Infection prevention and housekeeping: A collaboration of equals

The goals, duties and responsibilities of infection prevention don't solely reside with infection preventions and clinicians focused on quality initiatives. Reducing the outbreak and/or spread of germs and diseases is an objective belonging to all employees of the hospital, right down to the frontline workers.

A key group of those frontline workers is environmental services, also referred to as housekeeping, though the duties don't seem as inherently apparent.

"Infection prevention teams have the goal of preventing infections between patients, from patients to employees and employees to patients," says Rahul Anand, MD, infectious diseases physician and hospital epidemiologist at Middlesex Hospital in Middletown, Conn. "Housekeeping, or as we call it our environmental services team, are responsible for maintaining the clean and safe environment of care."

Historically, these were siloed missions. However, the missions are becoming less siloed and more entwined as hospitals and health systems note the importance of the work environmental services contributes to infection prevention goals.

What's more, hospitals now have a financial incentive to boost efforts regarding infection control with the new value-based reimbursement models, says Daniel English, former environmental services director of Cooley Dickinson Hospital in Northampton, Mass., and current director of customer support and senior advisor of environmental services for Xenex.

"We're seeing a huge increase in the workload for infection prevention because reimbursement is tied to reporting data," Mr. English says. "Data must be reported, and so there's a lot of number crunching and patient file reviews going on by the infection preventionists."

Mr. English says the enhanced reporting requirements presents a strain on infection preventionists who need to balance meeting new regulatory obligations while also spending time working with environmental services.

While new regulations provide challenges for hospitals, they also present an opportunity for hospital-wide collaboration to develop new strategies to better serve patients, says Dennis Pfleiger, vice president of healthcare services at Einstein Medical Center Montgomery in East Norriton, Pa.

"The change to value-based purchasing and public reporting of key infection statistics encouraged the disciplines to work together to find solutions to best serve our patients," Mr. Pfleiger says. "This allows for each group to understand that they had something to offer to solve the problem and not to operate in silos or feel that there is any blame for the outcomes."

Getting started
Like any new relationship, the joining of infection prevention and environmental services may begin cautiously and with light treading by members from both departments, especially if the two historically haven't worked closely.

"As environmental services, you're going to be very sensitive to what [infection prevention] is going to say because their comments are going to be a reflection on the work that you represent," Mr. English says. "From the infection prevention side, you're going to want the [housekeeping] team on board, but you want them to listen to you and take your direction."

For the past seven years at Middlesex Hospital, a member of the environmental services team has sat on the infection prevention committee and met with a systemwide committee as part of the infection prevention team. Dr. Anand wasn't with Middlesex Hospital when this started (he joined the hospital in 2013), but he says the change was ignited by the hospital wanting to be more proactive than reactive.

"They were always working together but what they were finding is there would be gaps that occurred," Dr. Anand says. "Any new product or process that was introduced into the system…like emerging infections where new cleaning processes are required, that required a more proactive approach to bring the processes together."

Characteristics of a strong relationship
Of course themes of collaboration, communication and teamwork underlie any strong relationship, including the one between infection preventionists and environmental services. Dr. Anand adds that it is a circular relationship, as well.

"If you look at the missions together, it's a relationship of collaboration of equals. It's also leadership and followership in the respective realms," he says. "We make their work better, and they make our work better."

The idea that each department is necessary to achieving the goals of infection prevention is critical to fostering this relationship, Mr. English says. Not only do all individuals involved need to feel their work is important, but they also need to be able to approach anyone else with concerns and establish a trust that each has the other's best interests at heart.

"It's good [if] the frontline feel they've got a connection and can bring things to infection prevention," Mr. English says. "It can be very damning if infection prevention is on the patient floor and doesn't speak to housekeepers, where as if they do speak to [housekeepers], it can make [housekeepers] feel strong in front of nursing staff."

Mr. English continues, "It's that feeling of they've got our backs. It's almost critical that the infection preventionists go to a meeting with environmental services frontline and tell them that."

Case study: Einstein Medical Center Montgomery
Last year, Einstein Medical Center Montgomery initiated a process to validate room cleanliness at discharge, a project that brought together infection prevention and environmental services.

Together, the infection prevention department and environmental services implemented monthly random adenosine triphosphate testing, a process that measures actively growing microorganisms and can serve as a performance indicator of cleaning process performance.

Infection prevention would conduct the ATP testing on recently cleaned rooms with environmental services there with them to look at what they are testing and discuss results.

Einstein Medical Center Montgomery initiated the project in June, when there was a 66 percent compliance rate with the monthly testing. By July, compliance rose to 80 percent. In February and March 2015, there was 100 percent compliance with the testing.

What's more, the healthcare-associated Clostridium difficile infection rate dropped from 0.42 infections per 1,000 patient-days to 0.09 infections per 1,000 patient-days.

Mr. Pfleiger attributes much of this success to thorough communication and commitment from both departments. "The infection prevention and environmental services staff discussed the results in a collaborative and non-punitive manner to build trust and respect," he says. "The monthly results were shared with the staff at each staff meeting by the vice president of the area to assure that everyone saw the importance of their role at Einstein Medical Center Montgomery and to celebrate the ongoing success. This enhanced the feeling that everyone makes a difference in the lives of our patients every day, every time, and helped to enhance job performance."

For the patients and the triple aim
Clinically, infection prevention and environmental services are critical to helping ensure patient stays are as effective and efficient as possible, without the threat of infectious diseases. However, the two departments play an important nonclinical role as well.

"You may not know or see what infection prevention is doing when you walk in to get your care," Dr. Anand says. "But cleanliness is something you pick up on immediately. It gives [patients] a very tangible part of their experience that the system is keeping things clean and preventing infection."

To take it one step further, a strong relationship between the two departments, and an ultimate lowering of HAIs, also feeds directly into healthcare's triple aim.

"If you truly have low infection rates and clean facilities, it does move the system toward better outcomes and lower costs on HAIs and a better patient and staff experience," Dr. Anand says.

More articles on infection control:

5 latest findings on UV light disinfection in hospitals
13 stories this year on CAUTIs, CLABSIs
How to clean, disinfect while preventing harmful exposure: 5 things to know

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