At three recent, but different, accreditation/Medicare surveys surveyors spent a great deal of their time discussing between themselves and with the administrator.
In fact at two centers the negative first impression began when the surveyors pulled up to the centers and were faced with weeds in the landscaping that were taller than the shrubs. Unfortunately for the owners of the one center, Code Enforcement showed up shortly after the beginning of the survey in response to complaints regarding the condition of the landscaping. Needless to say, the surveyors were not favorably impressed with that particular event! I daresay it might have been a first for them!
Hundreds of the earlier surgery centers are aging and are in dire need for emergency facelifts, and yet, the physician-owners are hard-put to invest in both cosmetic and maintenance-type improvements. Many of these centers need basic gardening assistance with their landscaping. Often, it may be nothing more than weeding and the addition of mulch.
Rains, and in the northern regions, heavy snows deplete mulching around shrubs leaving bare earth exposed. The addition of mulch rejuvenates the appearance as does the removal of weeds. Often, original shrubbery is in need of being replaced. One center in northern Florida totally altered its external appearance by replacing old shrubbery and trimming bushes and trees. This attention to the external appearance of the property relays a positive image to patients, visitors and surveyors alike! You care enough to take care of the building and grounds!
Imagine the first impression of a patient opening the doors to the waiting area and finding soiled carpeting that is in need of being re-stretched. (Imagine the risk management hazard of someone tripping over that loose carpeting!!) The patient/visitor/surveyor looks around and sees waiting room chairs that look (and are) outdated with soiled and stretched upholstery. Sometimes this upholstery is frayed and torn. Wood on the chairs is frequently scuffed. The color scheme frequently screams: "I was last decorated in the '80s/'90s."
The formica on the reception desk may be chipped. There is ground-in dirt on the bottom of the door frames and around door handles.
To compound the negative appearance identified above there may be even half-dead plants on or around the reception desk. Windows need washed, and where there are window treatments, they are often in need of either replacement or repairs.
Look up! Notice the dead bugs in the overhead lights many of which may even sport dead light bulbs.
Does all of this sound outlandish? Make an inspection tour of your center. Don your white gloves while you are at it, and after inspecting the waiting and reception areas for conditions described above, walk into the rest rooms. How clean are they? Do you even know HOW your housekeepers clean these areas? Oprah did a huge expose a few years ago about how housekeepers in hotels clean bathrooms discovering that they frequently cleaned the toilet then came back to the counters and sinks using the same cleaning cloths. We were all scandalized and appalled. ...BUT....do you know how it is done by your housekeepers? When was the last time you watched them clean?
In the bathrooms, look behind the toilet and under the sink. Inspect the condition of the pipes. When do you think they were last wiped off? What about that area between the pipes and the wall or behind the toilet? Notice the space where the flooring meets the baseboards or coving. Is dirt waxed in? When was the last time the door frames were painted? What about around the light switch? The door itself? When do you think the last time was that the entire door was wiped down? Or even, the door handle with a germicidal? Are the tops of the mirrors clean and dust-free? When was the top of the door frame and door last cleaned?
As you continue walking into the preop area, think of yourself as that patient/shopper. Now you are in the patient care area, and this is a pretty big deal to your anxiety-laden patient (and his caretaker). Is this area squeaking clean, warm and inviting? Is it neat, or does the poor condition of the waiting and reception areas overflow into this area? The latter is most usually the case. All too often the patient is faced with a cluttered nurses station immediately. Papers are strewn everywhere leaving a clear distinction of messiness and disorganization. There is often a lot of loud talking, and sometimes, laughing and joking around on the part of the staff. The patient notices cubicle curtains that appear faded, and sometimes, just ugly.
Being led into their cubicle, are patients met with sparkling clean equipment? Are stretcher bases clean and pristine, or are they nicked, scrapped and rusted? Do the wheels look dirty? How about the suction canisters and equipment at the head of the bed? Is there an inch of dust, or are they shiny and clean? Is the shelf at the head of the bed clean? Is the flooring in this area clean and intact, or, over the years has grime crept into the flooring seams and been waxed over to leave a nice and distinct black line? And, again, are we faced with grime around the bottom of the door frame, along the edge of the flooring at the coving? Are doors smooth and door frames free of scrapes from stretcher passage? When was the last time they were painted?
While the patient lays on the stretcher being attended, is he looking up at stained ceiling tile (which may contain aspergillas), or ceiling tile that is broken? From his bed, is he able to visualize the half empty cups of coffee left on the counters by the physicians, or the half-eaten food stuffs? And, again, is he left to be entertained by the dead vermin in the overhead ceiling lights?
The patient in PACU may be too sleepy to notice some of the issues that may exist in the preop area, but if they exist in preop, so, too, do they exist there.
Behind the scenes to the patient are areas that might make his hair stand on end. Does he notice the dust balls on the floor in the sterile processing area between the sterilizer and the wall, or the filthy bottom of the cupboard below the sink? Does he notice the condition of all the broken and pitted formica counters, doors, door frames? Fortunately, this area is "off limits" to patients. Look around. What if it wasn't? What would your patients say about the condition of this room, or the Decontam/Soiled Receiving? Are there gross stains on the wall covering? Are faucets corroded? What are the conditions of the inside of the cupboards and drawers? If you wiped you hand across them, would it come away covered in dust? Look closely. Surely there are no ant or roach houses neatly arranged on the ledges in these areas, right? While you are checking this area, run your hand across the top of the sterilizers and the sterilizer doors? How was that? Look at the condition of the floor?
Housekeeping closets can prove to be hair-raising when you are doing your cleanliness walk-about. Open these doors and really look inside. What is the condition of the floor sink? Are the walls nicked and stained? What about the floor? In some centers, this room is so packed, no one could possibly even get to the floor sink. Do you see any holes in the wall? One center had a hole that had to be at least 12"x12" in the wall through which you could view studding, etc. The condition of the housekeeping closet seems to be the source of the poor housekeeping throughout the center.
Last, but certainly not least, look at your Operating Rooms. Don those white gloves. Run your fingers across every ledge. They should come back clean, but too often they come back full of dust and dust balls. At one center, where there had been a rash of eight endophthalmitis cases, the dust on the arm of the microscope had to be almost a quarter inch thick. One that hand across the anesthesia machine, the tops and arms of all equipment...the tops of doors.....the tops of x-ray view boxes....inside anesthesia carts and anesthesia machine doors...on all flat surfaces.
Look at the condition of equipment wheels. No one is running them through germicidal solution anymore. Look at how cruddy they are — or aren't. Are the vents clean? How about the OR lights? Are they shiny clean? What about the video tower and those shelves? How about the legs on the mayo stand and its feet? Are the shelves on the prep and instrument tables clean? Is that electrosurgery generator and it's shelves sparkling? Note the presence of rust. No rust is allowed anywhere in the center! Get rid of the piece of equipment or have it rejuvenated. This applies to your hampers, too.
Cosmetically, what do your ORs look like. Initially, ASCs painted the walls with washable paint in warm pleasing non-hospital colors. Plain white walls were unheard of. The goal was clean but warm. Somewhere that concept has gotten lost, too, as ASCs become more hospital-like in their ORs.
Even your Decontam/Soiled Receiving room should be shining....no chipped formica....no lifted formica from excess water...no corroded faucets or plumbing. This is a critical space that needs to have a lot of special attention paid to the housekeeping in here
The preop and PACU areas need to be attractive, calm and soothing. They need to be clean and shining, too, but keeping up with the decorating maintenance in these areas is critical to the patient's impression of the center. Just redecorating the waiting/reception area but leaving the ORs, and their support areas in dire need of a face lift defeats the whole purpose. Many of the patients are awake in these rooms initially, and impressions are set.
When the ASC movement first started, the emphasis was on "high touch/high tech." The idea was to provide a warm, homelike environment in an area where the very latest technology was utilized. Somewhere along the way the warm/homelike environment has gotten lost throughout the older centers. This is evident even in the staff dressing rooms which have, also, been sorely neglected over the years. Walls have pits in them, are gouged, have torn wall paper, lifting formica, holes in the walls, dirt encased in wax along the edges of the floors and around the door frames. What dispiriting spaces to begin the day! Staff lounges are no better. Many have fallen into such disrepair and are so full of food, crumbs, etc. that a good visit from the health department is probably sorely needed.
Prepare some kind of check sheet to document your findings in every room and attach it to your report to the Board. Stress the importance of their investing into the center's maintenance and that if they don't, the surveyors will clearly notice, as they did recently citing the owner for not maintaining his center. Share with them that surveyors experience those first impressions, just like everyone else. The thought process is that if the owners don't care enough about the cosmetics of the building, then, they probably don't care about the maintenance, and that is where the digging on their part begins. It never ends well because they are basically right.
In several recent surveys the cosmetic appearance was stressed, but then they got to the rust, holes in the firewall, deteriorating harnesses in the generator, outdated copper pigtails in the medical gas closet, dead light bulbs in overhead emergency lights, bugs in overhead lights, door locks in egress doors that required two hands, panic bars that were 4" too high, not enough electrical receptacles at preop beds, seams gapping in flooring, incorrect or missing signage, fire alarms not being counted correctly on the logs or pulled during surveys, smoke alarms not being counted or tested correctly.
Surveyors have been heard to say, "If you can't take care of your building, then how can we expect that you are taking good care of your patients?" Think about it.
Infections are up dramatically in surgery centers. Remember the center with all the endopthalmitis patients and the dusty microscope arm. In one center, it was discovered that the air vents had never been cleaned. When done, it was found the vents were full of black mold. Infections are up. Swabbing is no longer done in ORs. Those petri dishes are no longer set out in the corners of the rooms at night. Possibly the environment has nothing to do with any of it, but what if it was you or your mother or child? Would you not want the best possible environment for the performance of the procedure in that scenario? Do your patients not also deserve that? Who knows? Maybe it would make a huge difference.