge rooms last on the schedule to avoid duplicative cleaning.

• When ordering cubicle curtains for a new facility or wing, order 1.5 the number needed to accommodate a continuous cleaning schedule.

• Purchase durable furniture, counters and equipment that can withstand the daily use of disinfectants, germicidals and bleach.

• Purchase chemicals and cleaning products that are color-coordinated for error reduction and to allow managers to easily spot-check that they're being properly used.

• Consider the costs of labor involved with cleaning and maintenance when selecting new flooring and other materials. Some materials require less attention than others, which results in significant cost avoidance.

• Remember that visual cleanliness checks are insufficient. Contaminated surfaces can appear clean.

• Follow all regulations regarding when to change gloves, mop heads, solutions and other requirements. The Centers for Disease Control & Prevention, the Healthcare Infection Control Practices Advisory Committee and others have released guidelines for such issues.


Sidebar - Winning the war on overtime

A good environmental services (ES) manager will have everything calculated to the penny: the staffing, the hours, materials and product. Data-driven decisions are made daily based on patient census and volumes, with staff levels flexed up or down based on need. So what happens when an ES manager's budget and staff overtime hours are strategically reduced?

Several options can help. A request to over-hire may be submitted to the human resources position control group. If additional employees are recruited to fill the ongoing vacancies, the overtime need will disappear. The obvious risk is that of accumulating too many employees should vacancy rates improve, but turnover is constant in most ES departments. Automation should be brought into the equation to control daily staffing on a departmental basis. Cleaning process efficiencies also may be improved through lean process improvement exercises. If all else fails, new positions hired at a slightly higher pay scale but recruited to work flexible shifts that may change every week may be considered.

Great management is required in environmental services. Leaders who will commit to delivering on business metrics, possess the required inspirational skills and truly care about quality are a perfect fit.