EvSOP: One Healthcare System’s Journey Toward Zero Infections Through Science-Based Cleaning

By John Scherberger, FAHE

In the field of healthcare environmental services (EVS), many processes have been introduced to address the challenges of maintaining hygienic and aesthetic balances in patient care and treatment areas.  Some are science-driven, and some are emotion-driven.  There are those that state nothing should be undertaken without having numerous peer-reviewed studies, and those that prefer the knee-jerk “my way or the highway” approach.  Some prefer the Rube Goldberg approaches that are so complicated the goal is lost in the process.  Others prefer the Occam’s Razor approach, a scientific and philosophical rule that purports the simplest of competing theories be preferred to the more complex; the simplest answer or solution is the correct one.

In the clinical field, too many people are looking for the "perfect" answer, and the "perfect" answer cannot be the simplest. It's actually the Greek philosopher Aristotle to whom the idea that perfection equals simplicity and vice versa is attributed. Aristotle was known for the phrase, "The more perfect a nature is, the fewer means it requires for its operation." For EVS, the "perfect nature" is the goal of removing potential pathogens (biofilm, virion, spores, molds, bacteria, simple and complex organisms) through a trap, capture, and remove process using healthcare-grade ultra-microfiber (HGUM©), and destroying simple and complex organisms through the use of Environmental Protection Agency (EPA)-registered hospital-grade disinfectants.  One must keep in mind that EVS is tasked with providing hygienic, disinfected surfaces, not sterile surfaces or environments.

In February 2019, after years of serious prayer, contemplation, business considerations and investigations, and number- crunching, CommonSpirit Health emerged from the alignment of Catholic Health Initiatives (CHI) and Dignity Health.  Both health systems have a long, proud legacy of serving all people in need, especially those who've been made vulnerable by poverty, age and other hardships.  Because CommonSpirit Health (CSH) is faith-based, Bible scriptures are referenced herein, for the Bible is an integral part of their ministry foundation.  They are used to tell the story of CSH Mission, Vision, and Values, not as evangelism.

Catholic Health Initiatives and Dignity Health systems brought together their two ministries to become the largest faith-based healthcare system in the United States, serving 21 states, with more than 700 healthcare sites, and contributing $4 billion annually in charity care, community benefits and government program services.

Modern healthcare is a business. Even with the countless hours of prayer, contemplation, business considerations and investigations, and number crunching, firm business and spiritual foundations (Ephesians 2:20 and others) were fundamental and essential.  Having laid the foundations, CommonSpirit Health (CSH) incorporated the truths found in I Corinthians 12:21-26 that just as the human body cannot “say” one part is more important than another, neither can a hospital nor hospital system say one part is more important than another: “The eye cannot say to the hand, "I have no need of you," nor again the head to the feet, "I have no need of you.” On the contrary, the parts of the body that seem to be weaker are indispensable . . . If one member suffers, all suffer together; if one member is honored, all rejoice together.”

As we have seen, the narratives of both Dignity Health and Catholic Health Initiatives are long and have firm foundations based upon a multilevel approach; but healthcare is more than organizational foundations.  And healthcare ministry, whether religious or secular, is the serving of people where they are, regardless of who they are, where they are from, where they are going, or their lot in life.  Healthcare ministry is, very simply, providing service to people in need.  The need often presents itself as a physical malady that is readily apparent; other times, the need is more difficult to see and treat, such as mental imbalances, whether chemical or physiological; often maladies manifest themselves in a Spiritual realm.  Regardless of the origin, physical, psychological, or spiritual, the needs are real and often compounded due to non-severability within a person. The uniqueness of people, physical, psychological, and spiritual, is integrated with and integral to the whole person and cannot be severable from the whole or remainder of a person.  Be it medical intervention or treatment or care, compassion, or empathy, they all work for good. Medical treatment is not always necessary or effective, particularly at end-of-life, but care is always necessary.

Patients are why hospitals and healthcare systems exist; but they cannot exist in a vacuum. They need people with a servant's heart, people who care, people with vision.  For without a vision, people and nations perish.

Some hospital departments may appear to take precedence, such as infection prevention during the current COVID-19 pandemic.  They have been tagged "front line heroes" by the news media. Still, they are fully aware that they are but members of integral multidisciplinary teams working for the good of patients, staff and the community.  CommonSpirit Health recognized years ago that multidiscipline, multimodal, and multi-organization systems have the greatest impact and widest success rates in terms of patient success and positive patient outcomes. The Centers for Disease Control and Prevention (CDC) recently launched the core components of Environmental Cleaning and Disinfection in Hospitals

The key elements align with what CSH already discovered:

  1. Integrate EVS into the hospital’s safety culture.
  2. Educate and train all healthcare personnel (HCP) 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 adequacy and effectiveness of cleaning and disinfection to staff and stakeholders.

It was with this similar thought in mind that CSH set out to build a robust, evidence-based, internal environmental services department. Much of their journey mirrors the CDC’s recently issued best practices around selecting appropriate cleaning and disinfection technologies and products:

- Ensure that cleaning and disinfection technologies and products are tailored to the setting and standardized as much as possible.

- Use a systematic process to select technologies and products, including advanced technologies (e.g., no-touch disinfection devices), for patient care areas.

- Convene all stakeholders, including the facility cleaning and disinfection program, EVS management, IP&C, materials management, and other relevant HCP in the decision-making process for factors such as:

-- compatibility with device manufacturer’s instructions for use

-- contact time

-- possible health risks

-- acceptability to HCP and patients

-- effectiveness in decontaminating a surface

-- impact on overall cleaning efficiency

-- required expertise and training

-- effect on surfaces or devices of repeated exposure to a product

Used with permission from CommonSpirit Healthcare

As you can see, convening all stakeholders, using a systematic process to diagnose, design, and deliver the best patient care in terms of quality and evidence based outcomes -- which is also cost-effective -- is key. Utilizing an approach founded in proven science, the Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee that focuses on the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections (HAIs), antimicrobial resistance, and related events in U.S. healthcare settings.

At the July 2017 HICPAC meeting, the CDC asked HICPAC to develop a process for both entities to use when formulating product-specific recommendations. HICPAC formed a workgroup to achieve this goal.  CDC’s HICPAC team, they commenced on their journey. Innovations in healthcare infection prevention are essential to improve patient safety and increase our ability to provide optimal care. During the last decade, numerous novel products have entered the healthcare market. CDC and HICPAC recognize the importance of being able to meaningfully and consistently assess these innovations, for which supporting evidence is often limited or of heterogeneous quality. To address these issues, the CDC asked HICPAC to develop a transparent and rigorous process for the Committee to use when formulating product-specific recommendations, and to provide the rationale for the criteria proposed.

The workgroup developed a tool (https://www.cdc.gov/hicpac/pdf/product-assessment-H.pdf) consisting of discrete elements for the review of product-specific evidence. This tool is intended to be used to assess the evidence for a novel product, compare and contrast two similar products, and serve as a workflow when guidelines are considering recommendations for a product.

In 2017, the San Francisco Bay Area (SFBA) Association for Professionals in Infection Control and Epidemiology (APIC) recognized the imperative need for IP and EVS to work together with allied healthcare professionals to look outside of their sandboxes, also known as silos, at essential innovations and renovations to healthcare disciplines that affect patient care and effective patient treatment. The seeds of the Environmental Services Optimization Playbook (EvSOP) program was planted. There exist science-based cleaning journeys in parallel universes, for in 2004, Tim Livesay joined Saint Joseph Hospital in Lexington, Ky., a Catholic Health Initiatives hospital.  He was tasked with converting in-house EVS departments to contracted or outsourced departments.  He had spent 15 years of his EVS career within the outsourcing world and recognized that "a lot of our savings derived from the efforts of team members."  It became evident to him and many others in the system that outsourcing wasn't going to happen.  To serve primarily as an "outsourcer" for the system, all the while recognizing the tremendous benefits of the team members and the value they brought to the system.  This brought him to a tough choice in his life; he could no longer serve two masters, an outsourced contractor, and the hospital system and its financial and spiritual needs.

Tim recognized the wide chasm that affected patient and staff outcomes that could not be addressed with outsourcing EVS.  The recognition quickly evolved into something that he had never imagined nor encountered: the most critical element of partnering with Infection Prevention professionals with EVS and rolling both disciplines up in and through infection prevention.  He and his team recognized that each discipline lacked core processes, integration, understanding of each other, and collaboration.

His enthusiasm and questioning were contagious. He was asked to sit on a Catholic Health Initiatives (CHI) committee to look at the profound and fundamental benefits, not just financial, of choosing the best solution for CHI intensely.  CHI brought CEOs, CFOs, CNOs, the best and brightest of their System EVS teams, Materials Management, Clinical Engineering, and many other discipline professionals to the committees formed.

This project was recognized to be a multi-year process, so a four-year program was developed.  It was about then that Catholic Health Initiatives and Dignity Health decided they would merge into one organization, now known as CommonSpirit Health.

Tim was ultimately promoted to serve as the national director of EVS on the ministry's CHI side.  Suffice it to say, the story of how CommonSpirit, Dignity Health, and Catholic Health Initiatives formed is not one of a lone EVS professional or the story of a handful of professionals dedicated to one task.  Nor is it a story of a journey of pushing agendas while pushing people aside.  It is a story of dedication, personal commitment, group pride in serving a ministry tasked with bettering the lives of those they minister to.

After the merger, ideas, proposals, concepts, discussions, plans, processes, and innovations did not slow down.  In fact, they began to flow so swiftly that CSH had to hit a pause button to bring everyone up to where they had progressed.  An avalanche of excellence was coming down upon them that it appeared to be the cause of missing the vision of System excellence needed to be accepted and embraced by all.

So, as Tim notes, they had to "literally hit the reset button, and we did the majority of our work at Houston's Baylor Saint Luke Medical Center.  The reset button included the opportunity to step back and look at the rose bushes of their successes but allowed them to look at the thorns and weeds that were being overlooked by viewing only their successes.  They needed to look at both ministries sides, CHI and Dignity, laying them side-by-side, and inculcate both teams successes, not only in the procedures, processes, and hands-on work of their teams, but also in the science behind the procedures, processes, and tools – Healthcare-Grade Ultra Microfiber, professional laundry processes, chemicals, a new manual, and electric equipment, dwell times for disinfectants, standardized cart set-up, knowing when to use disposables versus a reusable mop or wiper (clinicians vs. EVS), how to collect soiled laundry and how to distribute hygienic laundry.

CommonSpirit Health went back to the drawing board for standardized processes and procedures.  They are reviewing who does what when, how, and why.  They are moving toward standardized best practices to be used in every one of their ministry locations from the largest Baylor Saint Luke facility where Rob Tussey, VEPI, T-CHEST, is the director of EVS and national training manager for CSH, and where he finds his office today to the smallest outreach centers scattered throughout the U.S.

Tim describes Rob Tussey as "probably one of the sharpest young men I've ever encountered in my life.  "He's actually on the longest journey with me as we move through the symbiosis of two systems becoming one.” Through their and countless others of the CSH System, the free exchange of information, combining years of experience, knowledge, and insight, they have moved forward to examining systemwide software for EVS and infection prevention.  Through constant trials and testing, they are working with vendor partners to develop tools and processes that will benefit their teams, be environmentally safe for their facilities, and if discharged to the sanitary sewage systems, in municipal waste, or into biohazardous waste.  They have taken it upon themselves to recognize their ministry as a responsibility to the Earth that God has entrusted to them. To use a much-overused term and little understood today, they view their ministry, their business, and their lives holistically.

Used with permission from CommonSpirit Healthcare

CommonSpirit Health recognizes its responsibilities reach beyond the borders of their facilities.  The CommonSpirit vision is to create a highly engaged team that performs their jobs based on the science behind what they do.  They call it equipping their people to perform. By educating their people, they position them to provide quality service.  And in providing quality, they need to understand the deliverables day in and day out of what they’re doing within the ministry.  And when they understand their deliverables, their ministry, if you will, it's not just about EVS, it’s not just about laundry or linen.  It’s about the entire facility, the entire division in the ministry as a whole from a system standpoint.   Teaching the teams all elements of the program gives them the tools to encounter others with integrity. At the end of the day, they want to pursue excellence and being the best version of themselves day in and day out.  It’s not just about why they provide a clean, safe environment. It's doing their best to help save lives.