Greg May, CHESP, director of environmental services (ES), linen and sustainability at the University of California San Diego Health System, recently received an unusual request. An intensive care unit physician called to ask if he could order some pink pillowcases.

May assumed he could locate some, but wondered why the doctor wanted them. The physician said she aimed to conduct an experiment of sorts. She said that because there are up to 12 pillows on every ICU bed, it's difficult to tell which pillows have been used in places other than the patient's head, such as for propping up a patient's wounded leg or other areas of the body that could potentially expose the linens to infectious bacteria. She said that the pink pillowcases would alert caregivers that those pillows were to be used only for a patient's head. She theorized that this might reduce the chances of ICU patients' contracting a health care-associated infection (HAI).

May wondered why he had never thought of something so simple. "We're working on this now and we'll see whether it has an effect. I think we'll be looking logically at the environment … as we try to find ways to eliminate infection exposure risks," he says.

Improving safety

Across the nation, more and more ES directors similarly are looking for ways to improve patient, visitor and staff safety by doing a better job of capturing, measuring and monitoring data related to cleaning and infection prevention efforts. It's a trend many experts believe will grow in importance in the years ahead as financial penalties from the Centers for Medicare & Medicaid Services (CMS) for HAIs and preventable harm to patients continue to be assessed.

Achieving a safer environment and reducing HAIs won't be easy. Many ES departments have seen their staff trimmed in recent years as hospital executives have been focused on how to operate their facilities at Medicare reimbursement rates or below.

In this rapidly changing environment, many ES leaders have responded by making greater use of technology and cleaning equipment advances to improve efficiency. But with the budget squeeze continuing, finding enough money for more sophisticated technologies may not be easy. And with many expanding health systems continuing to push outpatient services farther out into their communities, ES directors will have their hands full managing the logistics of cleaning and care for these remote facilities.

"Clearly it's going to be a drain on their time away from their flagship hospitals. Travel distances are going to increase as buildings move farther away from the main hospital," notes Mike Bailey, CHESP, director of environmental services at Greenville (S.C.) Health System and president of the Association for the Healthcare Environment.

Remote control

Bailey adds that even when outsourced cleaning personnel are used for remote locations, ES directors have an obligation to ensure that these crews meet Joint Commission, CMS and other guidelines. That typically requires regular visits to these sites for compliance audits.

ES directors have had to deal with managing remote facilities over the last couple of decades, but there are many more of them today, and moving patient care to the lowest-cost and most appropriate setting — often outpatient facilities — continues to intensify.

And there are indications that holding outpatient facilities to the same cleaning and disinfection rigors of hospitals has been challenging.

A Centers for Disease Control and Prevention report published in the Journal of the American Medical Association in June 2010 found that among a sample of 68 U.S. ambulatory surgical centers (ASCs) in three states, lapses in infection control were common. More than half (57 percent) were cited for deficiencies in infection control. Two-thirds had at least one lapse in infection control among five areas reviewed, two of which included hand hygiene and environmental cleaning. More than 17 percent of the ASCs reviewed had identified lapses in three or more of the five infection control categories, which also included injection safety and medication handling, equipment reprocessing, and handling of blood glucose monitoring equipment.

John Scherberger, CHESP, REH, president of HealthCare Risk Mitigation Inc. in Spartanburg, S.C., believes there are two reasons ASCs and other outpatient facilities need close scrutiny from ES directors.

"First, they're moving patients in and out faster than a typical hospital OR," he says. "And oftentimes, outpatient facilities use OR technicians or nurses to clean the surgical field — people who haven't been specifically trained in environmental cleaning practices."

Manpower issues

As the number of Americans with health care insurance steadily increases with the Affordable Care Act rollout, patient volumes are expected to increase. Scherberger believes there will be a couple of ramifications from this increased patient load.

First, hospitals may see a leveling off in emergency patients as those who once were uninsured now will access coverage and seek care through an outpatient setting or primary care doctor. Second, the same hospitals that have seen their ES staffing levels cut to reduce costs may find it more difficult to maintain the level of support they will need as their organizations expand.

At the same time, hospitals likely will see an increase in patient acuity and perhaps longer lengths of stay.

What concerns Scherberger is that ES staffing levels may not be able to keep pace with demands for their services. And based on his review of U.S. Bureau of Labor Statistics (BLS) employment forecasts for health care housekeeping, he doesn't see indications that there will be a significant influx of ES positions in the coming decade.

The BLS forecasts, which are updated every two years and project employment in various job sectors for the next decade, show a net decrease of 4,000 housekeeping positions in hospitals in the reports covering the years 2008 to 2020. During the same time period the BLS forecasts an increase of 500 housekeeping positions for outpatient, laboratory and other ambulatory care services.

The upshot of these trends is that organizations will have to assess ES manpower needs more carefully if they're going to reduce HAIs and manage patient expectations on room cleanliness, which impact Hospital Consumer Assessment of Healthcare Providers and Systems scores. In the many health systems that are rapidly expanding through mergers, acquisitions and new construction, ES directors will need to calculate their manpower needs carefully and communicate effectively with their CFO and other executives to get what they need.

Kaiser Permanente, with 38 hospitals and more than 600 medical offices and outpatient locations, is doing just that. It uses a model called Environmental Services Computerized Tracking (ESCT) to help determine its ES manpower needs for all facilities. Janet McCalmont, environmental services project manager at Kaiser Permanente's Santa Clara (Calif.) Medical Center, says ESCT takes into account square footage, room type and other information to create staffing models.

Gaining efficiency

Even assuming adequate staffing levels, many experts believe ES teams will need to further improve efficiency through standardizing cleaning processes, using optimal equipment such as microfiber cleaning products, bed tracking and other software programs to shorten room turnaround times and other technologies.

Bailey anticipates adenosine triphosphate testing, fluorescent marking and other systems to monitor cleaning effectiveness will continue to gain acceptance as hospitals remain focused on reducing HAIs and readmissions. He expects room decontamination technology to be deployed in more hospitals, noting that his organization plans to demo systems in the coming year. He also believes tests to determine bacteria loads on health care surfaces will deliver results much quicker.

May says the need to get a better handle on why multidrug-resistant organisms such as Clostridium difficile continue to persist in hospitals even after cleaning will necessitate further action as well.

"I think the fact that you can look at a room that has been cleaned repeatedly and still findC. difficile is going to have to be addressed. I think you'll see a lot more research," May says.

Reducing waste

Accelerated progress also is expected in efforts to reduce regulated and nonregulated waste streams. As was evident in Health Facilities Management's 2013 Sustainability Survey, hospitals have been making incremental gains in efforts to reduce the amount of solid waste going to landfills, cut pharmaceutical waste and improve recycling efforts for paper, plastic and other materials.

McCalmont says that one of Kaiser Permanente's goals is to reduce its landfill waste by 40 percent by 2015 — a target she believes will be achieved.

"We work really hard with materials services and our nursing departments to reduce waste. One of the things we're doing is making sure staff can segregate recyclable materials. We have plastic, aluminum and glass recycling throughout our facilities. Some of our facilities are composting food and paper waste and we will continue to work on that," she says, adding that agendas and materials for meetings are no longer printed routinely and instead are sent to participants in electronic formats and shared via overhead projector.

Kaiser Permanente also is reprocessing its sharps waste and uses Green Seal-certified cleaning products.

May notes that because California's Medical Waste Management Act clearly holds top-level executives accountable for any infractions on behalf of their organizations, hospital CEOs will pay more attention to this issue in the years ahead.

By taking this diversified approach to manage sustainability and the cleaning and disinfection of hospital spaces, ES directors will give their organizations better opportunities to improve safety and optimize performance.

Bob Kehoe is the associate publisher of Health Facilities Management.