Changes to health care reimbursement, expanding demands for free care and an aging population have forced most facilities to tighten their belts almost to the point of constriction.

Environmental services (ES) managers have seen the effects of these constrictions and understand that the end is not readily in sight. To anticipate and handle these demands, they must act swiftly to determine not only current staffing needs but what unforeseen changes could mean to service levels, facility appearance and customer expectations.

It is the ES managers' responsibility to prepare their departments to face these demands and document their positions with defensible numbers and data. They also must demonstrate they understand the rules of engagement when dealing with their organizations' finance departments.

ES managers compete on a fiscal basis with other departments. A number of these departments include matrices, tracking devices, benchmarking and other tools that allow them to make a compelling case for their fiscal needs.

Before ES managers can defend their numbers, they must recognize and understand with whom they compete for operational or support services dollars. Which departments come before or after the ES department in the financial pecking order and, more importantly, what data do they use to make their cases for dollars?

Understanding the numbers

ES departments, by and large, do not take advantage of tools similar to those used by other departments, either because ES departments are not familiar with them, or the data are not easily obtained, reliable or do not exist. Additionally, measurement is not as clear-cut or as easily accessible as measurements such as kilowatt hours, British thermal units or average daily therms. Metrics like discharge volume, emergency department visits, operating room cases, transfers and births are numbers that the chief financial officer (CFO), vice president of finance, and director of finance understand and have handy. This is information that they trend, track and report. Therefore, these are numbers that ES managers also need to understand and use. Moreover, the CFO should be among the ES department manager's closest colleagues.

With the exception of transfers, the balance of these numbers represents a billable event for the organization and, as a consequence, have an inherent value to the financial stability of the organization. So, why shouldn't ES managers tie their productivity to these numbers and base their positions on the activity of the facility that affects the bottom line?

Despite ES managers' reluctance to utilize similar tools, the need for them grows exponentially and they must answer such questions as the following:

  • Do we have the proper number of hours dedicated to a specific area or task?
  • Do we understand our seasonal or additional shifts in volumes and demand for services that directly or indirectly affect how we provide our services?
  • What tasks or services have we had to take on with little or no additional resources as each facility and department continues to feel pressure to make budgetary cuts?

Assess resource allocation

A strong and defensible way to ensure the answers to these questions are accurate is to conduct an annual resource-allocation assessment. This will provide the directors in the health care environment with current staffing and volume needs. The resource-allocation assessment can be as complicated or sophisticated as the individual facility desires.

There are several computer programs available that can quantify the information. However, the data retrieved from these systems is only as good as the data that is fed into the system. The old phrase "garbage in, garbage out" has double meaning for ES and other departments that contribute to the management of the health care environment.

Using environmental cleaning as an example, every area in the facility needs to be measured, quantified for fixtures and all the cleanable surfaces. The tasks performed in these areas are then assigned. It is highly recommended that whatever system is employed, it is built upon generally accepted industrywide standards for cleaning. There are several national standards from which to choose, including the Association for the Healthcare Environment's Practice Guidance for Healthcare Environmental Cleaning.

Once ES managers have their inventories and measurements of cleanable surfaces and tasks, the frequency or volume numbers are introduced. This combination of facility space, surface and volume data will provide an accurate, detailed report on the exact time requirements for specific areas.

By the numbers

Using industry-accepted statistics is an effective method of presenting the need for resources or additional funds. Showing numbers and statistics is a strong way to illustrate the depth of an individual's knowledge of the current environment and a quick way to connect an ES department with the overall facility impact.

A Chicago Tribune investigative report alleged that in 2000, an estimated 103,000 patient deaths were linked to hospital infections, and the causes of 75 percent of these deadly infections (unsanitary facilities, unwashed hands and unsanitary instruments) were preventable. The Tribune also cited a Centers for Disease Control and Prevention (CDC) report that deaths linked to hospital germs represent the fourth leading cause of mortality among Americans. Tribune investigators found that hospital cleaning staff budgets had been cut steadily 15 to 20 percent each year, resulting in overwhelmed and overworked staff.

Similarly, according to The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention (, a paper by CDC economist R. Douglas Scott II, the low cost estimates of $5.7 to $6.8 billion annually [for health care-associated infection (HAI)], still are substantial when compared with the cost of inpatient stays for other medical conditions. According to the Agency for Healthcare Research and Quality, the three diagnoses with the highest annual aggregate inpatient hospital costs (in 2006 dollars) include coronary artery disease ($17.5 billion), heart attack ($11.8 billion) and congestive heart failure ($11.2 billion). Even if the effectiveness of HAI prevention is low, the direct medical cost of preventable HAIs is comparable to the costs of stroke ($6.7 billion), diabetes mellitus with complications ($4.5 billion), and chronic obstructive lung disease ($4.2 billion)."

If numbers alone are not enough to help ES managers make their case, they can reference regulations designed to promote health and safety. Understanding which regulatory agency carries the most weight at the health care facility will assist ES managers in choosing the correct regulation to reference.

For example, according to the Occupational Safety and Health Administration's OSHA 29 CFR 1910.1030(d)(4)(i) regulations, "Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area." The key words to this regulation are "tasks and procedures being performed." This is the ES manager's starting point for a strong, measurable, definable and defensible staffing model. What areas are being cleaned? When and how often are they being cleaned? What tasks are being performed in these areas? All of these questions add to a strong model.

If one were to equate the cleaning of a patient care area to any other service being performed in that area, such as a surgical procedure, one could make an argument that the tasks being performed for that area are critical to the quality, success and safe delivery of that care.

When a surgeon determines that a patient requires a particular procedure, there is an estimated time allotment associated with that procedure. If this estimated time allotment is utilized throughout the region or country for that procedure, the time is seldom questioned or minimized prior to the procedure. It would be unlikely that the health care facility would allot the surgeon only 30 minutes to perform the procedure.

Why then is it an all-too-common story to hear that an ES director is told, "you have 20 minutes to turn that discharge room around" despite the need for 30 or more minutes, based on national standards, for discharge cleaning to properly complete the room turn? Perhaps it is because the ES director does not utilize regional or national time and task standards. It may be because the ES director has not fully established the existence of a facilitywide resource allocation system including the tasks required, the cleaning frequencies needed and the impact to the level of service if the time allotments are compromised.

Unfortunately, the time to make the case to justify the proper time allotment is not when the room is being turned over, but when the ES manager is developing the departmental budget. The time to develop a resource allocation system that will facilitate the defense of staffing levels and potential impact to the service levels of the organization is today.

No time like now

An ES manager does not validate his or her budget needs at the CFO's table just prior to the budget year. The validation should start the day the ES manager becomes the manager.

The manager validates the staffing needs with every action or nonaction he or she makes. There is no time like now.

Bob Paine, CHESP, is director of operations for Acuity Concepts Inc., Foxboro, Mass. He can be reached via e-mail at

Sidebar - About this series

This bimonthly self-study series is a joint project of the Association for the Healthcare Environment and Health Facilities Management. Information on obtaining continuing professional education credit can be found here.