Environmental Services and Fighting Healthcare-Associated Infections

April 14, 2011

By Eric Rose

One good housekeeper can prevent more diseases than a dozen doctors can cure. Some patients are so ill that a healthcare-associated infection (HAI) can take a patients life, even if there were a room full of doctors to provide treatment. Just as medical personnel care for patients, environmental services (ES) professionals work to keep hospitals healthy. This article is a nuts-and-bolts piece meant to improve the health of healthcare facilities. There are a few basic things we need to do to make ES departments effective -- proper hiring and training of staff, adequate design of ES work areas, accurate appraisal of task loads, and concise time management of the frontline staff.


It is common practice to wait until an ES professional leaves to hire a replacement. Because of the normal hiring process, plus the extra care needed to hire competent people for healthcare, it can take three to six weeks to get a new employee in the door. This leaves gaps in coverage and is a major link in the chain of infection. It also encourages managers to keep incompetent employees just so they can keep warm bodies in full-time employee (FTE) slots. This creates more infections.

Staffing Formulas

Facility leaders to use the term X square feet cleaned per hour formula when determining FTE needs. This method does not always deliver the goods. Every room has its own personality and its own cleaning needs determined by the its size, purpose and by the type of patient that occupies the room. For example, hospitals in the Snowbelt will have more isolation rooms between Thanksgiving and Easter than the rest of the year due to respiratory diseases. This also means that childrens wards will have more patients during that time, because respiratory diseases put many children in the hospital. Isolation rooms take longer to clean than regular patient rooms, both in daily cleaning and in discharge cleaning. All this needs factored into the equation when determining staffing needs.

Additionally, the X square feet per hour formula harms the weekend shift. It takes more time to clean patient rooms than procedure and common areas that are often underused during the weekends and not scheduled for cleaning. Staffing needs are determined on this inaccurate scale and leaves the weekend patient short-handed, even before people call in sick on Saturday and Sunday mornings.


New ES professionals cannot be competent if the training program is lacking. Most training is delegated to supervisors and experienced front line cleaning staff. Both of these methods have their shortcomings. Read an accurate job description of a supervisor in a 50-plus-bed hospital and you will see there is little time available for training new employees. Training a new employee properly is a full-time job for at least two weeks, tapering off from there. It is also inadequate to have a frontline employee train the new hire. A new employee should learn tasks in a logical sequence, and not be exposed to the jumble of duties that an experienced ES professional faces in an average day. The new employee should first learn regular patient-room discharge cleaning, then regular daily cleaning, then daily isolation cleaning, then isolation discharge cleaning of patient rooms. The learning should be logical and progressive, allowing the new employee to absorb and retain the many new things they need to know to protect the patients and themselves.

In short, healthcare facilities need dedicated trainers. These trainers should be also responsible for quality control and retraining employees as necessary. Full-time trainers can also implement a logical training program that teaches each employee the steps needed to properly clean each type of healthcare settings; patient rooms, intensive care units, labor and delivery, common areas, procedure areas, administrative areas, etc. Awards and pins could be given for each skill set learned, creating pride and a higher level of competence, which would stop more infections.

ES Area Layout

ES departments are often given the nooks and crannies of the hospital from which to work. ES carts, floor-care machines, and cleaning supplies take a lot of room just to store. It takes even more room to efficiently load and disperse them to their appointed floors. A poor layout and a poor workflow plan can cost each housekeeper several minutes of productive time each shift as she or he tries to get to the ward. Mornings in the ES area can look like a crowd scene from West Side Story when the people are trying to get to work.

Order of Cleaning

Isolation rooms are often regular rooms temporarily assigned as isolation rooms. They are usually scattered throughout a ward. However, when nursing, foodservice, therapy and ES personnel work their way through the ward, they do so numerically. How many HAIs would be prevented if isolation rooms were left for last when doing rounds?

Information Gaps

Precautionary signs are place at isolation room doorways when appropriate. Nursing staff are usually responsible for placing and removing the signs. If, for example, an isolation patient is discharged at the end of the day shift, the night shift would be expected to clean the room. But if the precaution signs are taken down and the isolation cart removed, the night cleaner might go into the room unprotected and become contaminated. The signs and the isolation cart (which holds the personal protective equipment) should stay in place until the room is cleaned.

Time Management

This is a big issue in all efforts to keep a hospital clean. When FTEs are figured according to X' square feet per hour, it is assumed that each employee is working 7.5 hours per day. This is far from accurate. Ive seen employees produce as little as three hours of work a day when mismanaged. Let me list a few ways that time is wasted in the average ES department, which proportionately increases the risk of hospital-acquired infections. Realize when an employee wastes five minutes each workday, he or she wastes 2.6 work days per year. Wow!

- Many hospitals have a sliding time-clock rule for punching in and out. If a hospital allows employees in come in 6 minutes late without being penalized and allows them to leave 6 minutes early without being charged, then selfish employees can take 12 minutes each day from patient care.

- I had to tell ES workers that coats and personal items had to be stowed before checking in, and not recovered until after checking out. Otherwise, another 10 or 15 minutes can be lost each day.

- How long does it take to have a 15-minute coffee break? Far more than 15 minutes. First, the housekeeper must stow the cart so no one can get to the chemicals. Then they must travel to the cafeteria because they are not allowed to take break in the ward where they work. (They might hear private patient information if they take break in the nurses break room). Then they have their break, and perhaps stay a little longer to visit. Finally, they wind their way back to their work area and begin again. The problem is made worse if its the first break of the morning. Current culture has degenerated the morning coffee break into breakfast time. ES professionals will go to the cafeteria, order breakfast, wait for it to be prepared, and then have a brunch with friends. Unmanaged breaks can last 45 minutes.

- It is common for too many people trying to start work at the same time. The result is that some workers would just sit and wait for the others get out of the way. Common-area cleaners and floor-care workers should leave immediately with vacuums and clean entry mats and edges of carpeting that the riding vacuums cant reach. When those tasks are done, the supply room will be empty and they can return for their carts or machines and go to the next task. Time is wasted when one employee is allowed to set and watch another employee prepare to work. Remember that these small time wasters multiple like bacteria and translate into opportunities for HAIs.

There are many opportunities to reduce HAIs in the ES department; these are a logical place to start.

Eric Rose is a former environmental services professional. This article is distilled from a two-part article on Roses website www.importantlittlefacts.com/.