Archive for the ‘Patient Safety’ Category

Housekeeping…The Backbone Of The ASC

November 7, 2012 Leave a comment

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 pieces of napkins and a styrofoam coffee cup lodge in the corner by the entrance.  There is a sand-filled ashtray near a bench, but the ashtray is overflowing.  That nagging little thought is getting bigger.  When he enters the reception area he notices the wilting—almost dead—plant on the corner of the reception desk.  The carpet shows a clearly defined dark/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, for 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.

Infection Control Surveys

When CMS began the unannounced infection control surveys in the summer of 2009, it became evident that housekeeping practices in ASCs were an urgent issue in the rising rates of infections being reported in the ambulatory surgery Centers.  Surveyors came out of these surveys certain that housekeeping, the training of housekeepers, and the follow-up of the housekeeping practices was not a high priority among the leaders in the ASCs.  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 US what was discovered was that the ASC leaders largely hired housekeeping contractors who had “experience” cleaning healthcare facilities.  However, some of this experience was in cleaning doctor’s offices.  Some did list other ASCs.  On occasion, some owners of the housekeeping service had worked, themselves, 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 to observe their cleaning practices.  And yet, virtually all of the Centers had quite a litany of complaints regarding the services that were being delivered.

In performing inspections 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, in and on sterilizers, medical gas connectors, oxygen tanks and connectors…the list becomes extensive.  Rust 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 far from ‘seam-free’ and harbors bacteria.
  • Peeling and torn wallpaper—again, not smooth and seam free for washing w/o harboring bacteria.
  • Chipped paint on walls and door frames—same story as above as far as preventing adequate cleaning.
  • Nasty, dirty areas behind sterilizers and open drains that are full of what looks like mold.
  • Mold in air vents—dirty and dusty 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 that either have no or too long black hoses that are touching the bottom of the sink pan.
  • Housekeeping closets that are dirty, cluttered and un-kept.
  • 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 their 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.  In addition, the same mop head was taken into the second OR to use, but, then, so was 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 as to when she would change 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, nor 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 out of here’.

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.

  1. Comprehensive 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 entry into your Center.  What does it tell the patient about what he can expect from a safety/infection-free environment for him?  What does it tell him about your commitment to cleanliness?  Patients know about sterility.  They strongly suspect that the place where they are having their surgery should be above and beyond clean, if their outcome is to be good.  They all have friends or family, or they know someone who got 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 either physically or through housekeeping?
  2. Orientation.  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.
  3. Tools and Recommended Practices. Develop housekeeping checklists for each area.  Look at recommended practices from the 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.
  4. In developing checklists identify those things that are outside of the daily or weekly routine; e.g., carpets, tile, windows, upholstered furniture, stripping and waxing floors, woodwork, doors, inside cupboards, etc.
  5. Housekeeper’s checklists should hang in their closet.  Get in the habit of checking these several times a month.
  6. 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.
  7. Determine whether or not the housekeepers have had training in both blood-borne pathogens and toxic/hazardous substances, but also HIPAA.  If not, provide them with those policies and demand that the contractor provide further, documented training.
  8. Provide the housekeepers copies of your housekeeping policies and complete the orientation tool.  Observe their cleaning practices.
  9. 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, MSDS in their language!  There are sources for this available on the internet, or 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.
  10. Orient the ASC staff to housekeeping practices.  This should include not only what can be expected from the housekeepers, but what is expected of them.  It is unfortunate that we still see RNs who drop some piece of paper on the floor and leave it stating that it is not in their job description to clean, or they call the MA to pick it up.  The RN’s job is to provide a safe environment for their patient.  This includes a clean environment.  During a recent survey, the surveyor did 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!”…..not a good impression…and this is a room where medications are prepared!
  11. CMS expects that the leaders are periodically observing the housekeeping staff at work.  Schedule a midnight visit at least several times a year to ensure that best practices are being followed.
  12. Lastly, CMS also expects that the 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, eventually, word is going to get out that your Center is less than an ideal place for patients to have their surgery.  Remember, they do have a choice.

Language Barriers

October 4, 2012 Leave a comment


The question arises over and over as to whether people who are doing the housekeeping and who are cleaning instruments and scopes have to be able to read and speak English in order to be able to read instruction manuals for the use of equipment and for cleaning equipment and scopes, and for mixing solutions, reading instrument cleaning agent labels, and reading MSDS no say nothing of emergency instructions and signs.

According to OSHA, it is not necessary for those persons to be able to read English if the information is also available to them in their language, or if there is a translator who has trained them and/or is available to translate.….you best get your applicable MSDS also in that language and you had best get the instructions on the labels on bottles for mixing, etc. in that language, too.  

Can you GUARANTEE that there will always be a translator available when needed?  

What about during the night when housekeeping is there?  Think about it.






How are you all handling your patients’ health literacy?  Health literacy includes much more than reading proficiency.  It is a person’s ability to obtain, use and understand the information given to them.  It includes English proficiency and cultural beliefs.  We, as health care professionals, need to include these in our teaching even though we are feeling rushed in our busy ambulatory surgery/endoscopy centers.  Incorporating these learning styles, cultural beliefs and language abilities will result in the patient having a more positive surgical experience as well as outcomes.

It may be that many of us complete our cultural competencies as a chore, and not incorporate the distinctions we learn into practice in taking care of our patients.  What cultural competency means is that you are open to recognizing that people’s beliefs may be different from our own and some of these beliefs may influence how patients understand their health.

Should ASC’s Consider Valium A Safe “Take-At-Home” Pre-Operative Drug?

July 27, 2012 Leave a comment

I recently received an inquiry from one of our Clients regarding a practice the physicians wanted to initiate at their ASC.  The physicians believed that patients would be best served if given 0.5mg of Valium taken post-operatively at home the morning of surgery.  This would enable them to be nice and relaxed when they got to the pre-op area.

Consideradtion #1 Patient Age and Side Effects 

There are several issues going on here.  When considering what drugs to use with any patient, one has to consider the age of the patient and all possible side effects inherent to the age.  Obviously, the elderly and the very young have special considerations regarding their age whenever choosing a drug, but what is in consideration here is adult and geriatric patients.

Valium is a benzodiazeprine and is used widely to reduce tension and anxiety and, in surgery or certain medical treatments, to induce amnesia.  It is also used for seizures, restless leg syndrome, as a muscle relaxant, and for its sedative effects.

Adverse effects include anterograde amnesia.  Cognitive deficits can persist for up to 6 months or longer. Produces sedfation.  Paradoxicaol effects include excitement, rage, worsening of seizures in epileptic patients.  In patients suffering from, or prone to depression these symptoms can worsen.

The sedative effect of Valium may last longer in older patients.  There is also an increased incident of falls and accidents following the administration of Valium in the older patients.  It can lead to catastrophic side effects if mixed with alcohol. (Remember Karen Ann Quinlan?).  Valium is very addictive.  One physician discourages it use under any condition due to its degree of impairment in some patients.

Valium is detectable in the blood for up to 3 days.

If patients are given a sedative at home, doesn’t this increase their chances of falling at home?

Consideration #2 Falls Prevention Strategies at Home 

Falls in the elderly are a serious concern.  Within our ASCs, we initiate a “Falls Prevention Program.”  We inservice our staff in this area and measure their competency.  We track and trend falls and make changes in our Centers to decrease the possibility of falls.  We paint parking guards in the  parking lots and curbs.  We escort patients to their car.  We don’t leave patients alone to dress following surgery, but insist on staying with them to assist.  We identify patients at a high risk to fall with colored socks or wristbands.  We hold their arm when ambulating.  We recognize that the patient has received sedation, and are, thus, at a higher risk to fall.

BUT if these same patients are given a sedative at home doesn’t this increase their chances of falling at home?  I think of some of our elderly patients especially with their walkers, canes, and underlying health conditions that pre-dispose them to falling.  I know, too, how many times patients with underlying conditions get their feet “tangled up” and fall, and know that this risk has to increase when sedated.

Consideration #3 Alcohol Use by Patients

Valium can be lethal if taken with alcohol.  While alcohol use in the elderly is far below that of the 20 something age group, it is not uncommon.  Alcohol use in the elderly may, in fact, be under-reported.  Many retirees believe they can now sit back and do whatever they want.  Many believe they have earned the right to drink whenever and whatever they choose.  Many life-long habitual users may have increased their alcohol intake with all the golf games, card games, bingo matches, etc. to the extent that a “little nip” at breakfast is not uncommon.  This under reporting includes admitting to their physicians the extent of their use.  Valium and Alcohol do NOT mix…even that little nip can be dangerous.  It should be a concern that our patients fully understand this, discuss their use honestly with their physicians, and comply with instructions.

Consideration #4 Patient Depression and Dependence

Depression is increasingly common among our older population.  Their lives have changed, and are continuing to change, on an ongoing basis, in almost every aspect.  They retire from careers of 20-30 years that have demanded a large part of their lives and have helped to define them as individuals.  They become “stay at home” residents of the community.  This is where they might discover they have no hobbies, or they find that the hobbies they had before aren’t available to them now due to heath problems.  Their physical condition has changed.  They don’t have the stamina they once had.  They may be experiencing some underlying health conditions such as high blood pressure, cardio-vascular disease, coronary disease, diabetes.  Their mortality may be smacking them square in the face.   Husbands and wives are thrust together all day long, another adjustment.  Valium can increase this depression…but, the sedative properties may also provide an escape from all their problems and lead to dependence.

Consideration #5 Choosing Alternative Drugs 

The advantages of Valium under a controlled situation cannot be argued.  However, I would argue that there are other equally advantageous drugs that may be used to provide sedation and insomnia.  Cost may be a factor, as some of the alternative drugs are certainly more costly than Valium.

Consideration #6 Patient/Care Person’s Education 

Patients being given Valium should be reminded to not drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug.

At the very least, the patient’s care person needs to be thoroughly educated about the drug during the pre-operative phone call, so as to be able to take the necessary precautions.

Consider #7 Risk Management and an Alternative Strategies

I am not pointing fingers at this drug and saying, “No! No! No!”  Valium is a staple in any health clinic’s inventory as recommended by WHO.  I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to look at it seriously when prescribing it as a “take at home” med prior to surgery.

I recommend, as a licensed risk manager, that we not give the patients this drug at home prior to their admission to the center, but that we expedite the admission process such that their dosage could be given as soon as possible once they are admitted to the pre-op area.

We should always take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision.

%d bloggers like this: