Gap Analysis:
Getting Processes Back on Track
By John Scherberger, FAHE, CHESP
L
ast month in Healthcare Hygiene
magazine, the genesis of the
This article
Environmental Services Optimization
is the second
Playbook (ESOP) was featured in the
in a year-
first of a series of articles. For those
long series
who may have had an opportunity
describing
to read the article, ESOP came from a
an Industry
collaborative effort of the San Francisco
journey led by
Bay Area chapter of the Association for
environmental
Professionals in Infection Control and
services and
Epidemiology (APIC), Bay Area envi-
infection
ronmental services (EVS) professionals,
prevention
and allied healthcare professionals.
toward
The initiative, spurred by a recognition
better patient
that healthcare disciplines intimately
outcomes,
involved in multiple aspects of infection
quality and cost
prevention, were too often challenged
savings.
to look at patterns of change in
healthcare along the thought line of
what was necessary versus what was expedient. Things
were off track, with many initiatives in both disciplines.
Infection prevention and environmental services processes
had begun to stray from the paths of the patient-centered,
fundamental hygienic interests, proven healthcare culture,
and priorities to the way of convenience.
Things needed attention, and the first proactive application
of the ESOP program involved various gap-analysis efforts.
This article addresses some findings of the gap analysis
processes and provides a look at some of the over 35
healthcare industry experts that provide the direction and
oversight of ESOP.
Editor’s note
Staffing Resources & Methodology, Patient Progres-
sion, Cleaning Accountability
Present State
Patients are frequently left in waiting areas, without a bed,
or waiting for a room. Although this often is unavoidable due
32
to various reasons, when a ESOP gap analysis is performed,
one of the reasons usually traces back to patient rooms in
need of attention from EVS personnel.
When budgets need tightening and even reducing, all
too often EVS is the first department targeted since it is
considered an “expense” department as it is not a revenue
(think “income”) producing department. A challenge to
the perspective held regarding income versus expense
departments as regards to EVS is in order. For it is EVS that
provides the most visual “face” of a healthcare facility. If
EVS fails to fulfill its obligations, every other department
suffers since patients and visitors are of the universal opinion
that they know clean when they see it, even if they do
not understand the process and protocols that need to be
followed, they do recognize variations or differences and
areas missed. Should EVS reduce its presence and efficacy
due to personnel cuts, the perception of clean is the first
casualty of budget reductions or cost-cutting initiatives. The
reality of patients choosing other facilities will be a reality.
The reality of EVS departments is that they are investment
departments. Without EVS, hospitals will quickly close
their doors.
During the numerous gap analysis surveys conducted,
not only did EVS self-identify as being understaffed in critical
patient care areas, other departments reported EVS as being
understaffed. Nursing departments, infection prevention
departments, and administration ESOP champions identified
the reality of EVS understaffing.
The gap analysis surveys identified a lack of awareness and
communication of that awareness that existed regarding the
importance and value EVS provides in the role of patient care.
The failure to perceive or acknowledge expertise exhibited by
EVS in tending to the environment of care was recognized.
That vital message resonated fully with healthcare executives
and other key opinion leaders (KOL).
Communication was also lacking in
need for resources when census levels
CLICK
increased, the demand placed upon
TO VIEW
the emergency department (ED), or in
increased OR cases or types of patients
presenting that required additional
Disinfection Benchmarking
cleaning and disinfection in the ED.
Other communication gaps presented obstacles when
unexpected projects, at least unknown to EVS, began at
facilities without consideration of requirements placed on
the department that necessitated additional staff to support
these projects, such as renovations and additions. That may
march 2020 • www.healthcarehygienemagazine.com