Environmental Cleaning Tool Kit Quality in Environmental Cleaning Module 6

Objectives Upon completion of this module, participants will be able to: explain why quality is important in perioperative environmental cleaning; describe what is included in process monitoring; use a cleaning checklist or log, and; state how to measure cleaning practices.

Definitions Quality Performance improvement Benchmark meeting or exceeding expectations at a cost that represents value to the customer Performance improvement the continuous study and adaptation of a healthcare organization’s functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of individuals and other users of services Benchmark a comparative “best” as baseline for improvement

Why is quality important? Every patient deserves care in a clean, safe environment

Quality Assurance/ Performance Improvement Team members should understand and comply with principles and processes involved with environmental cleaning participate in a variety of quality assurance and performance improvement activities Quality assurance and performance improvement assists in evaluating worker safety formulates plans for corrective action

How can quality tools help us? Obtaining data from quality assurance or performance improvement tools can tell if benchmark goals are met identify areas where additional help is needed Ongoing feedback can show if problems are improving stabilizing l worsening Information or “data” is collected in a systematic way such as using a checklist to observe that everyone is cleaning the environment correctly. This information can show trends if we are getting better, staying the same, or in some cases, not performing as well as before. Benchmark is a process of comparing a practice’s performance (how we are performing our cleaning) with an external standard (such as national recommendations or guidelines). This type of comparison can be called a comparative “best” and can be used as a baseline (starting point) for improvement. Information is collected and then reported using different types of charts. Note, you could add your own line charts after this slide as an example.

Process Monitoring Process monitoring is a necessary part of every facility’s environmental cleaning program Process monitoring must include compliance with regulatory standards review of products and manufacturers’ instructions for use cleaning procedures monitoring cleaning and disinfection practices reporting and investigation of adverse events outbreaks, product issues, corrective actions, evaluation What is process monitoring? This means a standard way to look at what is occurring in the facility; are we following regulations, do we have access to the product instructions for use, and are we cleaning and disinfecting correctly. And if something happens, an “adverse event”, how does this get reported? How is it corrected so it does not happen again? If a procedure is changed, we look at how the change affects our cleaning processes. For example, did the change make a positive difference?

How should cleanliness be measured? Thoroughness of cleaning is the focus of performance improvement Measure cleaning practices visual observation fluorescent marking visual inspection of cleanliness ATP monitoring cultures Multiple measures should be used as a comprehensive assessment of environmental cleaning practices. Identify what types of measurement are used in your facility for team members now. Explain the process used at your facility so team members have clear idea and expectations. The information gathered by measuring cleaning practices can be used to drive process improvement activities, encourage compliance with established cleaning protocols, educate team members, and verify the competency of team members.

How should cleanliness be measured? Fluorescent marking Visual inspection of cleanliness Cultures ATP monitoring Explain to team members the steps involved with each type of process. Let’s go through each process. Please advance slide.

Fluorescent Marking Gel Courtesy of Ecolab® Inc. Fluorescent marking involves using a fluorescent pen to write on specific objects in the room, for example, the stainless steel tray in the picture. The room is then cleaned by team members. Once completed, an auditor will come back into the room with a black light and look for remaining marks on the items that were “tagged”. Courtesy of Ecolab® Inc.

Visual Inspection for Cleanliness Visual inspection is looking through the room, moving furniture, purposefully looking for dirt, dust, and debris.

Cultures 1. http://www.cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Sep2013.pdf 2. http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf 2 Obtaining cultures means items that have been cleaned are tested to see if microbial organisms (germs) are still on the cleaned objects. Sterile swabs, like long q-tips, are rubbed over the items and sent to the microbiology lab for further testing. 1

Cultures Courtesy of Ecolab® Inc.

Adenosine Triphosphate (ATP) Monitoring assists in evaluation of the environmental cleaning process the technology counts living and non-living organic matter in Relative Light Units (RLUs) uses a hand held device and swab ATP monitoring, or adenosine triphosphate monitoring, is the direct measure of biological concentration on surfaces. ATP is the universal unit of energy in all living cells and can immediately tell if surfaces and equipment are clean. Using a hand-held device and swabs similar to culturing, surfaces are wiped with the swab. The swab is then placed into the hand-held monitoring device and a reading is given.

Providing Feedback Providing timely feedback to team members of cleanliness in the perioperative area will improve practices If possible, immediate communication regarding cleanliness is best

Documentation Documenting completion of terminal and scheduled cleaning meets Regulatory requirements Facility standards Use a standard checklist or log Share with team members the logs and checklists used at your facility. Go over the lists and make sure staff know what sections they are responsible to complete. Use the teach back method and have team members state what is expected prior to completing the education.

Cleaning Log for OR, Preoperative, and Postoperative Areas This sample checklist is available in the AORN Environmental Cleaning Tool Kit at http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspx This sample checklist is a three page document and it shown on the following four slides. This cleaning checklist includes the OR, preoperative, and postoperative areas. You can print this out and have it available for your team members as you go over each area to clean.

Cleaning Log for OR, Preoperative, and Postoperative Areas (continued)

Cleaning Log for OR, Preoperative, and Postoperative Areas (continued)

Cleaning Log for OR, Preoperative, and Postoperative Areas (continued) This is the last slide for this checklist.

Cleaning Log for Operating Rooms and Procedural Areas This is another sample checklist is available in the AORN Environmental Cleaning Tool Kit at http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspx Note, the checklist is two pages and shown on this slide and the following slide. There are three sections of the checklist which include cleaning before the first case of the day, end of case cleaning, and terminal cleaning. This same checklist continues on the following slide.

Cleaning Log for Operating Rooms and Procedural Areas (continued) This is a continuation of the same checklist with the second page starting at the end of case cleaning and the last section of the checklist for terminal cleaning. This sample checklist is available in the AORN Environmental Cleaning Tool Kit at http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspx

Cleaning Log for Sterile Processing Areas This sample checklist is available in the AORN Environmental Cleaning Tool Kit at http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspx

Checklist for Enhanced Environmental Cleaning This sample checklist is available in the AORN Environmental Cleaning Tool Kit at http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspx

Resources   Association for the Healthcare Environment of the American Hospital Association. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Hospital Association; 2012. Brown JA. Healthcare Quality Handbook: A Professional Resource and Study Guide. 27th ed. Pasadena, CA: JB Quality Solutions Inc; 2013 Pasadena: 1,7, 9. Guideline for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:7-28. Guidelines for environmental infection control in health-care facilities. Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf. Accessed March 23, 2016. Please use the above resources for additional guidance, if needed.