EvSOP: The Genesis of the Environmental Services Optimization Project

By John Scherberger, FAHE

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 multimodal 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 (HAIs).

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 towards 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 healthcare 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 EvSOP Playbook throughout IP and EVS 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 EvSOP© 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 EvSOP© 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 EvSOP© 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 EvSOP© 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 EVS 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 EVS staff about the Project.

The EvSOP© 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 EvSOP© Project Board looks forward to the next year, where the readers of Healthcare Hygiene magazine will have the opportunity 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 been identified as critical to the success of EVS/IP healthcare programs.

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.

1. https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section10.html
2. https://www.cdc.gov/drugresistance/biggest-threats.html
3. https://www.cdc.gov/coronavirus/mers/infection-prevention-control.html#preparedness