By John Scherberger, FAHE
the April 2021 issue of Healthcare Hygiene magazine, the Environmental Services Optimization Playbook (EvSOP) article titled “Value- and Science-Based Healthcare Evaluation and Purchasing” took a very critical look at the lack of scientific and value-based processes in environmental services (EVS) departments.
The article used the whimsical Lewis Carroll poem The Walrus and the Carpenter to highlight the many ostensible and, to many observers, nonsensical issues considered when making many EVS purchasing decisions. It’s as if some people become the Walrus and concentrate on topics, such as if a product appears in a group purchasing organization (GPO) agreement and not the science needed to ensure that cost, quality and outcome is the sole guiding principle.
The Association for Healthcare Resource and Materials Management (AHRMM) of the American Hospital Association (AHA) is the leading membership group for healthcare supply chain professionals. It is essential to understand this about AHRMM: “The AHRMM Cost, Quality, and Outcomes (CQO) Movement refers to the intersection of cost, quality, and outcomes, and a more holistic view of the correlation between the following: Cost (all costs associated with delivering patient care and supporting the care environment), Quality (patient-centered care aimed at achieving the best possible clinical outcomes), and Outcomes (financial reimbursement driven by outstanding clinical care at the appropriate costs) as opposed to viewing each independently.” With just a bit of editorial action, the quote is taken directly from their website at: https://www.ahrmm.org/cqo-movement/what-is-cqo
This article is not about AHRMM; however, it is very notable that they do not say that neither cost, quality, nor outcome is the primary driver of their movement — it is a holistic intersection of the three considered to achieve the best clinical outcomes. Please note that clinical is science-based. Also, over the last few years, some organizations have added to the Triple Aim, making it a Quadruple Aim. Worldwide, the Institute for Healthcare Improvement (IHI) has been asked the same question: “Why doesn’t IHI support the fourth component since others have done it?” The IHI states on its website that the fourth defining component for these organizations could be “improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of healthcare, attaining joy in work, or for others, it’s pursuing health equity. Some organizations highlight other priorities. The military health system, for example, has added readiness as its fourth aim. Although IHI supports other organizations prioritizing these worthy efforts in pursuing a Quadruple Aim to deliver on the organizational strategy.”
If delivery of a Quadruple Aim is successful, IHI urges the organizations to keep the following four points in mind:
• Remember that the Triple Aim is about patients. At its core, the focus of the Triple Aim is to improve the lives of patients. Triple Aim outcome measures put patients at the center of care. Any modifications to the original Triple Aim should not take us away from our highest priority.
• We haven’t finished pursuing the original Triple Aim. In almost every organization and virtually any environment, we still have a long way to go to achieve Triple Aim outcomes. There are still gaps in the health of the populations that we serve. We miss too many opportunities to improve the care experience. We haven’t done enough to improve healthcare quality while reducing costs.
• Don’t lose focus. Don’t let a fourth aim turn your organization’s capacities and capabilities away from optimal delivery of the Triple Aim. No organization has unlimited resources, so we must deploy what we have in an intentional, purposeful way. Make sure you respond truthfully to a complex question: Will we spread ourselves too thin if we pursue more than three aims?
• Measure what matters. If you pursue a Quadruple Aim, you’ll need to reconsider your measurement strategy as a whole. Rarely do you hear anyone complain about measuring too few things; be mindful of limitations on your staff’s bandwidth and use deliberation and consideration to determine what data is necessary and how to collect and analyze it.
With the IHI thoughts in mind, it is the intention of this article to focus on the Triple Aim of Cost, Quality and Outcome (CQO).
What does CQO have to do with healthcare environmental services? CQO must be embedded in all EVS-related decisions because EVS helps save lives.
As asked in the April 2021 issue of Healthcare Hygiene magazine:
• Why are science- and value-based processes not part of the “DNA” of the procurement process decision-making when considering EVS tools?
• Why is science- and value-based product evaluation bypassed when considering or purchasing EVS tools (disinfectants and healthcare-grade ultra-microfiber products and subsequent reprocessing to hygienically clean outcomes through an accredited/certified healthcare laundry) for infection prevention processing of the environment?
• Why are EVS departments excused from science- and value-based product evaluation for essential functions of infection prevention trap-capture-remove tools purchased or services contracted?
• Why is science- and value-based training for EVS technicians
ignored or limited?
The article in the April 2021 issue of Healthcare Hygiene magazine did not ask why doesn’t EVS and IP always have a seat at the table when construction, reconstruction, renovations, flooring, fixtures, furniture, and mobile equipment they will process purchase discussions are in their initial stages?
Those questions must be explored and dissected at the local or system level. Until embracing EVS/IP into the cadre of healthcare professionals as peers, a coordinated movement to improve patient health and well-being following the CQO will be incomplete, not a holistic approach. For those reading this article, it is noteworthy that infection prevention and environmental services partnership is vital, as are the industry partners that support them.
•The Society of Human Resource Management defines environmental services as “Services that maintain environmental and infection control standards within established policies and procedures of the healthcare center”
•Both professions are connected and rely on each other’s expertise to administer evidence-based practice across the
continuum of care
• The professional association for infection prevention – APIC — promotes consumer education that highlights the collaborative work between infection prevention and EVS.
• Certification for Infection Prevention has Environment of Care as a testing category, where collaboration is questioned as
part of validating the competency of the infection preventionist
Speaking of a coordinated movement, the CDC is one of the major operating components of the Department of Health
and Human Services and operates as the nation’s health protection agency. The CDC saves lives by providing science-based information to protect people from health threats. This agency conducts critical science research and provides health information that protects our nation against expensive and dangerous health threats and responds when these arise.
The CDC recognizes the risk of infection from surfaces and, in 2020, provided descriptions and examples of each of six core
components to ensure a hygienic environment. Here are the six core components:
1. Integrate environmental services into the hospital’s safety culture.
2. Educate and train all healthcare personnel responsible for cleaning and disinfecting patient care areas.
3. Select appropriate cleaning and disinfection technologies and products.
4. Standardize setting-specific cleaning and disinfection protocols.
5. Monitor effectiveness and adherence to cleaning and disinfection protocols.
6. Provide feedback on the adequacy and effectiveness of cleaning and disinfection to staff and stakeholders.
These six core components are the bedrock upon which hospitals, long-term care facilities, dental offices and clinics, and every venue people visit to receive treatment to mitigate their ailments must build. The Environmental Services Optimization Playbook (EvSOP©) is the blueprint of how to build upon the foundation.
The processes that EVS incorporates in cleaning and disinfecting are science-based. Mixing cost, quality, and outcome movements from concept to completion is imperative. Also critical is the incorporation of the principles of cleaning and disinfection which are timeless, regardless of the microbes, multidrug-resistant organisms (MDROs), healthcare-acquired infections (HAIs), or pandemics presenting the challenge to the healthcare environment.
The CDC has this to say about cleaning: “Cleaning is the necessary first step of any disinfection process. Cleaning removes organic matter, salts, and visible soils, all of which interfere with microbial inactivation. The physical action of scrubbing with detergents and surfactants and rinsing with water removes substantial numbers of microorganisms. When a surface is not free of dirt (cleaned) first, the disinfection processes are compromised. The success of the entire process (cleaning and disinfecting) is seriously in doubt and is most likely a failure. Removal of all visible blood and inorganic and organic matter can be as critical as the germicidal activity of the disinfecting agent.
When EVS cannot clean a surface, it should be excluded from use with barriers or completely removed.” It also advises, “Ensure cleaning staff receives training on the proper use of cleaning and disinfecting products.”
The principles of cleaning and disinfecting environmental services must consider the intended use of the surface or item used in caring for a patient. The physical action of scrubbing with detergents and surfactants (wetting agents found in cleaning chemicals and some disinfecting chemicals) and rinsing with water removes large numbers of microorganisms from surfaces. If a surface is overlooked or not cleaned before the terminal or final processing procedures are started, the success of the disinfection process is highly doubtful, if not completely negated. It’s not enough to scrub a surface to loosen bioburden; the process must include tools that can trap, capture, and remove the bioburden residue from the intended surface. In partnership with the physical efforts — or elbow grease — needed to loosen and detach bioburden from a surface, healthcare grade ultra-microfiber (HGUM©) traps, captures, and removes the loosened bioburden from the surface.
The CDC retains the Spaulding Classification for patient-care items and equipment. It outlines three categories based on the potential for the instrument to transmit infection if the device is microbiologically contaminated before use. These categories are “critical,” “semi-critical,” and “noncritical.” In 1991, the CDC proposed an additional class designated “environmental surfaces” to Spaulding’s original classification to represent surfaces that generally do not directly contact patients during care. The CDC found that environmental surfaces carried the least risk of disease transmission and decontamination using less rigorous methods than those used on medical instruments and devices was appropriate Environmental surfaces were further divided into medical equipment surfaces (e.g., knobs or handles on hemodialysis machines, X-ray machines, instrument carts, and dental units) and housekeeping surfaces (e.g., floors, walls, and tabletops).
The following factors influence the choice of disinfection procedure for environmental surfaces:
● the nature of the item subjected to disinfection
● the number of microorganisms expected to be present
based upon the location, condition, and previous use of the
● the innate resistance of those microorganisms to the
inactivating effects of the germicide
● the amount of organic soil present
● the type and concentration of germicide used
● duration and temperature of germicide contact
● if using a proprietary product, other specific indications and
directions for use
Spaulding’s Classification is so clear and logical that it is successfully used by infection preventionists and other professionals, including EVS personnel, preparing patient-care areas. The EVS task is to render “noncritical” surfaces hygienically clean. Unfortunately, even healthcare workers, regardless of their primary discipline, must be reminded that the disinfection of surfaces cannot occur and is not effective until all potential contaminants are removed from the surfaces indicated to be disinfected.
Cleaning is a separate activity from disinfection. Cleaning must include scrubbing with the trapping, capturing, and removing of all potential contaminants. Surfaces must be free of contaminants before disinfection steps commence, or the disinfection solution may not be effective. If using a one-step cleaner and disinfectant, it is best to choose a substrate or textile that can trap, capture, and remove the bioburden/biofilm, including dry-surface biofilm, and deliver the disinfectant at the appropriate concentration for the required dwell or contact time as per the manufacturer’s master label.
Processing is the preferred all-inclusive term that includes cleaning with detergents and surfactants, using HGUM© infection prevention textiles to trap, capture and remove any surface contaminants, plus an approved EPA-registered disinfectant or an EPA-approved hospital-grade cleaner/disinfectant combination solution.
In considering CQO, one must factor in all the aforementioned factors, which are not an ounce-by-ounce comparison of a disinfectant cost, nor is it a unit rate per textile, but rather a combination of all elements, e.g., efficacy in cleaning and disinfecting, delivery of the disinfectant, quantity or consumption of the product used to achieve an optimal outcome. It also includes staff labor, Lean strategies in reduced steps and efforts, impacts on the patient and healthcare worker safety; the waste stream and environmental considerations, and of course, patient throughput or progression; the time it takes to appropriately process a particular area or space, including all fixed and mobile medical equipment, as well as a clear responsibility matrix, as to who cleans, what, when and how.
As we have seen, the fundamentals of the science of cleaning are worthy of review. In doing so, we must embrace the concept of implementation science. But what is implementation science in the realm of healthcare and mainly EVS? Perhaps the University of Washington provides the easiest to understand introduction at: https://impsciuw.org/implementation-science/learn/implementation-
Implementation science consists of “Interventions and evidence-based practices that are poorly implemented – or not implemented at all – do not produce expected health benefits. Even when effectively implemented, interventions and practice changes still might not produce expected health benefits if effectiveness is lost during implementation, or if the intervention or practice was never effective in the first place.”
Implementation science is the scientific study of methods and strategies that facilitate the uptake of evidence-based practice and research into regular use by practitioners and policymakers. Implementation science seeks to systematically close the gap between what we know and what we do (often referred to as the know-do gap) by identifying and addressing the barriers that slow or halt the uptake of proven health interventions and evidence-based practices.
How do we get “what works” to the people who need it, with greater speed, fidelity, efficiency, quality, and relevant coverage?
Just as infection preventionists have embraced implementation science in their practices, EVS professionals must enthusiastically embrace implementation science to produce science-based and value-based cost, quality and outcomes. EVS professionals must embrace, immerse themselves into, and incorporate implementation science into their departments’ culture, or others will leave them in the dust of progress.