Setting the Stage
Like most healthcare organizations, a community hospital had been facing significant financial pressure over the past several years. Expenses were under intense scrutiny and staffing budgets had gotten tighter each year.
This made it challenging for the Environmental Services (EVS) team to do their job well. EVS housekeepers operate behind the scenes, but they have a critical role in hospitals. They prevent the spread of infection and enable patient flow. With less and less staffing, a growing hospital, and no process changes, the team was struggling.
Mark McLean was the director for this area. He wanted to ensure that his team was respected by having everything they needed to do a high-quality job. Housekeepers started their day in the lower level of the hospital by filling a trash bag with their supplies. They then dejectedly drug that bag to their section of the hospital. Mark shared this as an example of disrespect since supplies should be where they were needed. His goal: no more dragging the bag.
We started by shadowing EVS housekeepers to understand challenges in their work. We then partnered with leaders to develop their goals and identify the right metrics to show performance, leveraging an A3 approach.
At that point, an interdisciplinary team came together for a 4-day value stream analysis. This included EVS leaders, housekeepers, nursing and quality representatives. This team built a roadmap of activities to transform EVS.
- Implement a system to make performance visible and encourage daily process improvement.
- Clean up the work area and get supplies to the right place, a process called 6S.
- Get consistency on what EVS should own versus nursing.
- Develop the best way for EVS to clean rooms, ensuring infection prevention and efficiency.
- Get the right staffing at the right time.
Implement a system to make performance visible and encourage daily process improvement.
First, we worked with area leaders to create a system with the following goals:
- Encourage the team by recognizing great work.
- Make performance visible, enabling the team to identify and address the root cause of issues.
- Cascade information up and down through the director, manager, supervisors, team leaders and housekeepers.
- Create consistency among the team.
The team created a visual tracking board and huddled around it each shift. They were now able to solve simple things that were getting in their way, like getting a key for rooms they needed to clean and getting equipment fixed. Information was also now able to flow between different levels of the organization, allowing the team to escalate challenges they couldn’t resolve on their own.
Clean up the work area and get supplies to the right place.
Housekeepers often had to search for supplies around the hospital. This takes time away from valuable work. A team of housekeepers came together to organize and standardize supply management. They tackled their main storage room, storage rooms in each clinical unit and mobile carts. Each type of supply had a well-marked space and stocking quantity.
The hardest part with any improvement activity is sustainment, so the team built sustainment into their daily work. It was clear who was responsible for cleaning and restocking each area every shift and when it hadn’t been done. The days of “dragging the bag” were gone!
Get consistency on what EVS should own versus nursing.
Over the years, EVS had adopted work from the clinical units. It is important for work to be performed by the right level, but this had gotten messy. Leader turnover didn’t help, and it got to the point that nobody was clear on who owned what. Housekeepers had to be trained differently for each unit. Equipment was getting cleaned multiple times or not appropriately. EVS stocked patient rooms on some units and not others. Housekeepers encountered leftover medication and protected information that should have been properly documented and disposed. This all delayed admissions and put infection prevention at risk.
A team of nursing leaders, nurses, EVS leaders and housekeepers came together to set clear standards. They decided who was responsible for each item and were consistent across the hospital. It took several months to get the roughly 600 nurses on board, but this was a critical step that supported the next stage of EVS improvements.
Develop the best way for EVS to clean rooms, ensuring infection prevention and efficiency.
Every occupied inpatient room must be cleaned daily and when turning it over for a new patient. Once there was clarity on what they needed to clean, the team observed to see if those items were already being cleaned. The results were surprisingly low.
A team came together for a 4-day event to determine the best cleaning process. The process they created included all infection prevention requirements in the most streamlined method. Previously, the team was given 30 minutes to turn over a room for a new patient. They showed that it was not possible to clean all required surfaces in that time, and a new 45-minute target was set. This illustrates the importance of setting appropriate targets. Setting an unachievable target can result in cutting corners and put quality at risk.
Get the right staffing at the right time.
Streamlining their work through the previous activities put the team in a better place to set the right staffing. Substantial preparation went into the staffing decisions.
- Daily assignment lists were updated to match current expectations.
- Actual cleaning times were tracked for areas that hadn’t been the focus of improvement activities.
- Historical data was analyzed on hospital occupancy and discharges in addition to training, vacation and sick time.
This data all came together to determine the number of required employees. It showed that the team didn’t have enough staffing to complete about 30% of their work. In fact, some employees were expected to do over 20 hours of work during their 8-hour shift. They needed 6 more full-time housekeepers to cover their work, and these positions were quickly approved. A new mid-shift was created for the majority of the new positions, which is when most discharges occurred and response times peaked.
Growing the team might seem like an expensive option. However, it was more than offset by lower overtime, less turnover and training time reductions. All of the process and staffing improvements also contributed to higher cleaning quality, lower rates of hospital acquired infections and quicker turnaround times. The team felt respected by having the time and structure they needed to do the best possible job, and patients received better care.