This article was written by Anne Dean, RN, BSN, LRM, CEO and co-founder of The ADA Group.
The patient's car pulls into the parking lot of the ASC. He is here for his pre-anesthesia/surgery assessment and education visit. He can't help but notice that there is trash here and there around the lot. A nagging little thought enters his mind about the apparent disregard for tidiness. He approaches the front door of the center and again notices some napkins and a Styrofoam coffee cup lodged in the corner by the entrance. There is a sand-filled ashtray near a bench, but the ashtray is overflowing. The nagging through is getting bigger. When he enters the reception area, he notices the near-dead plant on the corner of the reception desk. The carpet shows a clearly defined dirty traffic path. The upholstery on one of the chairs is badly stained, while another is clearly frayed along the front seam.
Does the above scenario sound implausible? It shouldn't, because it is a scene CMS surveyors are reporting across the country. That patient's nagging thought becomes a roaring symphony to CMS surveyors entering a center.
When CMS began unannounced infection control surveys in the summer of 2009, it became evident that housekeeping practices in ASCs were an urgent issue in the rising rate of infections being reported in surgery centers. Surveyors came out of these surveys certain that housekeeping, the training of housekeepers and the follow-up on housekeeping practices was not a high priority among ASC leaders. Indeed, some surveyors were heard making statements like, "It is clear that the leaders of this organization hire incompetent, unskilled and unqualified persons to perform housekeeping and sterilization services in this organization."
In assessing the housekeeping practices in some 36 surgery centers across the U.S., surveyors discovered that ASC leaders largely hired housekeeping contractors who had "experience" cleaning healthcare facilities. However, some of the experience was in cleaning physicians' offices. Some owners of the housekeeping service had worked in the housekeeping department of the hospital. Several centers interviewed performed all the housekeeping inservices internally, using their RN staff. In none of the centers did the organization meet with the housekeeping staff themselves to perform training or observe their cleaning practices. And yet, virtually all the centers had experienced a litany of complaints regarding the services being delivered.
In performing inspectors of the various ASCs, CMS has reported:
• Water-stained ceiling tiles throughout many centers. These stains harbor bacteria.
• Rust on stretchers, OR tables, IV poles, the legs of instrument tables, anesthesia and emergency carts, endoscopic cleaners, sterilizers, medical gas connectors, oxygen tanks and connectors. Rust also harbors bacteria.
• Dust everywhere — windowsills, blinds, tops of suction canisters, the top of emergency and anesthesia carts, microscope arms, behind equipment on counters, inside drawers in medication rooms and in the OR and sterile processing. Dust is a large contributor to post-op infections.
• Chipped and peeling Formica throughout the center on doors, counters, cupboards. This leaves a surface that is not "seam-free" and harbors bacteria.
• Peeling and torn wallpaper that is not seam-free for washing without harboring bacteria.
• Chipped paint on walls and door frames, which prevents adequate cleaning.
• Dirty areas behind sterilizers and open drains that are full of mold.
• Mold in air vents.
• Blackened, separated floor seams.
• Separated coving on floors in sensitive areas like the OR.
• Separated back splashes, leaving gaping spaces between the back splash and the wall in sterilization and soiled cleaning rooms.
• Housekeeping closets with improperly sized black hoses that are touching the bottom of the sink pan.
• Housekeeping closets that are dirty, cluttered and unkempt.
• Corners of floors, especially behind doors, that are dirty and appear to have been "waxed over."
In one center, CMS instructed the ORs/administrator to demand the housekeepers come in during the day shift, in order for CMS to observe them cleaning the ORs. It was disastrous. The cleaning crew mopped the OR walls with dripping mops, starting at the bottom and working their way up. The same mop head was taken into the second OR to use, along with the same bucket of water.
While observing housekeepers in another center, the observation was made that the housekeeper pushed the bucket full of solution out of the one OR, mopped the OR corridor and proceeded into the pre-op/recovery area. When the observer questioned the housekeeper about when she changed the water/solution in the bucket, the housekeeper replied that she changed it when it got dirty.
In another center, where the RN staff performed all housekeeping duties, it was discovered that counters were never being cleaned, not was deep cleaning behind equipment or corners being done. It appeared that the old "a lick and a promise" was the rule of thumb, as this service was being done at the end of the day's schedule, and staff were eager to get home.
One cannot assume that these are isolated occurrences. In the face of increasing numbers of infections in ASCs, we in this industry must cast a disparaging eye toward housekeeping practices in our own ASCs. We have to carve out the time to address this very serious issue. Here are several recommendations for robust housekeeping policies in an ASC.
1. Create robust housekeeping policies. Surgery centers should have comprehensive housekeeping policies. Housekeeping guidelines for hospitals and healthcare facilities can provide the stepping stone for your policies and protocols. Look at every area, beginning with the entrance into your center. What does it tell the patient about what he can expect from an infection-free environment? What does it tell him about your commitment to cleanliness? Patients know about sterility, and they strongly believe that their surgical facility should be clean if their outcome is to be good. They all have friends or family, or they know someone who contracted a post-operative infection. The condition of your center also has a huge impact on your marketing. What does it say to your patient community if you have not maintained your center through housekeeping?
2. Meet with staff to discuss "problem areas" in your center. Develop a housekeeping orientation program and tools. Include all areas and essential tasks. Look at your own expectations in each area. Meet with your key staff members to discuss and explore their expectations, issues and complaints. Incorporate clear instructions based upon this analysis as part of the housekeeping orientation.
Orient the ASC staff to housekeeping practices. This should include your facility's expectations of both housekeepers and staff. The RN's job is to provide a safe environment for the patient. In a recent survey, the surveyor performed the "white glove test" on the bottom of a drawer in the medication room. She held up a finger laden with dust and showed the RN, who was the medication management nurse. The RN said, "Housekeeping doesn't clean inside drawers." The surveyor remarked, "And clearly, neither do you, nurse." This does not make a good impression, especially since it concerns a room where medications are prepared.
3. Take advantage of checklists. Develop housekeeping checklists for each area. Look at recommended practice from AORN. These checklists should include terminal cleaning of the ORs, the expected schedules for the cleaning of all areas, and the contents of all the different rooms. What pieces of equipment are they to clean, if any? Also, develop checklists to document what the nurses are expected to clean and how often.
In developing checklists, identify those things that are outside the daily or weekly routine (e.g., carpets, tiles, windows, upholstered furniture, stripping and waxing floors, woodwork, doors, inside cupboards, etc.).
Housekeeper's checklists should hang in their closet. Get in the habit of checking these several times a month.
4. Expect housekeepers to undergo training. Put together a housekeeping training packet and meet not only with the supervisor, but with the housekeepers who are going to be cleaning your center.
Determine whether or not housekeepers have had training in both bloodborne pathogens and toxic/hazardous substances and HIPAA. If they have not, provide them with those policies and demand that the contractor provide further, documented training.
Also provide the housekeepers with copies of your housekeeping policies and complete the orientation tool. Observe their cleaning practices.
5. Explore language limitations in your housekeeping staff. During the orientation and training period, there should be a conversation regarding the ability of the housekeeping staff to read and speak English. If the staff is unable to do so, you are expected to provide instructions, checksheets, and material safety data sheets in their language. There are sources for this available on the internet, or you can contract with an interpreter to make these changes. You can also have the interpreter provide all the instructions verbally. Document this in the contract workbook with their contract.
6. Observe housekeepers at work to benchmark progress. CMS expects leaders to periodically observe the housekeeping staff at work. Schedule a midnight visit at least several times a year to ensure that best practices are being followed.
Lastly, CMS expects that leaders of the organization are conducting housekeeping inspection tours. It makes sense that the infection control coordinator be responsible for monitoring the housekeeping practices in the center. However, the leaders should hold this person accountable by reviewing the logs on a regular basis and demanding that the housekeeping practices and results of the weekly housekeeping inspection tours be included in her quarterly infection control report to the QA/PI meeting.
In closing, housekeeping practices are the backbone of the surgery center. Without good, sound and solid housekeeping services, low infection rates are in jeopardy, and your center's reputation could be damaged.
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