Measured Success

By Thomas Peck, CHESP

December 23, 2013 | Formats: Article | Content Areas: Administration, Environmental Sanitation Operations | Tags: Benchmarking, Environmental hygiene and sanitation, Environmental Monitoring Tools, Evidence-Based Practice Solutions, Leadership, Policies, Process Improvement, Staffing Models

Good isn’t good enough anymore. In today’s competitive healthcare environment, excellence will be the expectation not the exception. From meeting HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) standards for room cleanliness and quietness to lowering operating expenses as part of a Lean initiative, environmental services departments are facing significant challenges.

At the University of Wisconsin Hospital & Clinics, we use a very detailed department dashboard to measure our department’s successes and areas for improvement. At the end of each month, data and information that has been collected is automatically linked to the department’s dashboard. The finished dashboard depicts the department’s “report card” on 44 different objectives or goals.

Following is a small sample of the items we measure and include on our department dashboard:

Room Turnaround: Ensuring incoming patients have quick access to a clean patient room is essential. In cooperation with the nursing staff, we have set specific turnaround times for staff to respond to STAT beds, which includes our response time and overall cleaning time.

Room Cleanliness: Our number-one goal is to provide our patients with the best possible care. For environmental services, success or failure is often measured by our HCAHPS room cleanliness score. To promote more ownership, we also break the HCAHPS scores down by supervisor. Each supervisor’s HCAHPS score reflects the scores of the patient units that fall under his/her responsibility.

Surface Testing Results: Each month, we test the 17 most highly-touched surfaces in at least 63 patient rooms to determine the effectiveness of our cleaning techniques and staff adherence to our cleaning procedures. The results of these tests are used for staff education and to help focus our resources. Our goal is for our staff to always effectively clean all the highly-touched surfaces in all patient rooms. Successful cleaning procedures minimize the spread of pathogens that may lead to healthcare-acquired infections (HAIs).

Hand-Washing Compliance: A hospital-wide goal also adopted by environmental services is to achieve 85 percent hand-washing compliance in 2013 and greater than/equal to 90 percent in 2014. Again, a successful hand-washing campaign will help reduce HAIs. To further strengthen our department’s commitment, each of our supervisors completes at least six and often more than 20 individual employee hand-washing assessments each month.

Expenses: Every department, of course, has a finite budget. It is the manager’s responsibility to operate within these budgetary constraints. For our department, in conjunction with our Lean initiatives, we have set a goal for reducing expenses in Fiscal Year 2014 by 3 percent. This goal is now one of our dashboard measurements.

Customer Service: A hospital-wide customer service survey was completed to determine how accessible, timely, accurate, friendly, and efficient our service was to our customers. Based on the initial survey, improvement goals have been set that are now a part of the department’s dashboard.
Supervisory staff complete at least five customer or patient surveys each month to measure progress.

Supervisory Performance: A key to any department’s success is the overall performance of their managerial and front-line supervisory staff. Each month, every supervisor has set expectations and goals. These include, but are not limited to:

1. Completing at least two formal inspections on every employee.
2. Conducting a formal meeting with each unit manger in the areas covered by the supervisor. Each of these meetings is also attended by the responsible area cleaner. The results of these monthly meetings are then summarized and shared with all interested parties.
3. Complete at least five written hand-washing assessments.
4. Complete at least six customer service or patient surveys.
5. Conduct a formal staff meeting following the department template for that month.
6. Complete all assigned testing of high-touch surfaces to assess staff effectiveness.
7. Complete at least five public restroom inspections.
8. Achieve or exceed HCAHPS room cleanliness goals.

The overall result of each supervisor’s performance is included on the department dashboard.

Almost all of our reports and data collecting systems are computer or web-based. This makes it very simple to collect, enter, and communicate our monthly dashboard results to everyone in the department.

Next to each dashboard measurement is a colored box that quickly indicates areas in which we perform well, as well as areas that require attention. A green box signifies that the goal is being met or exceeded; a yellow box signifies that we are within 10 percent of our goal but should monitor; and a red box tells us that we are more than 10 percent away from our goal and immediate action is needed.

Through the use of a department-based dashboard, we are able to quickly establish where our resources and time should be focused each month. The dashboard also serves as an excellent basis for monitoring staff performance and for setting goals during the staff evaluation process. Sharing your department’s monthly dashboard results in the entire department assistance in fostering teamwork and a united purpose.