Breaking the Chain of Infection
And Meet the ESOP Advisory Council and Study Sites
By John Scherberger
The world around us is changing. Because of SARS CoV2/COVID-19, we are reminded daily of the basics that keep you and me at our healthiest. These are time tested and proven ways to manage most pathogens and the risk of infection. There are many different germs and infections inside and outside of the healthcare setting. Despite the variety of viruses and bacteria, microbes spread from person to person through a common series of events. Therefore, to prevent pathogens from infecting more people, we must break the chain of infection. No matter the germ, there are six points at which to break the chain prevent infections. The six links include the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
A short video on breaking the chain of infection from the Association for the Healthcare Environment (AHE) and the Association of Professionals in Infection Control and Epidemiology (APIC) provides reliable guidance on the way to stop germs from spreading is by interrupting this chain at any link.
Following this guidance results in a person becoming a “chain-breaker:”
• Cleans and incorporates excellent and frequent handwashing
• Stays up to date on vaccines (including the flu shot)
• Covers coughs and sneezes
• Stays home when sick
• Follows the rules for standard and contact isolation • Uses personal protective equipment the right way
• Cleans and disinfects their own spaces after use
• And use antibiotics wisely to prevent antibiotic resistance.
Practicing hand hygiene is a simple yet effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. When we need good guidance, we often turn to reputable and authoritative sources. These authorities have demonstrated effective, evidence-based practices. We come to rely on these authorities, they dispel rumors, cut through obfuscation, and tell us the straight truth. This article is the third in a yearlong series describing an Industry journey led by environmental services and infection prevention toward better patient outcomes, quality and cost savings.
Often the truth is not what we want to hear, but rather, what we need to hear. Some of these sources we come to rely on are: CDC; CMS; The Joint Commission; World Health Organization; APIC; AHE; AORN; Healthcare Laundry Accreditation Council (HLAC); Hohenstein Institute (RAL certification) and the Textile Rental Services Association (TRSA).
The previous two articles of this ESOP series noted that it’s too easy to deviate from the basics, and for a variety of reasons. That is why the ESOP Project drew so much positive attention as it was filling a void and connecting the often-overlooked details. The Project revealed that Human Factors Engineering (HFE) had been often overlooked or discarded outright. HFE incorporates the design of products, programs, systems, or services, in such a way that, when followed, removes the frequency and opportunities to deviate from basic best practices. Enter ESOP. As mentioned, a group of experts in their craft within healthcare, joined to form a scientific workgroup focused on environmental services/ infection prevention, and the optimization of cleaning through evidence-based facts. In this article, which continues online, we introduce you to a group of individuals whose sole goal was doing what’s right for the patient and for the system that supports that care. Joining this team was a group of healthcare facilities, ready to embark on a journey and implementation of these thoughts and ideas crafted into a playbook of best practices. This compilation within the Playbook brought together resources from around the world into one place. These facilities were ready and willing to implement the various features and provide honest feedback over the next two years to ensure this living, breathing, and scalable Playbook was genuinely world-class.
As mentioned in a previous article of this series, Sue Barnes led the local APIC chapter as president at the time of the concept of this project charter, partnered with other infection preventionists, Elaine Dekker, Aaron Jett, and Karen Anderson. Sue served as the ESOP Project Manager through 2019. Her oversight has transitioned back to the newly created ESOP advisory board led by Dr. Paul Pearce et. al.
Sue Barnes: Since retiring as the National Infection Prevention Director for Kaiser Permanente in 2016, Sue Barnes now serves as an advisor and consultant for industry partners and professional organizations, including APIC, AORN, and IDSA. She is board-certified (CIC) by APIC in Infection Control and Prevention and earned the designation of Fellow of APIC in 2015 (FAPIC). Sue has been in the field of Infection Prevention since 1989 and participated in developing many APIC guides, and served as a speaker for organizations including AORN and APIC. Also, Sue has published in journals including AORN Journal, American Journal of Infection Control, The Joint Commission Source for Compliance Strategies and The Permanente Journal. She served on the National APIC Board of Directors from 2010 to 2012 and the San Francisco chapter board of directors from 2007 – 2017.
William Rutala: William A. Rutala, Ph.D., MPD, CIC: Bill Rutala is a professor within the Division of Infectious Diseases at the University of North Carolina's School of Medicine, and serves as the Director of Hospital Epidemiology, Occupational Health and Safety Program at the University of North Carolina Health Care System.
• Professor, Division of Infectious Diseases, Department of Medicine
• Director, Statewide Program for Infection Control and Epidemiology, of North Carolina School of Medicine (Chapel Hill)
• Retired as Director, Hospital Epidemiology, Occupational Health, and Safety Program at UNC Health Care System, after 38 years (1979-2017)
He is also the director and co-founder of the Statewide Program for Infection Control and Epidemiology at the UNC School of Medicine and a retired Colonel with the U.S. Army Reserve. Rutala also holds the APIC CIC certification. He has been an advisor to the Centers for Disease Control and Prevention (a former member of the Healthcare Infection Control Practices Advisory Committee, HICPAC, 1999-2003), the Food and Drug Administration (a former member of the General Hospital and Personal Use Devices Panel), the U.S. Environmental Protection Agency (a member of the Scientific Advisory Panel on Antimicrobial Research Strategies for Disinfectants) and the Federal Trade Commission. Rutala is a member of various committees on the local, slate, national and international level as well as several professional societies, including the American Society for Microbiology, Association for Professionals in Infection Control and Epidemiology and the Society of Healthcare Epidemiology of America. He serves on the editorial board of Infection Control and Hospital Epidemiology and Journal of Hospital Infection. He has more than 650 publications (peer-review articles, books, book chapters, abstracts) in the fields of infectious diseases, infection control, disinfection, sterilization, and medical waste to include several guidelines (e.g., CDC Guideline for Disinfection and Sterilization in Healthcare Facilities). Dr. Rutala has also been an invited lecturer at over 400 state, national and international conferences (over 40 states, over 40 countries) and has testified twice before the U.S. Congress. Rutala holds a MS in microbiology, a MPH in public pealth, and a PhD in microbiology.
Paul J. Pearce: Paul Pearce, PhD, is a man who has many qualities that helped set the course for his professional life. Pearce is an entrepreneur, a risk-taker in that he follows the "road less traveled," a puzzle solver - scientific puzzles, and he seeks answers to the tough questions of medicine. His passion is to use his God-given talents to benefit as many people as possible. He is unabashedly an American and Texan. His drive and passion have opened a new frontier for him. The creation of The Pearce Foundation for Science and Medicine and help support ESOP into a reliable source for many in the healthcare field. Dr. Pearce has well over 45 years' experience in the field of microbiology. He is currently CEO of Nova Biologicals, the laboratory testing organization he founded over 30 years ago. His desire and drive propel him to share his vast interests, knowledge, and insight with healthcare as a whole, and ESOP in particular.
Lynne Sehulster: Lynne Sehulster, PhD, M(ASCP), CMIP(AHE), is currently a Health Scientist providing consultation as a sole- proprietor of Environmental Infection Prevention, LLC. She retired from the Centers for Disease Control and Prevention (CDC) in 2017 after a career spanning 20 ½ years. While there, she worked as a Health Scientist in the Division of Healthcare Quality Promotion (DHQP) within the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Before her coming to CDC, she served as an infectious disease epidemiologist for over 15 years at the Texas Department of Health (currently known as the Texas Department of State Health Services). Her areas of expertise include environmental infection control, microbial inactivation, and transmission of infectious diseases. She has advised the CDC and other federal and state health agencies, healthcare professionals, and the public on issues concerning environmental cleaning, sterilization, and disinfection, healthcare built environment and construction, healthcare laundry issues, prion disease epidemiology, and environmental management of emerging diseases. She coordinated and contributed to the CDC/HICPAC "Guidelines for Environmental Infection Control in Health-Care Facilities" that was released in 2003 and has assisted federal colleagues and other entities in the development of their infection prevention guidelines. Most recently, she is a contributor to the 3rd edition of the AHE Practice Guidance for Healthcare Environmental Cleaning (to be released soon). Sehulster received her PhD and masters of science in microbiology from Rutgers, the State University of New Jersey. Her post-doctoral appointment in viral immunology occurred at Baylor College of Medicine, Houston, Texas. And she received her certificate as a Microbiologist with the American Society of Clinical Pathologists (M[ASCP]). She most recently completed the requirements for her Certificate of Mastery of Infection Prevention (CMIP) from the Association for the Healthcare Environment. Dr. Sehulster currently serves as an Editorial Board member for the journal Infection Control and Hospital Epidemiology and recently retired from the Editorial Board of the journal Applied and Environmental Microbiology.
Michael R. Overcash: Michael Overcash, PhD, has developed an in-depth national research program in two distinctive areas. The first, life-cycle inventory research, focused on improving the new regions for utilization of the life-cycle tools, leading to the discovery of the Environmental Genome. Overcash has led the effort in life-cycle inventory techniques using a design-based methodology. The method resulted in the formulation of a database of approximately 1,500 chemical and materials manufacturing plants. It is based on a heuristics approach around unit processes and is the most abundant chemical life-cycle database in the world. Also, his work has focused on healthcare evaluations based on quality patient care that incorporates lower environmental impact. His approach included radiology, dialysis, medical textiles (surgical gowns, patient isolation gowns, drapes/tapes), food services, pharmaceuticals, patient treatment form MRSA, new and current chemicals, and plastics, flooring systems, recycling of plastics and other materials from hospitals, and healthcare disinfection systems. Dr. Overcash has been active in European life-cycle efforts and peer reviews of research in this field, including a year as a Senior Scientist with the Office of Naval Research, London, UK. The second in-depth national research program is sustainability research. In this field, he has helped organize the various models for sustainability in healthcare organizations used in studies and to seek the common characteristics of these models. Since sustainability's base is quantifying improvement, the integration of life cycle inventory is a central part of his sustainability research. Overcash also chaired subcommittees in recent sustainability projects on sustainable carpet standard and complex national infrastructures. He has contributed to the emergence of standards for the sustainability of products and services. Those standards are now in use in healthcare, in defining leading-edge research of this field. His professional contributions include fourteen books, over 700 articles for journals, symposia, and reports, and service on seven National Academy of Science committees. He has also served on scientific advisory committees for the U.S. Air Force, the State of North Carolina, the National Science Foundation, several offices of EPA, and numerous corporate research and planning groups. Overcash has pioneered the research field in industrial pollution prevention since 1980. His role as Director of the Office of Exploratory Research Center for Waste Minimization (EPA) allowed the development of critical research and new technology projects that define the research in the pollution prevention field. Overcash completed his undergraduate studies degree in Chemical Engineering from North Carolina State University. He earned a Master of Science degree in Chemical Engineering while on a Fulbright Scholarship at the University of New South Wales, Sydney, Australia. He received his Ph.D. from the University of Minnesota in Chemical Engineering. Overcash served as a Professor of Chemical Engineering, as well as a Professor of Biological and Agricultural Engineering at North Carolina State University. He received the Young Researcher Award from the American Society of Agricultural Engineers, the 1990 Environment Award of the American Institute of Chemical Engineers, and the EPA Distinguished Visiting Scientist award. Overcash has served as the Sam Bloomfield Chair in Sustainable Engineered Systems in the Department of Industrial and Manufacturing Engineering at Wichita State University. Currently, he is the Executive Officer of the non-profit, Environmental Genome Initiative.
Syed A. Sattar: Syed A. Sattar, M.Sc., Dip. Bact., M.S., Ph.D. R.M. (CCM), FAAM, is professor emeritus of microbiology at the University of Ottawa. He studies the environmental spread and control of human pathogens. Several of his microbicide test methods are now international standards. He has 240 publications, three books, and more than 340 invited lectures to his credit. He is a Registered Microbiologist of the Canadian College of Microbiologists and a Fel¬low of the American Academy of Microbiology. He is also an adviser to the Canadian and U.S. governments, the World Health Organization, and the Organization for Economic Cooperation and Development on various aspects of infection prevention. He received the Martin Favero Lectureship of APIC (2006), the Hygeia Gold Medal of the Rudolf Schűlke Foundation (2009), Queen Elizabeth Diamond Jubilee Medal (2012) and the designation (2014) of "Distinguished Microbiologist" of the Canadian College of Microbiologists.
Maureen Spencer: Maureen Spencer, RN, M.Ed. is an independent infection prevention consultant and has been an infection preventionist for over 40 years. She is board certified in infection control (CIC) and holds a master’s degree in education. As one of the early pioneers in infection control from the 70's, she was awarded the APIC National Carole DeMille Award in 1990 by her peers. This award honors an APIC member whose contributions have advanced the practice and profession of infection prevention and control. In 2007 Maureen was selected as one of the APIC Heroes of Infection Prevention for her work in establishing a MRSA and Staph aureus Elimination Program at New England Baptist Hospital, an Orthopedic Center of Excellence in Boston, that resulted in groundbreaking evidence that early preop identification of carriers and a decolonization protocol would prevent devastating total joint and complicated spine infections. This research was published in the Journal of Bone and Joint Surgery in 2010. In 2012 she was selected as one of the "Who's Who of Infection Prevention" and in 2017 she was recognized as a Fellow of the APIC (Association for Professionals in Infection Control and Epidemiology) for her advanced practice in infection prevention and leader within the field Maureen is currently an independent consultant, offering speaking engagements and consultations. Her recent position was the Director, Clinical Education at Accelerate Diagnostics, Tucson, AZ, facilitating education sessions with customers using the only fast antibiotic susceptibility system for bacteremia and sepsis on the market. Prior to that she was the corporate director of infection prevention for Universal Health Services, overseeing the IP programs in 28 hospitals in seven states. Her Infection Prevention nursing career in Boston include the Infection Control Director at New England Baptist Hospital, Director of the Infection Control Unit at Massachusetts General Hospital, Infection Control Nurse at the VA Medical Center and Carney Hospital. Maureen has presented numerous research abstracts and lectures at national and international conferences and has published many peer reviewed articles on healthcare associated infections. She is a well sought after speaker on prevention of healthcare associated infections and has presented around the US and internationally in Austria, Singapore, Thailand, Indonesia, Taiwan, Malaysia, Vietnam, Philippines, France, Turkey, Argentina, New Zealand and Canada.
Sarah Townsend: Sara Townsend, CIC, MS-HQS is an Infection Prevention Manager at the Children's Hospital of Philadelphia. Sara has a Master's degree in Quality and Safety in Healthcare and a background in both secondary education and respiratory therapy. An active member of the Delaware Valley and Philadelphia APIC Chapter, Sara has served on multiple committees and is currently an acting director. She also is the vice chair of the APIC Education Committee. Her special interests include infection prevention in ambulatory and procedural areas, CLABSI, and cleaning of the patient environment.
Sara is passionate about engaging teams to work together to share infection prevention strategies to improve healthcare outcomes.
Allyson Luva: Allyson Luva, MSN, BSN, RN, CIC has been an infection preventionist for over 10 years and is board certified in Infection Control (CIC) She has worked for Loma Linda University Health System for the past 25 years in a variety of roles, with the las 10 years in Infection Prevention. An active member of the Inland Empire APIC chapter, where Allyson has served on the board for the past three years as president-elect, president (2019), and now current past-president. Her special interests professionally include working with over 300 Environmental Services Technicians in IP education, policies, and best practices. Allyson is part of CLABI taskforce, critical care quality improvement committee, and Hand Hygiene task force for her health system. She has been a pioneer in leading innovative solutions for the reduction of healthcare associated infections, patient empathy, improved outcomes, and testing the industry norms. She has led an extensive study within her own facility on the efficacy of disposable and reusable products available in the market today, while working alongside Dr. Paul Pearce at Nova Biologicals laboratory which she plans to share through ESOP and at the upcoming APIC / SHEA conferences.
John Scherberger: John Scherberger, BS, FAHE, VPEI, T-CHEST, is the principal at Healthcare Risk Mitigation in Spartanburg, SC. Healthcare Risk Mitigation is a consulting enterprise that assists healthcare, laundry, hospitality, and other professionals. His consulting assists in enhancing their operations through education and the incorporation of industry Best Practices into their services. He incorporates risk mitigation improvement into healthcare laundry operations, healthcare Environmental Services, hospitality housekeeping operations, infection prevention processes and practices, personal care professions, and guest interactions and processes. He is a Fellow of the Association for the Healthcare Environment (FAHE). He is a Certified Trainer, EPEC (Education for Physicians on End-of-Life Care), from the Feinberg School of Medicine, Northwestern University, Chicago, Illinois, a Certified Trainer in Pastoral Crisis Intervention from the International Critical Incident Stress Foundation, and a Certified Dementia Specialist from the Norman J. Arnold School of Public Health, University of South Carolina, Office for the Study of Aging. Trade journals, magazines, and periodicals have published his timely and insightful articles over the years. John has been a speaker at multiple national and state healthcare association conferences. He has 30+ years in the hospitality and foodservice management industries and an additional 15+ years in healthcare management.
He is a past-president of the board of directors for the Healthcare Laundry Accreditation Council (HLAC) and a former member of the board of directors for the Certification Center of the American Hospital Association. He is a past board member of the Association for the Healthcare Environment (AHE) and the South Carolina Chapter of the AHE. John is a recognized subject matter expert in Environmental Services and hospitality housekeeping, healthcare laundry operations, food service safety and hygiene, and infection prevention and control. He has expertise in emergency preparedness, Critical Incident Stress Management, contract negotiations, healthcare and hospitality microfiber textiles, and biofilm, and the negative impact it has on patient outcomes.
Sandra Rials: Sandra Rials has served as the Association for the Healthcare Environment's director of education since 2014, having started as an education manager in 2011. She has an extensive background in healthcare education and training, including instructional design, evaluation, process engineering, and the implementation and development of learning strategies and modalities. Rials has worked for organizations such as The New York Presbyterian Hospital, Provident Hospital, St. Joseph Hospital (Chicago), Blue Cross Blue Shield of Illinois, and Aetna Healthcare.
Ms. Rials is a Six-Sigma Green Belt with a Master's of Sciences degree in Instructional Design and Technology; her undergraduate degree is in Marketing and Management.
Robert Tussey: Robert Tussey T-CHEST / VPEI has a hospital hospitality background as a Director of Environmental Services (T-CHEST and T-CSCT Accredited) Trainer for American Hospital Association - Association for the Healthcare Environment - Certified Healthcare Environmental Services Technician Train the Trainer and Certified Surgical Cleaning Technician Train the Trainer, Certificate of Mastery in Value-based Product Evaluation and Implementation. He grew up in Eastern Kentucky where he learned the value of family and hard work. His passion to help people grew with his knowledge and experience, all rooted in his faith and desire to teach others. Once he finished college, he pursued an ordination as pastor in the Baptist Church while serving as an Environmental Services Professional. After marrying his best friend, Robert was inspired to find the best version of himself. His desire to help others continued to grow when his father passed away after suffering a fall in a healthcare facility and his mother contracted Clostridium Difficile, he saw firsthand the effects of a nosocomial illness and hospital safety. Continuing his education into HAI’s and the role of pathogens in the environment of care, working alongside leading experts, he furthered his education and certifications, and now serves as Director of Environmental Services for the largest hospital in the largest faith based health system in the United States. He specializes in the cleaning and disinfection of environmental surfaces (fomites), and led an extensive two-year study for the collaborative project to support the reliable design and optimization of cleaning in U.S. and Canadian healthcare. His passion for science and always doing what is right, has led him on a journey to evaluate infection prevention textiles and further clarify the unique differences in materials, methods, and means used to achieve zero infections. His unique approach to common problems for Isolation Room Cleaning faced within EVS, was recently recognized by CMS as a best practice. His innate ability to work within a multidisciplinary team, alongside Dr. Mayar Al Mohajer MD, MBA; and Brian Pearson Infection Prevention Specialist drew the attention of CMS for improved patient outcomes, with zero cross contamination. He is applying this same work process to COVID-19 Isolations with tremendous success.
Scott Beaton: Scott Beaton is the Kaiser Permanente National Product Manager for Linen and Laundry, overseeing and maintaining a system that serves 35 California hospitals with more than 60 million pounds processed annually. He has extensive experience in laundry plant operations, project management, contract management, Title 22 compliance, supply chain operations, financial analysis, and strategic planning and implementation. He possesses a master of arts degree in management from Webster University. He is a proud veteran of the United States Air Force. Before joining Kaiser, Scott was the Operations Manager of Sodexo-Stockton, one of the most substantial Customer Owned Goods (COG)healthcare laundries in the United States. Beaton was responsible for the day-to-day operation of a 120,000 square foot, seven days/week, three-shift plant. The plant produced more than 60 million pounds of laundry a year, with a workforce of 300 employees.
He has over 25 years of industry experience in linen and laundry operations, supply chain, and manufacturing. He is a certified OSHA general industry trainer and an ISO 9001-2000 certified internal auditor.
Aaron Jett: Aaron Jett has a clinical background as an Infection Preventionist and APIC - CJIC partner, Environmental Specialist, Certified Safety Professional (CSP), and OSHA walkway auditor (WACH) for STF injury prevention. Also, he is a designated trainer for the Association for the Health Care Environment of the AHA and Certified Master Infection Prevention (CMIP). Mr. Jett is appointed to train and certify through AHE's Certified Health Care Environmental Services Technician and Certified Surgical Cleaning Technician programs (T-CHEST/CSCT). He is a Master Trainer of AHE's Value-Based Product Evaluation and Implementation Program (VPEI), a component of AHE's Strategic Leadership Programs. Jett grew up in Southern California, learning the family-owned maintenance and contract cleaning business. His passion for helping people grew with his knowledge and experience, all stemming from his volunteer work, disaster relief efforts, and teaching others. Graduating with honors, he pursued a course in Fire Prevention and worked as a first responder for the State of California Dept. of Forestry and Fire. When his father fell ill, he took over the day to day running of the family business, tripling its size and eventually selling it after meeting his wife. His desire to help others continued to grow when immediate family members contracted MRSA and Clostridium Difficile due to hospitalizations. He knows firsthand the effects of a nosocomial illness. He continued his education into HAIs and the role of pathogens in the environment of care. He works alongside leading healthcare industry and allied experts. Expanding his training and certifications, he now serves as voice for the healthcare industry and an infection prevention resource to many of the top health systems in the U.S. and Canada as well as leading healthcare contract cleaning companies. Jett is focused on Joint Commission national patient safety goals and achieving the triple aim (CQO). He volunteers his time to advocate for Rare Disease Awareness and supports AHE's Mission. He is the ESOP International Project Lead.
Alicia Cole: Alicia Cole is listed among "25 of the Nation's Best Practices in Patient and Family Engagement" by the Caregiver Action Network. Honored by President Obama in a national address for her advocacy work, Alicia now serves on the Presidential Advisory Council for Combating Antibiotic-Resistant Bacteria (PACCARB). She was appointed to a four-year term by Sylvia Burwell, Secretary of Health & Human Services. She was selected as a Co-Lead for the Stewardship and Prevention Working Group of that esteemed council. Her comeback from clinging to life in 2006 as the survivor of multiple antibiotic-resistant hospital infections, near-fatal sepsis, and necrotizing fasciitis (flesh-eating disease) fuels her passion for saving others from the anguish and suffering she endured. The battle to save her life following routine fibroid removal included: six additional surgeries, nine powerful antibiotics, nine blood transfusions, near amputation of her leg, an open abdomen for three years, and ten years of weekly aftercare. While bedridden and recovering, Alicia, with a talk-to-type program, began using social media to share her experience and advocate for quality improvements in healthcare. She helped co-sponsor and lobbied successfully for passage of two California laws for infection prevention education for health care workers and public reporting of hospital infection rates known collectively as "Nile's Law" (SB158, SB1058.)
In 2016, Alicia was one of five to receive the prestigious Humanitarian Award from the Patient Safety Movement at its Global Summit. The other recipients were President Barack Obama, Vice-President Joe Biden, Senator Barbara Boxer, and German Professor Kai D. Zacharowski, MD, Ph.D., FRCA. Alicia currently serves on the Patient & Family Executive Council for the Centers for Medicare & Medicaid Services Partnership for Patients 2.0. She also sits on the Environmental Services and the Education & Awareness Sub-committees of the California Department of Public Health's HAI Advisory Committee. In between doctor's appointments, the former Ohio State Alum returned to school and obtained a Post-Graduate Certificate in Healthcare Management & Leadership from UCLA School of Public Health. She also earned a Patient Safety Certificate through the American Society for Healthcare Risk Management's annual Learning Academy.
Loretta Fauerbach: Loretta Litz Fauerbach, MS, FSHEA, CIC is the Lead Infection Preventionist for Fauerbach & Associates, LLC, Providing Global Infection Prevention Services. Mrs. Fauerbach's expertise encompasses the healthcare continuum of care after being the Director of Infection Prevention & Control for Shands at the University of Florida for 28 years. Mrs. Fauerbach received APIC's, "Carole DeMille Lifetime Achievement Award, 2007" for her contributions/achievements in the field of infection prevention and control. She was the Infection Preventionist leader of the Shands Hospital at the University of Florida's 4E Surgical Intensive Care team that won the "Health and Human Services Partners in Prevention Award" in 2002.
Loretta is an active member of APIC, SHEA, and ASM. She is currently a member of the Healthcare Infection Control Practice Advisory Committee (HICPAC) and is the managing editor of the AHE Practice Guidance for Health Care Environmental Cleaning, 2019 edition. She has served on the APIC's Board of Directors and APIC committees: Membership; Guidelines and then the Practice Guidance Team Leader; Communications Team Leader; and served as a member and co-chair of APIC's Nominating and Awards Committee. In 2002 Ms. Fauerbach testified before the Institute of Medicine on APIC's behalf related to healthcare-associated infection data. Ms. Fauerbach has served as APIC's liaison to AAMI, HICPAC, FDA, and IDSA, producing which sentinel guidelines by those agencies/associations. She was also APIC's leader for the SHEA/ APIC/ CDC Communication Network. She represented APIC on the Joint Commission's expert panels for the monographs on hand hygiene, influenza vaccination, and Tdap vaccination. Fauerbach has presented at regional and national meetings and authored articles for peer-reviewed journals. She was a section editor of The APIC Text of Infection Control and Epidemiology and author of two chapters, a chapter author of "APIC's Elimination Guide: Guide to Preventing Clostridium difficile Infections"; and a chapter author for The Joint Commission/APIC Infection Prevention and Control Workbook. She was a member of the SHEA spring conference committee for 2017-2018.
Buffy Lloyd-Krejci: Buffy comes to the ESPO Project with more than 20 years of expertise in successfully developing and implementing data-driven healthcare and public health programs. She is Board Certified in Infection Prevention and Control (CIC) and 2019 AZ APIC chapter President. President for the Arizona Association for Professionals in Infection Control and Epidemiology (APIC) state chapter. As a national consultant, she offers solutions to federal, state, and local public healthcare professionals implementing interventions to mitigate healthcare and community-acquired infectious diseases. She specializes in bringing best infection control and antibiotic stewardship practices to underserved healthcare settings such as outpatient and long-term care facilities (LTCFs). Buffy has participated in a Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid (CMS) collaborative projects. The projects supported hundreds of LTCFs enroll in the CDC's National Healthcare Safety Network (NHSN) and begin reporting Clostridioides difficile Infection (CDI) monthly surveillance to establish a national CDI benchmark as well as reduce CDI incidence. Buffy is passionate about utilizing surveillance data for action and has recently launched the application of her mobile data tracker for collecting infection control audit data such as hand hygiene compliance. Once captured, data automatically uploaded to a database and then to a facility-specific dashboard where measurable outcome data reside. Buffy completed her Bachelor of Science degree in Applied Mathematics, where she was a member of the Mathematical Epidemiology Research Group (MERG). She, along with her colleagues, developed and presented at multiple national conferences a standardized infection ratio (SIR) model that described how the human papillomavirus (HPV) spreads within a population among boys and girls, thereby guiding policymakers towards vaccination protocols. She completed her master of science degree in Biomedical Informatics through Arizona State University while having the assignment of a Mayo Clinic Research Affiliate. She, along with her colleagues, developed a diabetes mobile app, iDECIDE, that utilized an evidence-based equation to account for patient preferences for insulin dosing. Buffy is working toward her Doctor of Public Health/Epidemiology degree through Capella University, with anticipated completion in early 2020. Her research study is in partnership with the University of Arizona School of Public Health and the CDC, where she is working with an LTCF enroll and report surveillance data into the NHSN to mitigate CDI and improve upon infection control practices.
Ashley Kelly: Ashley Kelly is a HR Transformation Consultant for Kaiser Permanente, national program office supporting the business management and planning needs with human resources across the enterprise. She also provides coaching and leadership development across the service area in the areas of team engagement and workplace safety. Ashley's background is in Environmental and Support services. She has lead multi-disciplinary departments of up to 350 FTEs. Ashley is currently in progress towards completing her Doctorate in Organizational Change and Leadership having finished her doctorate coursework and expected to complete her final dissertation defense around the time of this article.
Hillary Feder: For more than 30 years, Hillary has been a leader in strategic plan design, program planning, and branded product design to support enterprise engagement (employee, client, vendor, board, et cetera) initiatives. She has a diverse background in many different industries with a particular passion for her work in the healthcare area. Involvement with health care professionals has shaped her personal life, and in turn, she has taken those lessons into her professional life to developing better outcomes in healthcare. Hillary's innovative, analytical, and practical approach shapes organizational cultures to communicate, recognize, and express appreciation in meaningful, relevant ways and that closely align with an organization's values, purpose, and business objectives. The results of her work in healthcare settings increase employees' discretionary efforts, which strengthens the patient and patient's family experience. Hillary makes a difference wherever she goes.
Hillary received a Bachelor of Science degree from Boston University School of Management. She also has completed the Strategies For Business Vision and Growth Program, John M. Morrison Center for Entrepreneurship, the University of St. Thomas. The Promotional Products Association International awarded her the Master Advertising Specialist (MSA)designation. The MSA designation recognizes demonstrating expertise and commitment to the use of branded products to support programs that reinforce, incentivize, and recognize accomplishments. She has been recognized nationally for her ability to take ideas and turn them into meaningful actions and outcomes. She is deeply committed to supporting community with her leadership. She serves on numerous community and non-profit boards with a deep commitment to each organization's work: Alerus Twin Cities Region Advisory Board; Promotional Professionals Awards & Recognition Committee; Sabes Jewish Community, Board Chair; partnerships in fundraising with Second Harvest Heartland & St. Jude Children's Research Hospital; Super Bowl LII Business Connect Vendor; Final Four VIP Recognition Committee.
Peter Harmon: Peter is a leader in operations and strategic planning, Peter has gained a diverse background in many different industries. He has owned multiple businesses and has experience in financial services, grocery, home improvement, general merchandise retail as well as international business. In over his 25-year career, he has held many titles from an owner, Director, Regional Vice President, as well as fulfilling an executive position at a Fortune 500 company.
Peter became interested in Environmental Services a several years ago. He has operational and process improvement experience with over 40 hospitals. Currently he holds the title of Regional Manager Environmental Services for Trinity Health.
Peter has a Bachelor degree in Business Administration from Wichita State University and earned his Master's degree in Business Administration from Louisiana State University, Shreveport.
Jim Gauthier: Jim Gauthier is an infection prevention and control resource as well as an industry liaison to support the improvement of environmental hygiene solutions and the adoption of science-based best practices. Before joining the industry side healthcare in late 2015, Jim was most recently an infection control practitioner (ICP) for 12 years at Providence Care in Kingston, Ontario, Canada. Jim has more than 35 years of experience in medical laboratory technology and infection prevention. He has experience across many healthcare areas, including acute, ambulatory, behavioral health, and long term care. He has provided consulting and shared expertise with infection control stakeholders, including schools (teachers, custodians, and students), dental offices, healthcare facilities (medical clinics, acute care, and long term care), community care, funeral directors, optometrists, and public health.
He has delivered lectures and training at many conferences throughout the world (England, Germany, Austria, Croatia, Malta, France, and New Zealand). Jim has also been an active member of Infection Prevention and Control (IPAC) – Canada, throughout his career, and has served as a board member and president. Jim has been Board Certified in Infection Control (CIC®) since 1990.
Keith H. St. John: Keith St. John received his bachelor of science degree in medical technology from the University of Delaware and his Master of Science degree in Clinical Microbiology from Thomas Jefferson University, Philadelphia. He received additional training in Infection Prevention and Control at the CDC in Atlanta. Keith has been an Infection Preventionist for the past 30+ years, including 17 years of directing IPC programs at major tertiary teaching institutions (i.e., Temple University Hospital; The Children's Hospital of Philadelphia.) Keith is certified in Infection Control & Epidemiology and is a past President of the Certification Board of Infection Control & Epidemiology (CBIC.) Keith is also a Fellow of APIC (FAPIC.) In 2005-2010, as well as continuing to serve during the next term from 2012-2015, he was a member of the United States Pharmacopeia Convention Expert Compounding Committee. He was co-author of the current chapters of the USP on Pharmaceutical Compounding - Sterile Preparations <797> as well as the USP Chapter on Hazardous Drugs – Handling in Healthcare Settings <800>. Keith is a co-author of a chapter in the ASHP Compounding Sterile Preparations book entitled Microbiological Issues in Compounding Sterile Preparations, published in 2017.
Keith has been very active with APIC:
• Philadelphia-Delaware Valley APIC Chapter President
• First State (Delaware) APIC Chapter President
• Member of the National APIC Governmental Affairs Committee
• APIC Text Revision Task Force
• APIC Education Committee,
• Previous member, Editorial Board for the American Journal of Infection Control.In addition to his long-standing affiliation with APIC, Keith is also a current member of The Society for Healthcare Epidemiology of America (SHEA), The Healthcare Infection Society (HIS-UK), The International Federation of Infection Control (IFIC), AORN, AVA, and IPAC-Canada. He is a newly inducted member of the Surgical Infections Society in 2019. He has co-authored several journal articles, abstracts, and book chapters relating to infection prevention and control. Keith has a particular interest in environmental microbiology, disinfection, and sterilization practices, as well as skin antisepsis.
ESOP Study Sites
ESOP Project-focus areas to be featured in upcoming project study site spotlights: Enhancing the patient experience, quality outcomes, and operational excellence. Antimicrobial, Resource, and Economic Stewardship
» Improved Knowledge and Competency – Consistency in Application of Policies & Procedures, Enhanced Training, and utilization of resources. Improve EVS staff competencies
» Improve Adequacy of Staffing Levels & Resource Allocation – Ensure proper allocation of resources and optimum number of FTE’s for required cleaning and disinfection tasks. Methodologies and Best Practices
» Standardize Cleaning Process and Procedure - Checklist of who cleans what, how, and when
» Benchmark Targeted Room Turnover times – Operating Room between case cleaning and end of day terminal cleaning; Occupied patient daily cleaning and Discharge Cleaning
» Hand Hygiene – Increase duration & quality
» Equipment and Supplies – Cart Set up and Cleaning/Disinfection of equipment, Improved Communication between shift changeover ensuring no missed steps
» Ensure Transmission Based (Enhanced) precautions are followed – Who puts up the signs and who takes them down? Consistent signage
» Sharing of Infection Rates with EVS, and EVS report to Infection Control
» Environmental Services Recognition, Engagement, and Retention
» Disinfectant leaves residue causing time to re-wipe surfaces, wasted supplies
» Current Mop and Towel quality and efficacy concerns, proper application of tools, availability of resources
» Use of U.V. disinfection, when, where, how
» Operating Room Cleaning Procedures
As ESOP has expanded, additional resources have contributed throughout the journey, and we'd like to take a moment to say thank you. This list is in no particular order, and if we have missed mentioning someone, please accept our apologies. The ESOP Project is a collaborative effort to support the reliable design and optimization of cleaning in the U.S. and Canadian healthcare facilities. It has expanded internationally with one Project site now in place and successfully operating in 15 hospitals in and around Nairobi, Kenya, Africa.
Thank you to: Patti Costello, Kelly Pyrek, Linda Lybert, Maria Bovee, Caroline Etland, Dr. Matthew Hardwick, Darrel Hicks, Dr. Christine Greene, Michael Diamond, Mary Millard, Amber Hogan Mitchell, Dr. Rodney Rohde, Glenda Schuh, Shari Solomon, Dr. Curtis White, Dr. Charles Gerba, Carol Calabrese, Fabiola Demuth Tennessee Dept. of Health, Caroline Haggerty Penn Med, Frank W. Christiano Northwell, Jennifer Sippel, Nancy Bjerke, Veronica Pugliese, Randy Rowell, Sean Brown Lake Cumberland Hospital, Deris Elliott, Greg May, Michael German, Rebecca Bartles Providence St. Joseph, Rock Jensen, Lori Grooms, Kim Delahanty, Tim Livesay, Allyson Luva, Marlene Castillo, Swantay Nance, Nazar Masry, Bhushan Shelat Stanford, Paul Alper, Phil Jalbert, Ted Schmidt, Rebecca Walker HAI section of the Division of Acute Disease and Epidemiology central office of the South Carolina Department of Health and Environmental Control; Andrei Roudenko Director of Environmental Services UCLA Medical Center, Denise Graham, Helen Johnson, Nicolas Abella, Kirk Huslage, Jenny Bender, Kay Carl, Lea Beach, Hala Nashed, Sharon Keene, Jeff Barna, Tanya Henry, Dr. Marion Kainer, Rebecca Pines, Stephan Tomasino, Jose Watson, Joshua Churchill, Marcus Jordan, Robert Rogers, Sue Starr, Jane Ngivu.
John Scherberger is the owner of Healthcare Risk Mitigation of Spartanburg, SC. He is a fellow of the Association for the Healthcare Environment (AHE) and a subject-matter expert in environmental services, healthcare laundry/microfiber, and infection prevention. He may be reached at email@example.com.
Gap Analysis: Getting Processes Back on Track
By John Scherberger, FAHE, CHESP
Editor’s note: This article is the second in a year-long series describing an Industry journey led by environmental services and infection prevention toward better patient outcomes, quality and cost savings.
Last month in Healthcare Hygiene magazine, the genesis of the Environmental Services Optimization Playbook (ESOP) was featured in the first of a series of articles. For those who may have had an opportunity to read the article, ESOP came from a collaborative effort of the San Francisco Bay Area chapter of the Association for Professionals in Infection Control and Epidemiology (APIC), Bay Area environmental services (EVS) professionals, and allied healthcare professionals. The initiative, spurred by a recognition that healthcare disciplines intimately involved in multiple aspects of infection prevention, were too often challenged to look at patterns of change in healthcare along the thought line of what was necessary versus what was expedient. Things were off track, with many initiatives in both disciplines. Infection prevention and environmental services processes had begun to stray from the paths of the patient-centered, fundamental hygienic interests, proven healthcare culture, and priorities to the way of convenience.
Things needed attention, and the first proactive application of the ESOP program involved various gap-analysis efforts.
This article addresses some findings of the gap analysis processes and provides a look at some of the over 35 healthcare industry experts that provide the direction and oversight of ESOP.
Staffing Resources & Methodology, Patient Progression, Cleaning Accountability
Patients are frequently left in waiting areas, without a bed, or waiting for a room. Although this often is unavoidable due to various reasons, when a ESOP gap analysis is performed, one of the reasons usually traces back to patient rooms in need of attention from EVS personnel.
When budgets need tightening and even reducing, all too often EVS is the first department targeted since it is considered an "expense" department as it is not a revenue (think "income") producing department. A challenge to the perspective held regarding income versus expense departments as regards to EVS is in order. For it is EVS that provides the most visual "face" of a healthcare facility. If EVS fails to fulfill its obligations, every other department suffers since patients and visitors are of the universal opinion that they know clean when they see it, even if they do not understand the process and protocols that need to be followed, they do recognize variations or differences and areas missed. Should EVS reduce its presence and efficacy due to personnel cuts, the perception of clean is the first casualty of budget reductions or cost-cutting initiatives. The reality of patients choosing other facilities will be a reality.
The reality of EVS departments is that they are investment departments. Without EVS, hospitals will quickly close their doors.
During the numerous gap analysis surveys conducted, not only did EVS self-identify as being understaffed in critical patient care areas, other departments reported EVS as being understaffed. Nursing departments, infection prevention departments, and administration ESOP champions identified the reality of EVS understaffing.
The gap analysis surveys identified a lack of awareness and communication of that awareness that existed regarding the importance and value EVS provides in the role of patient care. The failure to perceive or acknowledge expertise exhibited by EVS in tending to the environment of care was recognized. That vital message resonated fully with healthcare executives and other key opinion leaders (KOL).
Communication was also lacking in need for resources when census levels increased, the demand placed upon the emergency department (ED), or in increased OR cases or types of patients presenting that required additional cleaning and disinfection in the ED. Other communication gaps presented obstacles when unexpected projects, at least unknown to EVS, began at facilities without consideration of requirements placed on the department that necessitated additional staff to support these projects, such as renovations and additions. That may sound implausible, but those situations arise much too often and are a result of a lack of communication, cooperation, and collaboration.
Coincidentally, two study sites, one new and another with a significant addition of a 17-story building, did not include a seat at the table for EVS leaders to discuss the impact these initiatives would place on cleaning and disinfection. Whether intentional or a gross oversight due to a proliferation of a silo mentality is unknown. The new building cited in the gap analysis did not include consideration or the need for added dock space, waste-stream support, EVS storage, clean utility, or soiled utility rooms, or types of surfaces fabrics and equipment that could exist and function in a healthcare environment and reasonably cleaned and disinfected.
Additionally, although necessary for clinical staff support, no allocation of space for scrub-dispensing equipment was considered nor available after the build, further burdening the labor budget for non-essential patient-care tasks.
The silo actions had a vital and negative impact on staffing and resources in EVS. They required significant time and effort by many departments to find creative ways to work around diminished space and lack of ready resources such as tools, equipment, and storage while failing to provide additional funding to meet the needs of many departments. At the same time, EVS and other departments experienced labor issues necessitated by transportation and time requirements due to the demand for moving both people and assets from one point to another.
Multiple analysis surveys addressed different impacts on EVS, and clinical staff directly responsible for patients. A lack of communication and understanding of task assignments was cited numerous times in the surveys. Failures to communicate between discipline responsibilities for what needed cleaning and who was responsible for cleaning, and when cleaning was required. Without a definite responsibility matrix, dirty equipment waited for the responsible party to clean, disinfect, and remove it. Without a distinct model, EVS ultimately inherits the responsibility of ensuring every item, in the room, is processed.
The project advisors assigned to the study sites observed two measurements of time:
1. Wheels out to wheels in (a term to indicate when a patient leaves a room, to when another can come in), often referred to as room turnover time
2. A more widely recognized and accepted measurement relative to EVS, room turnover time, meaning the time it takes to process a discharged room.
Minimal room turnover time was significantly evident and emphasized for both patient-room discharge and isolation room cleaning, as well as OR in-between case cleaning and end-of-day terminal cleaning in the OR. Numerous surveys indicated continual pressure to reduce processing time which resulted in undue influence upon staff to incompletely fulfill the necessary tasks that provide hygienic spaces for patients. Infection preventionists recognize the practice is unsafe and indicated they strive to support the needs of EVS in adequately fulfilling their duties and responsibilities to both patients and nursing staff.
Through the implementation of the ESOP program, executive-level leadership was engaged immediately through an invitation to join as an executive sponsor. Minimal time is requested to invest in the overall project, except for the necessary project kickoff and post-project report. The executive sponsors participate in the program whenever they wish and when influence is required, or deemed necessary, to remove roadblocks encountered or facilitate collaboration and resource allocation.
Communication within the multidisciplinary team incorporates a simple template that allows the departments a method and means to validate effective communication, report changes, monitor infection rates, and gain collaboration. Value analysis teams, if not already functioning, is set in place that allows regular and thoughtful communication. And involvement in projects and purchasing of products or services are performed by a team of vested stakeholders. The value analysis teams ensure that all purchases meet the requirements of the facility, as well as proper infection prevention and environmental service cleaning and disinfection guidelines.
Caroline Haggerty and Sara Townsend, from PennMedicine and Children's Hospital of Philadelphia, respectively, enacted a "Who Cleans What, How, and When" program. The program facilitated education and buy-in to ensure that everyone was clear on the manufacturers’ instructions for use (IFU). The IFUs, proper cleaning and disinfection, coupled with a responsibility matrix and utilization of AHE's Certified Surgical Cleaning Technician certification training (CSCT), and Certificate of Mastery of Infection Prevention (CMIP), along with a capstone project, ensured each item was adequately cared for to provide the best patient care.
Training – Evidenced Based Certification
There was a variety of programs in place for both in-house (hospital managed) and contractor (outsourced) training; however, standardized resources across facilities lacked the requisite methods and means to fulfill obligations and the equipment varied. The content of the existing programs typically was outdated to current industry standards and the latest practice guidance by the authorities having jurisdiction. Policies were outdated, including the training materials and resources on-hand. In many cases, the passion and desire to serve were evident, yet the tools, knowledge, availability, or time, and financial support was lacking.
As introduced last month, the Association Healthcare Environment (AHE) (https://www.ahe.org) was available to program participants to provide significant resources. Resources included instructor-lead train the trainer programs with world-class content. The AHE was ready to deliver educational formats for audiences to make an immediate impact on patient care involved in the program. Through extensive research and comparative analysis, AHE training proved to be the best program available in the market today for program participants. The training delivers thoughtful and practical solutions that effect the best patient outcomes possible, as well as quality and reduced cost of care.
During the ESOP roll-out, participating study sites were able to be assigned an advisor with extensive experience and knowledge to help support identified gaps or areas agreed upon to focus on, thereby helping implement necessary resources to drive long term sustaining gains. Advisor participation continues to be a precious resource to ESOP sites and remains as a benefit to new program sites.
William Rutala said it best: to have good patient outcomes, one must start with good products and good processes (training). No one can be gifted with a Ferrari and become a professional driver without the necessary instruction, training and guidance. Ongoing support and coaching are also essential. Coaching requires actively engaged leaders inspecting the expected. Coaching involves direct observation and effective rounding. Getting out of the office and observing the principles of the Gemba – otherwise known as “the place where value is created” -- walk.
Too often, EVS departments had inadequate equipment, broken, misplaced, worn out, or inappropriate materials and tools for the job at hand. That is akin to expecting a surgeon to perform heart surgery with a butter knife and a pair of pliers. EVS's role in patient care is to promote a hygienic and healing environment.
This role requires wipes and mops that are appropriate for the healthcare setting to clean and disinfect and have the capability to work on the surface intended without adverse effects on the targeted surfaces or equipment. Wipes and mops must be compatible with EPA Registered Hospital Grade Disinfectants, effectively remove bioburden from the surfaces, and remove the dry surface biofilm (DSB). Wipes and mops must effectively remove residual endotoxins left by disinfectants and ineffective or poor-quality. so-called microfiber. Mops and wipes must also be capable of removing and not re-depositing residue that typically leaves surfaces appearing turbid- dirty, cloudy, streaked, and sticky (usually from certain disinfectant solutions), and that can negatively impact patient experience scores.
Through the ESOP Project advisory board, leaders in healthcare regularly convene via teleconferences to discuss the gaps in industry products, processes and outcomes. One teleconference highlighted that science-based definitions were nonexistent for many commonly used terms and products, thus causing many undesired consequences. For example, after an extensive search of available products for wiping and mopping, and working with the manufacturers and distributors to ascertain intended use while looking at available innovative research and design for future products under development, a matrix was created to evaluate performance characteristics as appropriate for a healthcare setting. These criteria (shown below) demonstrated missing definitions upon which to assess all products for best patient outcomes, efficacy, quality, and overall costs.
The gap analysis determined incorrect product applications according to IFUs, proper reprocessing or laundry and care instructions, life-cycle analysis -- that is, when to replace products.
Definitions of what constituted a microfiber product varied considerably, within both disposable and reusable products, much like calling all modes of transportation automobiles, without respect to the desired outcome. Definitions of research laboratories and facilities varied greatly, and most testing was done to manufacturer expectations, not necessarily what was best for clinical outcomes, impact to the healthcare worker physically or ergonomically, resource management, expense, and local environmental impact.
The definitions of what constituted proper laundering and reprocessing to meet CDC and CMS guidelines were not clear. Additionally, even when aware of the guidelines, it was often ignored or needed to be clarified and evaluated by third-party organizations to ensure appropriate adherence to processing protocols.
Awareness is Essential, and Pride is Not Beneficial
Every journey begins with the first step, and that first step is crucial to ensure traveling upon the proper and correct direction. Everyone involved in healthcare knows of a colleague, a peer, a supervisor, or a person of some authority that refuses to acknowledge that they don't know everything, and that attitude of "It's my way or the highway." Those people are a stumbling-block to progress and quality. They are obstacles to attaining better patient outcomes. They are of the ilk that refuses to admit that there may be a better way to do things.
Fortunately, there were some healthcare professionals in the San Francisco Bay area who decided, for the sake of their patients and their communities, to step back and step up and reflect upon what may be wrong, what was wrong, and how to change. They were aware that somethings were just not right, that something radical was needed. And they decided that the adage: "If it's to be, it's up to me." The idea for a program suitable for all infection preventionists and environmental services professionals throughout the country capable of being replicated began. ESOP program found its germination in the Bay Area and is now growing beyond the original boundaries, and the program is now international. For more information, visit: zeroinfections.org
John Scherberger is the owner of Healthcare Risk Mitigation of Spartanburg, SC. He is a fellow of the Association for the Healthcare Environment (AHE) and a subject-matter expert in environmental services, healthcare laundry/microfiber, and infection prevention. He may be reached at firstname.lastname@example.org.
The Genesis of the Environmental Services Optimization Project©
By John Scherberger, FAHE
Editor’s note: This article is the first in a year-long series describing an Industry journey led by environmental services and infection prevention toward better patient outcomes, quality and cost savings.
Healthcare is ever-changing, never stagnant, always challenging, and the confluence of interests, cultures, and priorities is constant. However, in the meeting of these often-different matters, the patient must always be the focus of healthcare ministering – care, comfort, support.
Infection prevention is everyone's responsibility and goal. It takes a trained multidisciplinary team implementing multi-modal interventions to fulfill the purpose.
A healthcare facility will never be germ-free because bacteria, viruses, molds, and fungi outside the facility are always carried inside. Infiltration into healthcare facilities is extremely easy for contaminants and pathogens. They can be taken by air currents, clothing, supplies, carts, emergency services stretchers, and, of course, inside and on the skin of every person entering a facility.
Despite the variety of viruses and bacteria, germs spread from person to person through everyday interactions. Therefore, to prevent germ transference, everyone must work to break the chain of infection.1
How to identify and break, or interrupt, the six points of the chain is critical to overall outcomes. At whatever point the chain breaks, the potential for infection stops.
The six links in the chain include the infectious agent, reservoir, portal of exit, mode of transmission, the portal of entry, and susceptible host.
Recently, the Centers for Disease Control and Prevention (CDC) released a report, “Antibiotic resistance threats in the United States 2019,”2 updating the state of infection prevalence and antibiotic resistance. Most of the attention focused on the revelation that more people have died from antibiotic-resistant infections than was previously believed.
The CDC categorizes pathogenic infection threats as "concerning," "serious," and "urgent." The "urgent" category is to expand¬ to include the fungus Candida auris and carbapenem-resistant Acinetobacter. The group is now five, having joined C. difficile, the deadliest antibiotic-resistant germ on the CDC's urgent list; Carbapenem-resistant Enterobacteriaceae; and drug-resistant Neisseria gonorrhoeae.
A Pause and Self-examination Were Needed, and Experts Weighed In
Recognizing this need, the San Francisco Bay Area (SFBA) Association for Professionals in Infection Control and Epidemiology (APIC), decided to reflect in 2016-2017 and to work with their environmental services (EVS) peers and with allied healthcare professionals to look at the change, and what is necessary versus what is expedient. It was apparent that something was amiss with both disciplines in their joint efforts to reduce healthcare-acquired infections.
Scientific and medical peer-reviewed decision-making for some infection prevention and environmental services processes departed from the paths of the patient, varied in application, fundamental hygienic interests, proven healthcare culture, and priorities to the way of convenience. Also, too, was the lack of attention given to this vital frontline of technicians and the role they play in the environment of care for best patient outcomes, and that the resources, time, people, recognition, safety, and tools they use couldn't be overlooked or ignored.
The recognition of the divergence from the proper path resulted in a pause and self-examination of past practices and the formation of a project designed to support optimization of the EVS programs in two SFBA hospitals.
Sue Barnes, RN, CIC, FAPIC, who was, at the time, president of the SFBA, was project manager and SFBA chapter members were recruited. The two hospital teams consisted of infection preventionists (IPs), EVS directors and managers, and nursing representatives. Association for the Healthcare Environment (AHE) industry champions committed to the Triple Aim of Cost, Quality, and Outcome provided project sponsorship. Because of the scope of the project, AHE executive director Patti Costello and the entire AHE education staff were intricately involved. The goal was to design a playbook of best practices that would bring scientifically recognized, evidence-based, and peer-reviewed practice guidance to the forefront, while at the same time providing the vetted resources to the teams that need it the most. The Playbook is designed as a "DIY" (do-it-yourself) performance improvement project guide, and a toolbox of necessary resources to gain alignment, communication, and sustained focus toward sustaining gains at healthcare facilities that implement the Playbook.
The project guide followed a self-assessment performed by the EVS department in each participating hospital. The self-assessment would be followed by developing an improvement plan and use the Playbook as a guide for implementing the plan. The Project started with a multidisciplinary kick-off event and site visit by IP/EVS experts from the project team. It featured educational presentations, including information regarding the AHE certification programs, tools, and resources.
The updated project includes training and online resources to support reliable cleaning and disinfection in health care facilities. The Playbook is in place at 10 hospitals across the U.S. and one in Kenya, Africa.
The long-term goal is sharing the ES Optimization Playbook throughout IP and ES communities to facilitate project replication at other hospitals to improve patient outcomes and lower cost of care.
ESOP© advisors recently shared their perspectives about the relationships between IP and ES, and how the two could work together to produce better IP outcomes.
"I saw firsthand the benefit of engaging with environmental services when I did several projects in my Kaiser career," says Sue Barnes. "I always felt that EVS is the most excellent audience for any infection prevention presentation. They're still engaged, they're eager to learn, willing to change things and very vocal if they don't agree. And so, I always learn something from them.
She adds, "In my experience, the EVS teams are sometimes looked at as being lower on the totem pole, especially in an environment that also houses world-renowned surgeons. But the value they bring to the table is crucial--especially when it comes to infection prevention.”
"The participation of environmental services on an infection control committee is one way that the partnership between EVS and IP requires strengthening," Barnes says.
Implementing New Practices and Facing New Challenges
The ESOP© Project readily recognized that having an executive champion, a person with wide-spread influence, who understood the critical role that EVS plays in infection prevention is essential.
"Honestly, it's all about competing priorities when describing executive pain points and the lack of focus on EVS in infection prevention," Barnes says. "If executives had a better understanding of how important EVS practices are to infection prevention, and how foundational to the patient's outcome and safety a hygienic environment is, then they would likely prioritize it more."
That is why the ESOP© advisory council included a lot of resources in the Playbook to help teams educate executives and get the project champion on board. Executives receive talking points to assist in the implementation of the project. The talking points help EVS personnel and IPs articulate their processes, goals, desired outcomes, and the importance of staying on target with the project.
The Playbook program necessitates each hospital to identify an executive champion and complete a survey guided self-assessment. The self-assessment is used to develop improvement plans.
With the first two participating hospitals in the San Francisco Bay area, Barnes says, "That, in addition to what they might identify as opportunity areas, we (the ESOP© Project committee) recommended some key elements for the improvement plan and provided tools to support each element."
Those elements include:
• Enhancement of the cleaning assessment program
• Enhancement of EVS reporting to the infection control committee
• Identification and pre-training local EVS super-trainers
• EVS shadow training program by super trainers with a 16-point checklist
• Enhancement of EVS recognition program
Participation in the program includes a voucher for one EVS technician to attend the AHE Trainer program for Certified Healthcare Environmental Services Technician (T-CHEST). The train-the-trainer certification equips the EVS professional to train everyone on their team.
T-CHEST and CHEST are crucial for EVS staff to know only the "how" to perform their duties effectively, but the "why" it is essential to perform their duties properly. Barnes believes certification for T-CHEST and CHEST is crucial: "There is a need for expansion of AHE training at every hospital. I hope that this becomes a regulatory requirement at some point."
While the program is DIY, it is not without support. Just some of the things the ESOP© team facilitate is:
• Planning a kick-off event to engage stakeholders at each hospital
• Multidisciplinary site visits at the end of each kickoff to tour the facility and provide input from experts in infection prevention and environmental services
• Weekly meetings with each hospital team to support their efforts
• Planning their exit luncheon to review progress and plan for continuing/sustaining improvement.
• Coordinating a project evaluation via survey monkey.
As we have seen, the ESOP© Project currently has 10 hospitals in the process of implementing the Playbook, and the first three hospitals to complete the pilot have demonstrated promising results. These results include AHE training, enhancing the EVS staff recognition program which provides morale, partnership, and ownership by staff, improving staff quality assessments of cleaning processes and outcomes, accountability in collaboration with the nursing department, validated cleaning responsibility matrix, upgraded room and operating room turnaround times to ensure patients receive timely and effective treatment, and improved and optimized cleaning and disinfection processes with evidenced-based tools, and validated quality outcomes.
Advisory board members have said the training and delineating responsibilities between nursing and ES staff duties for cleaning and disinfection is beneficial. The AHE certified training programs, demonstrations, and hands-on training identified as some of the most important aspects for frontline ES staff about the Project.
The ESOP© Project allows everyone to take a step back from the daily operational hustle and analyze at what accomplishments and the processes involved. Management and supervisors take deeper dives into policies, training, application, and proper education on the tools used in the cleaning and disinfecting procedures.
The ideal and desires to excel in a dedicated group of IPs and EVS professionals were robust and durable. Yet, improvements need implementing, given the challenges within the healthcare environment of care.
After initial efforts and successes, the ESOP© Project moved the Playbook to a web-based platform. Participants suggested simplifying the number of steps initially identified as needed for the Playbook as too many people were wary and quite overwhelmed by the initial ten steps of the Playbook. Thus, a review -- based upon feedback from all stakeholders -- was undertaken, and a four-step process enacted. Surveys were initiated to expand beyond EVS and look at the perceptions of IPs and clinicians, and, most significantly, added an expert advisory panel to support the study sites. The survey indicated what needed focus. Then, based upon the results of the study, experienced advisors in the identified areas were offered to the study sites.
Notable, too, was the introduction of standardized protocols for ATP and fluorescent marker systems, as well as scholarship vouchers for AHE signature training programs included for participating study sites classes.
One substantial piece of information provided from the survey results involved misinformation and variability concerning disposable and reusable products, the need to define the content and makeup of disposable and reusable products, particularly products alleging to be "microfiber," and proper product testing and evaluation of wiping and mopping products used by EVS and nursing departments. Extensive independent laboratory testing of both disposable and reusable "microfiber" was undertaken to verify manufacturer claims to actual results.
Actress Alicia Cole, who was afflicted by multiple life-threatening and life-altering HAIs, was approached, and she volunteered to serve on the ESOP© Project advisory board. She is advocating for advanced legislation and reporting of HAIs, improving patient care environments, assuring hygienic healthcare conditions for all care, and improving the patient experience. Along with Sandra Rials, the national training director at AHE, they implemented a patient empathy component to the project and the EVS impact on patient perception of the quality of care.
Also, Lynne Sehulster, PhD, formerly CDC HICPAC co-author of the Guidelines for Infection Control in Healthcare Facilities (2003), and a laundry and linen expert, has developed a comparative analysis of CDC/CMS, laundry accreditation, and certification guidelines. The extensive comparative analysis is of accreditation and certification programs available in the United States, Canada, Mexico, the European Union, Germany (in particular), Australia, New Zealand, and Japan. The analysis will aid EVS and IPs in identifying proper laundry (including reusable infection prevention Healthcare-Grade-Ultra Microfiber©) and handling for hygienically clean laundry outcomes.
An advisory board was established in the months immediately following the initial ESOP© Project committee meeting. The board currently consists of more than 35 professionals, including research PhDs, IPs, EVS professionals, teachers/trainers, allied professionals, healthcare laundry professionals, healthcare textile manufacturers, microbiological labs, and a host of passionate and dedicated authorities in the healthcare industry.
During the development of the Playbook and testing at facilities across the U.S. and Canada, and one study site in Kenya, significant improvements were noted, and gaps in industry practices were identified. However, with the success of the implementation of the ESOP© Project, another pause must be taken, and questions asked.
Those inquiries include: "What products, processes, systems, and guidelines have a lower net negative impact on the environment and better patient outcomes?" "What outweighs the overwhelming needs of providing patients and staff with hygienic environments in which to recover and work?" Will the actions meet the "Ethics of Mother Care?"
What is the Ethics of Mother Care? It is this: "Any action or the contemplated actions of my peers or organization must be good enough for my mother." If they are not, they do not pass the moral and ethical standards needed for healthcare.
Healthcare does not operate in a vacuum. Patients must always benefit from treatment and care. The patient should form the definition of benefit. Infection prevention, environmental services, waste stream management, and sustainability are a few healthcare disciplines must always anticipate how those actions affect lives -- both patients and staff. The principles of medical ethics -- respect for autonomy, non-malfeasance, beneficence, justice, and application are not just for physicians, nurses, and medical researchers. The principles apply to everyone that receives a paycheck from healthcare, including contractors, medical supply chain professionals, and adjunct professionals such as healthcare laundries, food purveyors, waste management providers, and professional associations made up of all of these professionals.
Nevertheless, too often, decisions have been made in silos without regard to the first and only need - the patient. Usually, the needs of the patient are put on a side-rail while the ideas of supposed convenience or the motivation for financial profit become thrust to the forefront of decision making. Something was wrong and needed correction. A departure from doing what was right to what was expedient was happening in healthcare across the U.S.
The ESOP© Project Board looks forward to the next year, where the readers of Healthcare Hygiene magazine will have the opportunities to follow a diversity of thought leaders and be exposed to a variety of ideas, processes, and procedures all based upon science and data. Each month a component of the Playbook will be featured that has is identified as critical to the success of EVS/IP healthcare programs, with a compendium review in the January 2021 article.
Currently, the news media is bringing awareness and urgent attention to the novel coronavirus. Coronaviruses are a large family of viruses whose effects range from causing the common cold to triggering much more severe diseases, such as severe acute respiratory syndrome, or SARS.
Worries continue to grow that the China quarantine is not enough. With international air travel, deadly microbes emerging from other countries could easily infiltrate our communities, schools, and places of work. The interim guidance from the CDC3 recommends eight critical steps to minimize or prevent transmission of respiratory pathogens like Middle East Respiratory Syndrome Coronavirus (MERS-CoV). For EVS technicians, identification and patient placement are vital. Utilizing standard, contact, and airborne precautions with appropriate PPE, hand hygiene, caution around Aerosol-Generating procedures, and using Healthcare-Grade-Ultra Microfiber© for adequate removal of microbes from contaminated surfaces along with EPA Registered Hospital Grade Disinfectants with a label claim for (MERS-CoV) or human coronavirus is necessary.
With the increase, hospital administrators, IPs, nursing services, physicians, and EVS professionals face an increase in surveillance reporting and efforts needed to ensure hygienic environments.
Join us for a featured look into the world of environmental services and infection prevention over the next year. We want to share with you a video (https://www.dropbox.com/s/mp8vcrpm2pubqol/LLUMC%20EXPRESSIONS%20VIDEO_1.mp4?dl=0) from Loma Linda University Medical Center which illustrates the acceptance and enthusiasm exhibited by so many LLUMC professionals whose one purpose is improving the outcomes and lives of patients. They truly understand that a patient is a person first with a life worth living and they will continue being a person long after the cease being a patient.
John Scherberger, FAHE is the owner of Healthcare Risk Mitigation in Spartanburg, S.C. He is a subject matter expert in healthcare environmental services, healthcare linen and laundry operations, and infection prevention.