Symbiosis is a close relationship between two different biological organisms in nature. Mutualism is when both species benefit from the interaction and outcome.
Take, for example, the goby fish and pistol shrimp. This relationship enables protection from predators, access to food and a safe place to live.
The shrimp digs a burrow for the goby fish to sleep and breed (the shrimp lives there, too). In return, the goby fish protects the near-blind shrimp from predators while out of the burrow. The goby and shrimp maintain constant contact via the shrimp’s antennae when the shrimp is out in the open. When danger is present, the goby flicks its tail and the shrimp retreats to the burrow.
This lifelong partnership is usually forged as juveniles.
The result is a symbiotic relationship that allows for a greater survival rate for both species.
In a hospital environment, infection is the enemy. And there are two teams that need to form a symbiotic relationship to combat this predator: infection prevention (IP) and environmental services (ES).
Together, this relationship can help create a sustainable outcome of reduced or even no hospital-acquired infections.
An Expert Weighs In
Sue Barnes, RN, BSN, CIC is an infection prevention consultant with 30 years of experience in the field of IP. Sue is board certified in infection control and prevention, and nationally recognized in the field of IP.
Previously, she served as the national program leader for Infection Prevention and Control for Kaiser Permanente’s (KP) 7 regions, 35 hospitals and 431 medical offices.
In addition to being published in prominent industry journals and participating in the development of widely used infection prevention protocols, Sue is an avid speaker.
She is also an APIC Fellow and co-creator of the “Environmental Services Optimization Playbook,” a DIY performance improvement guide for ES departments.
The program includes training and online resources to support reliable cleaning and disinfection in health care facilities. The Playbook is currently being tested at six hospitals across the U.S. and one in Kenya.
I sat down with Sue so she could share her perspective about the relationship between IP and ES, and how the two could work together to produce better IP outcomes.
“I saw firsthand the benefit of engaging with environmental services when I did a number of projects in my Kaiser career,” said Sue. “I always felt that ES is the most excellent audience for any infection prevention presentation. They're always engaged, they're eager to learn, they're willing to change things and they're very vocal if they don't agree. And so I always learn something from them.”
I mentioned to Sue that someone once described to me infection prevention as a three-legged stool, and she agreed with the comparison.
Each of the three legs has a critical role in supporting the stool. The first leg is a good hand-cleaning program. The second leg is antimicrobial stewardship. And the third leg, that is environmental cleaning practices.
Without each of these three legs, the stool comes toppling over.
In my experience, the ES teams are sometimes looked at as being lower on the totem pole, especially in an environment that also houses world-renowned surgeons.
But the value they bring to the table is crucial--especially when it comes to IP.
What Makes the ES and IP Relationship Work?
“The participation of environmental services on an infection control committee is one way that the partnership between ES and IP can be strengthened,” said Sue.
She said the key was to “ask, invite and expect ES to participate actively in that committee,” and to have them “share information on their quality assessment program, where they're finding problems, and help them actively solve their problems.”
What about implementing new practices: what challenges tend to arise?
Sue said it is critical to have an executive champion--someone who understands the important role that ES plays in IP.
“Honestly, it’s all about competing priorities,” she said when describing executive pain points and the lack of focus on ES in IP. “If executives had a better understanding of how important ES practices are to IP, and how foundational to the patient's safety is a clean environment, then they would likely prioritize it more.”
That is why Sue included a lot of resources in the Playbook to help teams educate executives and get the project champion on board:
“We provide the talking points, so that the person who wants to implement the project just hands those documents to the executive. This gives them a tool that helps them articulate what they're trying to do.”
The Infection Prevention Playbook
I was curious to find out how the Environmental Services (ES) Optimization Playbook has worked for the hospitals it is being tested on.
Sue explained that the original Playbook pilot was the result of her and her team (members of her local APIC chapter) coming together to test their strategies over a 12-month period.
The Playbook program “asks each hospital to identify an executive champion and then complete a survey guided self-assessment,” she said. “This is used to develop their improvement plan.”
Sue added that “in addition to what they might identify as opportunity areas, we recommended some key elements for the improvement plan and provided tools to support each element.”
Those elements include:
- Enhancement of the cleaning assessment program.
- Enhancement of ES reporting to the infection control committee.
- Identification and pre-training local ES super trainers.
- ES shadow training program by super trainers with a 16-point checklist.
- Enhancement of ES recognition program.
Participation in the program includes a voucher for one ES technician to attend the Association for the Health Care Environment (AHE) TCHEST certification training to train the trainer, so this person can go back and train everyone on their team.
Sue believes this is crucial: “There is definitely a need for expansion of AHE training at every hospital. I hope that this becomes a regulatory requirement at some point.”
While the program is DIY, it is not without support. Just some of the things Sue and her team facilitate is:
- Planning a kickoff event to engage stakeholders at each hospital.
- Multidisciplinary site visits at the end of each kickoff to tour the facility and provide input from experts in IP and ES.
- Weekly meetings with each hospital team to support their efforts.
- Planning their exit luncheon to review progress and plan for continuing/sustaining improvement.
- Coordinating a project evaluation via survey monkey.
While all six hospitals implementing the Playbook are still in progress, the first hospital pilot showed promising results.
This included TCHEST training; enhancing the ES staff recognition program (which Sue said can “really help build morale and partnership”); improving their quality assessment of cleaning; and cleaning accountability in collaboration with the nursing department.
How Technology Can Help IP and ES Efforts
I’ve outlined previously how technology can build high-performing hospital service departments.
Technology can also be a key piece in ensuring efficient, complete and repeatable best practices in hospital cleaning.
Applications like ReadyList (of which I am a co-founder) allow facilities to standardize workflow and cleaning processes, ensuring staff follows infection prevention protocols with reportable metrics.
This type of technology enables ES and IP to work together towards a common goal: zero hospital-acquired infections.
The delicate balance of a hospital ecosystem requires that teams come together to improve operational outcomes and patient survival rates.
When infection prevention and environmental services forge a symbiotic relationship, the result can be reduced or even no hospital-acquired infections.
But these teams need to make the effort together.
“ES departments are eager to learn and collaborate,” said Sue. “And ES managers don’t typically have the time or skill set to coordinate a project. So it takes a team effort to get it done.”
The Playbook program is keeping Sue and her team busy, so they are not currently accepting new clients at the time of writing.
Brian Herriot is a hospital operations leader and Co-Founder of ReadyList, Inc. The ReadyList mobile app's smart and integrated electronic checklists guarantee patient rooms and OR's are 100% ready, so clinicians are fully equipped to provide better care.