Breaking the chain of infection

MD Anderson’s ES team steps up fight to protect patients

Article Images

From left: MD Anderson’s Luis Morales, CHESP, manager; Alonzo Gonzalez, CHFM, CHESP, director of patient care properties; Jerry Mathis, EVS manager; and Jeff Brown, CHESP, EVS manager.

Photo copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center

At the University of Texas MD Anderson Cancer Center — one of the world’s premier cancer institutions — the primary goal of the environmental services (ES) department is to help break the chain of infection.

Because cancer patients’ immune systems may be compromised as a result of treatment, preventing potentially life-threatening infections is absolutely critical, ES leaders say.

“In any other ES department, the focus would be on infection, but because we are a cancer center, we take the duty that much more seriously,” says Alonzo Gonzalez, CHFM, CHESP, director of patient care properties. “We work very closely with our hospital infection prevention department in identifying any areas of concern and any means of improving our outcomes.”

The ES team takes a multidimensional, collaborative approach to improving outcomes at the Houston institution that is consistently rated No. 1 in the United States for cancer care by U.S. News and World Report.

This approach, which has decreased infection rates substantially over the years, is central to the ES team’s overall goal of providing a healing environment along with a clean, well-maintained facility. And it is one of a host of reasons MD Anderson was chosen as the winner of Health Facilities Management and the Association for the Healthcare Environment’s 2014 ES Department of the Year award in the 450-plus beds category. The award recognizes outstanding ES performance in 14 critical areas.

Clean team

From hand hygiene to enhanced environmental cleaning, the ES team is continually working to create an infection-free environment in the 600-bed facility containing 2.3 million feet of cleanable square footage.

Along with strict cleaning protocols and mandatory staff training in safety and infection control, leveraging the newest technology is critical to the team’s success. The ES department recently completed a successful radio-frequency identification-enabled, hand-hygiene monitoring technology pilot program on eight patient beds, and plans to expand the program. The Web-based program and ID devices worn by staff communicate through the hospital’s AeroScout wireless system.

The ES team uses the Xenex pulse ultraviolet lighting system to help keep patient rooms and high-touch environmental surfaces free of contamination. The system is used primarily in isolation rooms to prevent the spread of Clostridium difficile, methicillin-resistant Staphylococcus aureus and other infectious diseases. “The Xenex system ensures that our rooms are clean for patients,” Gonzalez says. “We have used this system in thousands of discharges.”

Because timing is critical, ES leaders use bed management software to communicate with the admissions department, ensuring timely availability of patient rooms. Managers also rely on turnaround staff schedules adjusted around peak days and hours for discharges. “If a high number of discharges occur outside the peak times, our on-duty building attendants step out from their assigned work zones and get the rooms cleaned, disinfected and ready for the next patient,” Gonzalez says.

The team relies on microfiber wet mops, cloths and dust mops, which have saved the facility thousands of dollars by reducing the use of cloth mops and paper products. Another green initiative — the Pulse Mopping System — increases productivity, reduces chemical waste and saves on water usage.

Measuring the progress of cleanliness efforts is critical. MD Anderson relies on ATP (adenosine triphosphate) testing to verify the cleanliness of high-touch surfaces in patient care areas. The system measures the amount of organic materials in a sample (blood, mucus, bacteria and viruses), indicating whether a surface needs to be recleaned or cleaning methods need to be changed. “We use APPA [Association of Physical Plant Administrators] standards to gauge our findings and compare the results from one year to the next to see if the results have improved or declined,” says Jeffery Brown, CHESP, environmental services manager. “This helps us to identify the areas we need to focus on to improve our ratings.”

As another tool, MD Anderson recently adopted a quality space program — a visual inspection process using measurements ranging from 1 (the cleanest) to 5 to validate and ensure a clean healing environment. “To be effective in our fight against the spread of germs, it was determined that we must maintain a performance in the range of level of 1 or 2,” says Gonzalez, adding that the department has accomplished this goal.

Such enhanced cleaning techniques have resulted in steadily decreasing infection rates at MD Anderson. For example, between 2011 and 2013, the incidence of nosocomial multidrug-resistant organism (MDRO) infections decreased from 1.092 infections per 1,000 patient days to 0.721 infections per 1,000 patient days. Senior leaders recognize the ES team’s contribution to the facility’s low infection rates.

“As we learn more and more about the role of the hospital environment in transmission of multidrug-resistant organisms to our very susceptible patients, environmental services was not afraid to experiment with new technologies, learning new methods and training on new processes to enhance environmental cleaning and improve our rates related to MDROs,” says Roy F. Chemaly, M.D., FIDSA, FACP, professor of medicine, director of the infection control section and director of clinical virology in the department of infectious diseases, infection control and employee health. “Their hard work is reflected in part in our rates that are below benchmarks nationwide. We appreciate all they do to keep our patients safe.”

Measuring satisfaction

Along with keeping patients safe, keeping them satisfied is central to MD Anderson’s mission. To measure those gains, the ES department uses an internal dashboard along with data from Press Ganey Associates Inc., which consistently ranks the ES department in the 90th percentile for courtesy and cleanliness. In addition, Press Ganey recently presented MD Anderson with a Summit Award for sustaining a mean score in the 95th percentile or higher. “The award reflects how seriously we take patient satisfaction,” Gonazalez says.

While staff routinely spend up to 20 minutes a day in each patient room, ES managers also put in face time by making random, in-person rounds to visit patients. To supplement that strategy, the ES team recently adopted new technology also used by the facility’s nursing staff — iRound software, which allows staff to conduct patient satisfaction rounds on mobile devices and get immediate feedback. Managers pleased with the results on a limited scale plan to expand iRound to 21 patient floors in the near future.

“Most of the time, patients are generally satisfied, but if we get an occasional complaint or constructive criticism, it only helps us to make improvements,” says Brown. “We want to make sure that patients not only have a clean room, but that their perception is that the room is clean.”


Because the facility is constantly expanding, cutting costs wherever possible is critical. Although the ES department doesn’t generate income, the team saves significant costs by working to help keep infection rates low, reducing inefficiencies and adopting green technologies/recycling strategies, among other initiatives.

For example, using microfiber products has produced an estimated savings of $81,177 a year. In terms of recycling, estimated savings for landfill diversion of solid waste in 2013 was $66,360. In-house recycling strategies also are translating into cost — and resource — savings. The “Battle of the Buildings” recycling competition among nine buildings or building groups measures each group’s total recycled waste stream, with a winner awarded for the most points.

And because the ES department must adapt to ongoing building and expansion, managers are continually seeking to realize those changes at the lowest cost. For example, a series of projects planned for 2010–2013 included expansion of the Alkek Hospital patient tower from 13 to 24 floors and expanding the Children’s Cancer Hospital. ES leaders estimated the need for 40 additional employees to handle the full list of planned projects.

“By aggressively evaluating any vacant positions and the existing schedules, we managed to meet the staffing need of the increases in service from 2010 to 2013 with a net total growth of three full-time employees,” Brown says. “We are an in-house operation and we want to remain in-house, which means we have to stay very competitive.”

Above and beyond

In fact, that mindset is one of the reasons the ES department has such an impressive track record, yet is continually looking for ways to improve. Hospital leaders who know how to inspire and motivate their staff through initiatives like communication boards, town hall meetings, weekly team huddles and reviewing the “Thought of the Day” (one example, “take ownership of patient needs”) with their respective teams are getting the desired results across the board.

“Although the team is highly productive, we’re always asking them to do a little bit more, to do a little bit better,” Gonzalez says. “We accept the fact that we have areas where we’re doing great and areas where we need to improve, but our goal is to keep getting better.” 

Article Images

Wentworth-Douglass Hospital’s ES management team (from left): Rob Daigle, CEH, CHESP, EVS manager; Caitlin Collins-Heon, second-shift supervisor; Abdul Chaggouri, third-shift supervisor; and Michael Catanzaro, REH, CLLM, CHESP, EVS director.

Photo courtesy of Wentworth-Douglass Hospital

Team cleaning delivered with a special touch

Wentworth-Douglass Hospital ES staff enrich the patient experience

Along with a warm smile and a friendly greeting, it’s not uncommon to see an environmental services (ES) staff member at Wentworth-Douglass Hospital helping a patient find the right department or directing a visiting family member to the cafeteria for coffee.

Nor is it unusual for an ES team member to go to even greater lengths to help a patient, says Sheila Woolley, R.N., MPH, NEA-BC, vice president of patient care services and chief nursing officer at the 178-bed community hospital in Dover, N.H. — the largest acute care hospital in the Seacoast Region of New Hampshire as well as Southern Maine.

Woolley recalls one ES staff member who sought out the hospital’s child life specialist to assist with added diversional activities for an adult with developmental issues to help keep him more engaged during his hospital stay. “That’s just one of the many stories I could tell you about the helpfulness of ES staff members,” says Woolley. “They are truly goodwill ambassadors for the hospital.”

And the ES department has the numbers to back up its actions. The most recent Press Ganey Associates Inc. scores of 95 on courtesy and 94 on cleanliness have landed the department in the 98th or 99th percentile for both categories all four quarters of 2013. Recent HCAHPS scores show that 83 percent of patient rooms and bathrooms were described as “always clean.” Perhaps even more impressive, the department’s scores improved during the construction and 2013 opening of the hospital’s showpiece, the 133,000-square-foot Garrison Wing addition, which required across-the-board retraining of new and existing ES staff on a new team-cleaning concept.

Hospital leaders stress that the ES department’s firm grasp on the importance — and interrelatedness — of cleanliness and helpfulness to patient satisfaction has elevated the team to the upper echelon in terms of performance.

“The importance of the ES department to the hospital cannot be overstated,” says Daniel Dunn, senior vice president of operations. “They are an integral part of the patient care team and are highly aware of how their roles relate to our patients and the hospital culture overall.”

Such commitment is one of the many reasons Wentworth-Douglass Hospital has been selected as the 2014 ES Department of the Year award recipient in the 150–450 bed category. The award, sponsored by Health Facilities Management and the Association for the Healthcare Environment, recognizes outstanding ES performance in 14 critical areas.

Team cleaning

That can-do attitude was critical when the ES department was notified in 2012 of plans for the new four-story Garrison Wing addition that opened in January 2013. Already responsible for cleaning and maintaining 363,882 square feet of space, the team of 59 employees, 51 of whom are full time, was now charged with adding the new wing to its workload. The wing — featuring private, patient-centered rooms with wider doors and larger windows — also came with a considerable amount of new detail, including sconces, window trim, hardwood trim and no-wax floors.

Despite the challenge, Environmental Services Director Michael Catanzaro, REH, CLLM, CHESP, and Environmental Services Manager Rob Daigle, CEH, CHESP, took a “how can we do this?” rather than a “there’s no way we can do this” approach to the project. Along with organizational development practitioner Michele Clark, R.N., Catanzaro and Daigle quickly launched the Operation Excellence Project using the Lean Six Sigma Toolbox. Among other changes, the ES team restructured its cleaning format from a single-clean to team-clean concept and redesigned the standard process for unit, room and discharge room cleaning.

“We went to a partner cleaning concept and made the changes across the board,” Catanzaro says. “Everyone saw an increase to his or her duty roster, which helped the process.”

In meeting its budget restrictions, the team saved the facility an estimated $440,000 and increased its already impressive cleaning statistics. “We ended up covering 2,500 square feet more per person on a daily basis than with the single-clean approach,” says Catanzaro. “This is why we chose the team-clean concept.”

Leaders credit not only the program, but the considerable commitment from every staff member for the team’s success. “The staff thrived within this concept and accepted the challenge to not only maintain Press Ganey scores, but to improve the scores to reach the 99th percentile in both cleanliness and courtesy.”

Becoming ‘preventionists’

Getting the staff to that point requires an effective strategy and buy-in from every team member — a process that begins with training and education. Because the ES staff are often in and out of a patient’s room more than anyone else, understanding the “why” behind the cleaning measures and chemicals is a top priority — especially in terms of infection control and prevention. ES leaders encourage staff members to ask questions and understand their roles as “preventionists,” beginning with the signage on the door of each patient room.

“All staff are trained on the type of precaution and detail work that will be involved with each room. Each employee is trained on cleaning precautionary rooms and the type of personal protective equipment required,” Daigle says.

The use of ultraviolet (UV) black light technology implemented in 2013 for high-touch areas has helped to assess cleaning thoroughness and reduce health care-associated infections. Twenty-two high-touch areas are assessed in each room with UV light and a gel marking system after daily cleaning. Recent results show the department is exceeding anticipated results of 90 percent by 2.5 percent. And Clostridium difficile numbers that had been considered a high priority in 2012 dropped by 28 percent in 2013.

“The ES department is 100 percent behind the high-touch program and really looked forward to putting it in place,” says Jim Miller, infection control coordinator. “They took on the entire monitoring process for themselves from the very beginning.”

While ES managers embrace the new technology, they fully recognize the hard work of each staff member in surface cleaning. “Disinfection of a room not first cleaned properly would be fruitless,” Miller says. “Nothing replaces elbow grease.”

Technology tie-in

The ES department also has adopted new technology that ramps up cleaning while offering green benefits. Adding “Boost” technology — a chemical-free, floor-stripping machine — has improved appearance while reducing odor normally created by chemicals used to strip and wax. “This has greatly improved our customer service value to both the patients and employees,” Daigle says. “We cannot stress enough the impact this has had on the hospital staff.”

And adding microfiber technology that offers ease of use, infection control benefits, cost savings and labor savings, has “changed the way staff clean floors at the facility,” Daigle adds. “In the new wing, all the floors are slip-resistant and no-wax, which makes using the microfiber that much easier.”

New technology also has allowed the department to speed up its discharge process. After purchasing an electronic tablet, management and charge personnel were trained on receiving and updating a discharge electronically — an enormous asset during Code Purple situations indicating more than 90 percent occupancy. The system ensured that 90 percent of the discharges were received electronically, providing accurate start and finish times. Discharge times went from 35–90 minutes to 25–50 minutes.

The next goal is to have notifications go directly to staff via their interhospital phones (IPs), to further cut bed turnaround times.

Communication is key

No matter what the project, ES staff are well aware that nothing would run smoothly without one important component: communication. Whether speaking to patients, co-workers or supervisors, open dialogue is embedded in the routine of every staff member. Along with basics like meeting and greeting patients and making sure staff phone numbers are available to patients, staff use such initiatives as leaving tent cards upon discharge, offering new patients the staff member’s name and the date of room cleaning. “While You Were Out” tent cards are left for patients who may have been out of the room or asleep when the room was cleaned.

Patients and family members calling for service always talk to a live person and quick follow-up is made by staff. The department provides an IP for each staff member and a dedicated 24-hour IP phone for all calls monitored by management or charge personnel.

Along with biweekly managers, supervisors and charge meetings, the departments hold daily stand-up or huddle meetings — taking five to 10 minutes to talk about the status of relevant issues — on all three shifts, a huge success. “This is an informational session vs. staff hearing something through the grapevine,” Daigle says.

And when members of the team are performing well, they know it. Managers post online Press Ganey and HCAHPS data for the staff to see, making it easy to compare their department with other hospitals. “It is great to see the competitiveness of the staff when it is posted outside the office,” adds Daigle.

Along with commitment to patient care, that competitive nature puts the ES team in the unique position of setting the bar rather than striving to reach it. That level of performance is not lost on managers who regularly reward staff with snacks, meal vendor services and other celebrations. “If it’s a hot day, we’ll go out and buy ice cream for all three shifts,” Catanzaro said. “Pizza parties are common.”

Bottom line: Leaders are well aware that the department’s true value lies in its human resources.

“Once you strip aside the technology, the system and other protocol, what you really have here is an amazing group of loyal, dedicated people,” Catanzaro says. “They understand that you get out of it what you put into it. Pride goes a long way with our staff.” 

is a freelance health care writer based in the Chicago area.

Environmental Services Department of the Year 2014


450+ beds category

University of Texas MD Anderson Cancer Center


Alonzo Gonzalez CHFM, CHESP, director of patient care properties

150–450 beds category

Wentworth-Douglass Hospital

Dover, N.H.

Robert Daigle CEH, CHESP, EVS manager

Certificate of Merit

450+ beds category

Memorial Medical Center

Springfield, Ill.

Gabe N. Ceperich director of environmental services, linen distribution, grounds

150–450 beds category

Blanchard Valley Hospital

Findlay, Ohio

Robin Cramer environmental services/communications manager


Walter Vernon president, Mazzetti, San Francisco

J. Hudson Garrett Jr., Ph.D. vice president, clinical affairs, PDI Inc., Orangeburg, N.Y.