Hygiene in Healthcare Effective Management through Outsourcing

Moderating the session, Stan Atkins,Group CEO, British Institute of Cleaning Science (BICSc) along with other experts from the healthcare sector, discussed on some of the pressing issues of meeting hygiene standards and the concept of introducing outsourcing. The other panellists included Dr Ami Varaiya, Consultant Microbiologist from Dr Balabhai Nanavati Hospital, Dr Suleman Merchant, Acting Dean – Professor & Head of department of Radiology from Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Dr Akash S. Rajpal, Founder, MD & CEO of Ekohealth Management Consultants Pvt Ltd, Prashant Sule, Managing Director of PCI Environmental Services Pvt. Ltd and Christopher Blessing, MD of Caere India.

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You never outsource the risks because if anything goes wrong, it will all trace back to the management

– Stan Atkins

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Parameters for hygiene levels in Hospitals

Maintaining staff morale is very important. Fault finding is easy, while correcting right or wrong is the way forward. The panelists agreed that infection control committee is a must to ensure that standards are met and maintained.

Parameters are set on the basis of the current hygiene practices in place and the future requirement. However, in terms of delivery what matters most is the standards set by the organisation and implemented by the service provider.

Hygiene is a culture whereas hygiene with standards and parameters are only the by-product of that culture. Once the hygiene culture is imbibed in the staff, it is easy to demonstrate the parameters and standards.

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In government run hospitals, labour problems exist…In such a scenario, benchmarking of hygiene services is essential

– Dr Suleman Merchant

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Unfortunately there are no set national or international standards. International standards are only perceived to be in place, but it is not so. “For example, there is no set standard for colour coding in any country while it is universally accepted that colour coding helps prevent cross contamination.”

In Maharashtra, the Ministry of Environment and Forest (MOEF) has identified colour coding for infectious and non-infectious waste – black for non-infections waste, yellow is meant for infections waste that goes for incineration and red for infectious waste that goes for autoclaving or hydro-claving. This colour coding has helped curb many outbreaks.

Emphasis on hand hygiene during any training will pay rich dividends in the long run. Going by standards for nursing staff, they are supposed to wash their hands seven times in an hour. Washing with soap and water takes 60 seconds per wash which sums up to one hour in every eight-hour shift, while washing with alcohol rub takes 10-18 seconds per wash saving 40 minutes per eight hour shift. However in India, the alcohol rub has not gained much prominence. It’s been proven worldwide that availability of bedside hand-rub or hand-wash solution significantly reduces infection, including cross infection. These points need to be discussed and implemented in our hospitals as well.

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Taking an active interest and being involved in the outsourced function would help the management keep a check on the quality and ensure effective implementation of set standards

– Prashant Sule

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Spot audits, internal audits and surprise checks are also must on a regular basis. Colour codes and other technical aspects are explained to workers in their local language. These are some of the measures taken to ensure that the standards that are set and explained to the staff are sufficient. The audits help understand the level of compliance.

Outsourcing

Any area which is not the core area should be outsourced. The core areas in a hospital include patient care, treatment and surgery areas. However, what is important is the role of the management in the outsourced function. Taking an active interest and having an involvement in the outsourced function would help the management keep a check on the quality and also ensure effective implementation of set standards.

Most management look at outsourcing keeping in mind the budgetary requirement. Any Facility Manager should have a budget line while looking for service providers. Selecting the lowest bid for the outsourced function is bound to have its share of issues. Stan emphasised that the key to remember is that “you never outsource the risks because if anything goes wrong, it will all trace back to the management”.

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Hygiene is a culture whereas hygiene with standards and parameters are only the by-product of that culture

– Dr Ami Varaiya

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Outsourcing is also another way of ensuring that an agency specialising in a certain functions (cleaning, maintenance) recruits trains and ensures quality delivery. “This is especially important for a country like India where Trade Unions and political parties have a say in the selection of labour. Since risk is still the pain area for the management; a quality conscious organisation would only transfer the management control while handholding the training, setting cleaning guidelines, quality control and spot audits. This would ensure that the parameters and standards that the organisation has set are maintained even if the services are outsourced.”

It is important to note, especially in government run hospitals, labour problems exist largely because of internal and external forces manipulating the staff. In such a scenario, benchmarking of hygiene services is essential. In government hospitals, there is an added disadvantage of the opportunists indulging in in-sourcing an outsourced service. In a classic example, it was noted that a Class IV employee had illegally outsourced his work. On payday, he would collect his salary and then subsequently take a small portion of it and pay three or four people who have been doing his job. While the work is performed to perfection, we can question the legality of the case here.

Another issue faced in Government hospitals is when workers affiliated with the Union do not perform. The management is unable to question them for fear of losing all the staff. The work gets done, but its quality is questionable. In such a scenario, communication and managing relationships is the key.

Here again, imbibing the culture and importance of hygiene in the staff through motivation and training is important. Commitment to hygiene by the top management is equally important.

The management must also set aside a separate budget for hygiene, only then will this whole exercise have any value. Most accredited hospitals have separate budget for hygiene however how much of it is utilised is still questionable.

Risks involved in each area to achieve cleaning specifications

The requirements or specifications are decided from the time the operations and the kind of infection control parameters to be achieved are set in different departments. In association with the housekeeping agency, the department in-charge would list down the machinery, tool and chemical requirement for that department.

Dealing with attrition of trained staff

Attrition is a fact that is unavoidable. Staff rotation within an organisation or outside of it is inevitable. Employees switch jobs regularly for better prospects. This is a continuous cycle. Nonetheless, training is important and a continuous training approach should be in place in any organisation. Most often staff from one particular industry tends to stick to the same industry albeit in different companies. Continuous training programmes ensure that the staff are well trained and well equipped to handle their jobs.

It is important to maintain employee loyalty and ensure effective work output. This is possible through regular appreciation in front of peers, making them feel like a part of the organisation and imbibing a feeling of achievement at the end of the day.

What are the training requirements?

Once again there is no specific training standard for cleaning. Each organisation sets and follows its own training – which could cause confusion when the employees switch employers. Third party accreditation is important to cut out this confusion.

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Any area which is not the core area should be outsourced

– Dr Akash S. Rajpal

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Continuous Medical Education is of prime importance; second, a checklist of what is expected and if that has been done and thirdly, audits. Training = Safety.

The aim of any hospital is the decrease the infection rate. The acceptable rate of infection by WHO is 2% and the aim of most hospitals is to bring their levels of infection down to 2% or less. It is also imperative to align the housekeeping staff on the vision and mission of the hospital.

It is assumed that most workers have some basic qualification, however in some cases janitorial staff is illiterate. In such cases, training should be imparted in local language with the aid of pictures or signboards. Experiential learning is by far the best form of learning. Full advantage of such learning could be drawn when a new worker is teamed up with an experienced worker in a kind of “buddy mentoring” format.

Outsourcing cleaning or employing permanent staff

Outsourcing has its benefits. Firstly, the outsourced agency has the expertise and the skills to manage the task at hand. Secondly, there is the danger of running into legal issues as far as permanent staff unions are concerned. In addition, the outsourced agency would be responsible for the resource management part – be it recruitment, training or even attrition. Thirdly, the outcome in terms of cleanliness and hygiene in healthcare are met with because of the service provider’s access to the right equipment, tools or chemicals.

There is a pressing need to set standards and parameters for hygiene in healthcare. SOPs, spot audits, internal audits, communication, training and re-training are some of the key pointers in ensuring healthcare hygiene.