Hygiene in Healthcare – A Diagnosis

Walk down the narrow lanes of some of the government-run hospitals and it would be bustling with activity. Right from fruits to full fledged lunch plate would all be available at the doorstep of the hospital.

“Don’t quote me,” said a government official, while discussing about the illegal food stalls mushrooming outside government hospitals in Mumbai. “All these hospitals run on charity and the poor people coming from far off places get to buy food at affordable rates from these food stalls. They practically live out of the footpath. It’s disheartening and not so easy to vacate them or ban hawkers from setting stalls?”

Resultantly, the piling food garbage outside the hospital and the unclean ambience are what greet one at some of the leading government hospitals in India. If the entrance to a hospital is such, then how would the hygiene standards be inside? If people are getting treated in a government hospital, then they are doing so only under unavoidable circumstances rather than choice. In such cases, the cost of treatment is a deciding factor rather than the “clean” factor.

While government hospitals are charitable institutions and in many cases refrain from adopting “scientific cleaning practices” as it comes at a price, the private set ups claim a handsome price for both treatment and the clean factors.

Step into any of the washrooms at Tata Memorial Hospital and the next moment you would jump out with the suffocating smell of uric acid. Walk into the men’s toilet in the outpatient area of AIIMS Trauma Centre, New Delhi, you will be greeted with urine flowing out of the broken pot and people walking in and out of the same toilet, carrying uric acid in their shoes all over the place.

Are all government hospitals always dirty and unhygienic or for that matter are all private hospitals as clean as they look? On a rainy day, CIJ set out to ascertain the cleaning and hygiene practices at some of the leading private hospitals in Mumbai. People were walking in and out of the sliding glass door carrying their wet footmarks into the lobby/reception area of a hospital. Contaminants, microorganisms, dirt, road mud… all were neatly making way into the hospital and probably contaminating the already sick patients waiting to be treated. The entryway, just above a few flight of steps, only had a 3ft by 5ft common mat which was soaked in rainwater. A common man walking into a hospital with wet shoes, leaving a trail behind would not realise the results of his action. He wouldn’t know that he is carrying the germs in his shoes into the hospital because of improper matting at the entrance.

With more and more housekeeping service providers bidding for hospital cleaning contract, it is time to ponder if they are actually qualified to take up the job. Further, are hospital authorities well versed in cleaning practices? Hygiene definitely cannot be compromised either on the part of the housekeeping professionals or the hospital when it comes to dealing with lives.

But, shouldn’t a private hospital facility head know what kind of matting should be put at the entrance? Shouldn’t a janitor be stationed at the entrance to mop the floor? Shouldn’t there be a wet sign board to caution entrants?

Ideally, any premise with heavy traffic should have a 30ft matting at the entrance. In case of space constraint the matting can be laid outside-in. To ensure that the dirt and grime do not enter the premise, the entryway matting should be a combination of Z-web mat up to 10ft, loop mat up to 15ft and aqua mat up to 5ft. But, this private hospital had none of it. The janitor assigned to mop the entrance was multi-tasking and had been called elsewhere.

As much as the entryway to any hospital directly or indirectly affects the health of its inmates, so does the backyard, where all the waste gets stored before being disposed off.

“For single use only”

The SSKM Hospital in Lala Lajpat Rai Sarani, Kolkata, has suddenly woken up to the fact that the syringes with “For single use only” being supplied to the hospital are far from being fresh ones. Syringes, saline bottles, medical equipment and catheters reaching this hospital are actually recycled from clinical waste, largely resulting from the inefficient disposal system of the hospital. These recycled clinical accessories have been in use in this hospital for several years now and probably the ill-effects have already taken shape in the form of HIV cases.

This is not just a single case of a government hospital in Kolkata but a peek into the backyard of some of the leading government hospitals of Mumbai makes ground for a flourishing recycling business.

Five leading government hospitals are concentrated in Parel, Mumbai, where thousands of patients come each day to be treated. Loads of bio-medical waste packed in yellow and red garbage bags are dumped in the backyard to be collected by NGOs and municipal vans. What happens between the dumping and collection processes is a known fact. At one of these hospitals, CIJ spotted a woman ragpicker sorting and segregating syringes from the waste!!!

Even though there are separate compartments to store different wastes, it is so much easier to dump all the waste together, leaving it to the collecting agency to scuffle with the rubble. What, if a used needle jutting through the yellow bag pricks a poor safai karmchari? It’s sure death! Who should be held responsible for this death – the hospital authorities for their negligence in disposing off waste appropriately or the municipal corporation for not implementing proper waste collection regulations? Well, what has the ward officer/ assistant commissioner of Parel to say about this?

“Our primary aim is that we remove the waste that comes to the collection points which are strategically located. The hospitals must have an internal machinery to segregate or stack waste properly and bring it to the municipal collection point. What is done from the collection point to the dumping yard is the Municipal Corporation’s primary responsibility.
“For collection of bio-medical waste, we have separate vehicles which collect waste from individual hospitals. We have a schedule for collection of waste and our compactors go to these hospitals.”

Then where are things going wrong? “Probably between the time the waste is dumped by the hospitals and the time it is collected by the corporation vehicles? Or may be during the night.” The F-South ward of MCGM has prestigious hospitals like the TB hospital, KEM, Tata Memorial, MG hospital and Wadia hospital. Are all these hospitals oblivious about waste disposal and the frightening affects of malpractices?

If hospitals were using backyards to dump waste, one of them had a full fledged kitchen setup. The scene outside this hospital kitchen was frightening. Food waste was thrown mercilessly around with a stray dog feeding on it; a water pipe was lying close by and probably from this pipe was being used for cooking; and the food cooked out of this kitchen was being supplied to the hospital! No wonder, local food stalls are flourishing just outside these hospitals, as they seem more hygienic than what is served out of the backyard kitchen.

“Well, it is not that the people working in the hospital do not understand cleanliness, it is the lack of strict supervision or penalization of the designated officers when the norms are not followed. The infrastructure in most of these hospitals is over saturated. After a certain point, even the authorities are helpless,” said the municipal official.

One other critical area in a hospital that serves as a store house of germs is the washrooms.

Washroom woes

Step into any of the washrooms at Tata Memorial Hospital and the next moment you would jump out with the suffocating smell of uric acid. Walk into the men’s toilet in the outpatient area of AIIMS Trauma Centre, New Delhi, you will be greeted with urine flowing out of the broken pot and people walking in and out of the same toilet, carrying uric acid in their shoes all over the place. The maintenance, which is mostly handled inhouse, includes a soap wash of the toilets at least twice a day and intermittent spraying of anti-septic solution to keep the odour under control. Many a time the safaiwalas do not turn up to clean the toilets and the authorities are either not aware or are too busy handling patients that the clean factor takes a back seat.

T o ilet s are a major issue even in private hospitals. Except that since housekeeping services are being outsourc ed, the toilets get cleaned more often. In spite of having systems in place and the facility outsourced to qualified service providers, CIJ observed serious lacunae at Fortis Mulund.

CIJ spotted outsour ced women janitors in washrooms doing exactly what an untrained staff would do. The mops used to clean the passageway inside the washroom were being used all over and kept aside with the mop end on the floor. Excess water in the passageway was being pushed into the toilets using the same squeegee in and out and that too a wrong one. The supervisor claimed that the janitor was new and that she would learn in time. But this mode of handling cleaning tools was happening at all levels of the hospital.

While, a common man may not comprehend the repercussions of this practice, any expert would agree that this wrong practice could be a major cause of contamination, spread of germs to other parts of the hospital and a major health scare.

The toilets otherwise are cleaned periodically through the day using all-purpose cleaning solution, wet mop and squeegee. Sani cubes are used in the toilets for odour control besides other toilet accessories of hand wash, etc. Ironically, the hospital is planning to “upgrade” the cleaning processes by replacing Sani cubes with Naphthalene balls!! Naphthalene balls have chemicals like naphthalene and pradichlorobenzen which are dangerous. Prolonged exposure can kill red blood cells, causing hemolytic anemia till the body is able to replace them. Symptoms include fatigue, loss of appetite, restlessness, fever, or jaundice, and severe cases
can result in kidney or liver damage. Eco-friendly sani cubes are available in the market for use especially in the toilets.

Housekeeping Role

Outsourcing housekeeping services is yet to catch up but, in some hospitals outsourced janitors are being used to perform many other activities besides cleaning. They also do the work of hospital attendants! A janitor who is engaged in cleaning or even washing toilets is involved in attending to patient’s needs! This is true of not just private set ups but many government hospitals have in-house cleaners doing multiple tasks. Time and again doctors and nurses have been confronted for unhygienic hand hygiene practices leading to cross contamination but hospital authorities seem “oblivious” about disease spreading through janitors working as attendants. These janitors may have also handled hazardous waste! “At Fortis, we are already working on recruiting new staff as hospital attendants,” said the Executive Housekeeper.

From the primary observations at both private and government hospitals, apparently a common man’s initial lookout of any facility is the medical expertise. Ironically, the cleanliness and hygiene factor probably comes to fore only during the consecutive post-treatment visits.

From the industry perspective, it is quite clear that clinical care takes priority and cleanliness & hygiene forms a complementing factor in the healthcare business. Even though hospitals are implementing the clean factor and also engaging professional cleaning systems, they are not as hygienic as it should be. Hygiene definitely cannot be compromised either on the part of the housekeeping professionals or the hospital when it comes to dealing with lives.

With more and more housekeeping service providers bidding for hospital cleaning contract, it is time to ponder if they are actually qualified to take up the job. Further, are the hospital authorities well-versed in cleaning & hygiene practices and are they keeping regular checks on the implementation ensuring cleaning standards at all times? Well, there is always scope to learn a lot more.

Many government hospitals are attempting to keep clean but given the nature of the people visiting these places, it calls for high level trained staff to firstly educate the people on hospital hygiene. In a maiden attempt, the Government of Puducherry has set up a state-of-the-art hospital and has outsourced the cleaning function to professional integrated housekeeping service providers. In the following pages, CIJ reports on the systems adopted by Fortis Hospital, Mulund, and the standards set at the Puducherry government hospital.

Rajiv Gandhi Government Women & Children Hospital, Puducherry

Setting professional cleaning standards

Be it a private or government hospital, everyone, rich or poor, wants a clean ambience, as the very sight of a clean surrounding heals away half the ailments. “At Rajiv Gandhi Government WCH, Puducherry we have made such clean and modern facilities to give every expecting woman, the feel of a mother’s home,” says Dr Dilip Kumar Baliga, Director of Health & Family Welfare Services, Government of Puducherry.

Lack of basic facilities, unclean surroundings… added to the money demanded by hospital attendants from patients, wipes out smiles from expecting mothers. It is this smile that the Government of Puducherry has attempted to restore by giving an ambience that makes one happy. More than Rs.47 crores has been invested in the making of this WCH.

This 700-bed hospital standing on 300,000sqft area is well-equipped with all modern facilities for safe delivery, peadiatric care including neo-natal care. It has everything and every look of a private hospital with a five-star ambience. To complete it all, the entire hospital support services has been outsourced to a professional service provider, Faber Sindoori.

Emphasising on the need for professional cleaning services, which may not be possible in the existing government hospitals, Dr Baliga says, “If you see, in any government hospital the safaiwalas or sanitary workers are in their 50s and have been a part of the organisation for many decades now. They are habituated to cleaning with a broom and a cloth mop or at the most a stick mop. This has become a way of their life. Expecting them to change with changing hospital cleaning needs and cleaning tools is difficult. “We understand that it will not be possible to maintain the new ambience and standards required of the modern hospital by employing our own people. Hence, we took a conscious decision to outsource professional housekeeping services for the new project.”

At the General Hospital located at the heart of the city, more than 6000 patients along with relatives turn up as outpatients every day. People from nearby Tamil Nadu too visit this hospital. The maternity wing with 330 beds has now been shifted into the new hospital. A major issue of the maternity wing was the toilets. De-clogging of sewer lines had to be resorted to every other day. It was very difficult to get people not to throw things into the toilets and drains. The new facility has 380 toilets with facilities to ensure that clogs do not occur.

“Maintaining a hospital is much different than maintaining an airport or hotel as it also involves sound public relations in handling & being courteous to patients, disposing-off bio-medical & hazardous waste, educating people, cleaning toilets at least four times a day & on demand and other aspects. Therefore, the pre-bid meet with the bidders discussed these aspects.

“To qualify for the bid, standard marks on aspects like 10 points for the size of the company with documents, 10 points for three years constant turnover and 10 points for work experience and field of operations. The more the hospital experience the more points were given. The bidders were ranked out of the 100 marks and those below 50 marks were rejected. The ratio of bid was 60:40 of the technical bid and the financial bid.” Faber Sindoori with over three years experience in maintaining leading Healthcare and Non-healthcare institutions in India was awarded the contract for Facility Management Services. Seven support services have been outsourced to a single vendor. “This way I would have to deal with just one person, which makes things easier in coordination and implementation.”

The standard operational procedures followed in this hospital for all services are at par with any international hospital standards and the performance of each service is closely monitored by the administrators in the hospital. To ensure uncompromised quality standards are maintained for patient safety.

Maintenance includes servicing of fans, ACs, maintaining the generator, ensuring medical gas supplies, landscape maintenance, catering & diet supplies and security. The in-house staff is directly involved in pharmacy, labs, including diet, etc. “We have built a nice kitchen with all modern facilities to ensure that the quality of the food supplies are of good standards. The hospital will procure the raw materials and the outsourced kitchen staff will prepare food as per the menu specified. The food has to be brought in a trolley to the respective patient’s bed and served only after the duty nurse has approved it. Other services include collection of tray and plates and washed thoroughly in the dishwasher provided by the hospital,” adds Dr Baliga. One of the major advantages of employing outsourced staff is that we can monitor the consistency in performance and advice them to improve the services as and when needed. Such practices will not be effective with the Government employed staff. Besides, in keeping with the Faber Sindoori’s International benchmarking services to healthcare institutions, the staff is rotated between hospitals every three months as an effective cross training approach. This also enhances the workers’ experience to work under various circumstances towards patient safety.

Faber Sindoori took up the job from the time OPD services began in mid-January 2011. “We realised a lot of education is required to make patients coming from rural areas to adapt to the corporate surrounding. Faber Sindoori staff has been guided to effectively take care of the operational situations and handle the patients politely. A nice pantry provision has been provided for the visitors’/patients’ use.”

Supervision

In order to ensure an effective operational work process, the hospital has facilitated the service provider with adequate office space in their administrative wing. All service requests received by the hospital administrator are passed on to the Maintenance manager to complete the work within the stipulated time. Besides, the maintenance on each floor is handled by the Floor Manager. Round the clock monitoring is practiced, to ensure prompt and timely completion of all requests from the user department.

Waste Management

As a common practice, all clinical waste from the hospital is sent to the government incinerator in a packed container and other general waste is disposed off as municipal waste. Under Puducherry Pollution Control Board authority, a new common bio-medical waste management plant has been set up with modern facilities to handle the workload. The waste engineer attached to this plant along with trained waste lifters visit the WCH every day to collect the waste bags at a scheduled time. Strict operational measures are adopted in the hospital to avoid any irregularities in waste management.

To ensure that the waste is disposed off in the respective bags by the hospital staff, the head nurse of each ward has been made in charge. Any discrepancy the head nurse will be penalized.

Cleaning at International Standards

At WCH, we have been trained to perform the proven International benchmarking maintenance standards required of a healthcare facility,” says Ezra Alexander, Facility Manager from Faber Sindoori stationed in the hospital to handle the support service functions.

“While cleaning requirements is critical in any hospital, the challenge in the Government hospital is to deal with the people coming from rural background who are not exposed to the ideal usage of modern facilities in a hospital. The education of the new patient begins as soon as he or she enters the hospital while meeting our Front office executives.

“We provide them with pamphlets on various quality standards to be practiced in the hospital. The team is available at each floor to educate new patients getting admitted each day in the hospital.

“The initial period of operations were most challenging. Being a Government hospital, people followed the same old practices of littering wherever they pleased. But today, after six months of operations, with our constant education, people have changed their mindset and have started throwing waste into the bins. Lately, the patients walking in are more cooperative and are helping us to maintain the place clean. This is a dramatic change.” The trainers also impart education and training to the housekeeping staff. At present 267 staff are employed in this premise to facilitate all seven support services.

“With all the amenities like gardens, personal care, cleanliness and proper healthcare facilities, the women walking out of this hospital with their new born child have often said with their smiling face,  ‘it’s like leaving from the mother’s house’,” says Ezra.

Fortis Hospital Ltd, Mulund

Improving Ambience & Cleanliness

“ While an impressive entrance makes all the difference to any patient or visitor, the clean and hygiene factors get much noticed in private hospitals, given the fact that a more educated crowd gets treated at these premises,” says V Vijayarathna, Regional General Manager, Fortis Hospitals Ltd.

Any private healthcare facility mainly focuses on two aspects – one, on the clinical part relating directly to patient’s health and two, on the hospitality services which include keeping the premise, the patients’ rooms and the environment clean. Apart from hospital inmates undergoing treatment, the large number of outpatients who spend considerable time in the hospital, also get exposed to the environment.

Given the limitations of operating in the same premise of Wockhardt hospital that was designed 10 years back, the Fortis Hospital in Mulund, Mumbai, has its unique maintenance challenges. “Even though the fundamental principles of the two organisations have a number of similarities, there are significant differences as well,” says Dr Vijayarathna. The Fortis group emphasises a lot on the way the facility is designed and kept up. “We are already working on the design changes to improve the ambience. This would involve the flooring, the entire surrounding, change in the complete interiors with totally different kind of a material, etc. We have two blocks – the 120,000sqft block which is about 10 years old, the other 180,000sqft about a year old out of which 80,000sqft is operational now – and there is a huge difference between the two.

“In all our new projects, the project team designs the entire premise involving the architect and the interior designers. In the old projects, the operational team gives their feedback to the team about what exactly is happening and what are the requirements with a project report.”

Fortis has a system of getting feedbacks on the ambience and cleanliness from visitors and patients. “Even in areas where the ambience cannot be altered for various reasons, we ensure that the fundamental cleanliness is always maintained. Our focus is primarily on clinical programmes and the required technologies & inputs but patient care always comes on the top. No compromises are made on cleanliness and healthcare delivery.”

 

“Our focus is primarily on clinical programmes and the required technologies & inputs but patient care always comes on the top. No compromises are made on cleanliness and healthcare delivery.”

Since, the inpatients or outpatients visiting the hospital come from educated background, littering is not an issue. “Besides, the environment is very clean and the required facilities like dustbins and washbasins are placed in key areas, especially where people gather.” As far as the team maintaining the premises is concerned, the housekeeping boys and the girls undergo a rigorous training and it is an ongoing training programme. “They are clearly instructed and informed on maintaining the cleaning standards. Further, we also educate our employees to respond to any situation or area that is not up to expectations. Irrespective of what level of organization we belong to, when something unclean is spotted, we either clean it up ourselves or get someone immediately to clean up. Each of our senior managers has been assigned an area in the hospital and they ensure it is kept clean.”

While the housekeeping has been outsourced to Sanjay Maintenance Services, the in-house maintenance team consists of chief engineer-building maintenance, executive housekeeper and the overall maintenance in charge. There are170 housekeeping workers at the janitorial level. Fortis has recently appointed an executive housekeeper with a hospitality background and well versed with the hospital infection-free environment requirement. Equipment, tools and cleaning agents required for maintaining cleanliness are jointly decided by the executive housekeeper and the outsourced team.

“We have very sound SOPs in keeping with the corporate organisation of a hospital and the JCI regulations. The cleaning and infection control regulation are very stringent and an important part of hospital environment.” “Whoever gets on board has to have the basic understanding of what the hospital is. All housekeeping staff undergo a five-day training course on simple processes like holding the broom or the mop the right way, the cleaning process and self protection, especially on wearing gloves in areas where it is most needed. In case of any discrepancy in the expected standards, the origin of the problem is identified. We ensure that the person responsible is put back into the training session. The same strictures are followed at the laundry right from segregating soiled linen to delivery of clean linen.”

Discrepancy can occur given the high attrition rate of housekeeping staff. “At times, owing to staff shortage or work pressure, people are pushed to perform. We make a conscious effort to avoid such situations. We emphasise that even in case of staff shortage, on priority the critical areas need to be covered adequately. At no point, an untrained worker should be allowed to get into the system. That would be more damaging than not having the premise clean.”

Currently, there are 240 operational beds and in two years time, this hospital will have 500 beds after the new block becomes functional. A floor with 52 beds has been opened up and still there are four more floors to go.