D2. EPS Sanitation Procedure Guide Maimi VA.docx

SANITATION PROCEDURE GUIDE

ENVIRONMENTAL MANAGEMENT SERVICE

Table of Contents

Foreword

The Environmental Management Services (EMS) Sanitation Procedure Guide is a document which provides standardized guidance in the development of sanitation practices for VHA Healthcare Systems EMS programs. It is provided in the form of a template that can be tailored to meet facility needs and include facility specific data related to procedures, products, and practices and form the basis for a contract with facilities regarding sanitation and environmental management. This standardized guide is a tool developed to help create a procedure and guideline manual specific to each facility.

EMS consists of dedicated employees whose responsibility is to perform duties to maintain the healthcare environment. In addition to maintaining physical and biological cleanliness, EMS creates healthy, healing environments for our nation’s Veterans and their families. The full responsibility for the physical and biological cleanliness of the facility remains with EMS regardless of where sanitation employees are locally aligned.

This EMS Sanitation Procedure Guide is based upon successful programs and best practices currently in use throughout the VHA Healthcare System. The Standard Operating Procedure (SOP) templates provide general guidance for products and equipment. Facilities should customize the SOP templates by inserting specific information where prompted within the document.

This Sanitation Procedure Guide consists of necessary procedures and training applicable for EMS programs throughout VHA’s healthcare system. The scope of the procedure guide includes the duties and tasks required to maintain an effective environmental program.

Environmental Programs Service (EPS) is available as a resource to answer any questions individual medical centers may have regarding the customization of this procedure guide for each facility.

Aubrey Weekes, MBA Director, Environmental Programs Service VHACO (10NA7) Acknowledgements

The revision of the 2019 Environmental Management Services Sanitation and Procedure Guide would not be possible without the expertise, guidance and dedication of the following individuals.

Work Group Leadership Vonda Broom IPT Advisor Vonda.Broom@va.gov Deputy Director Environmental Programs Service VHACO (10NA7)

Calvin Clawson IPT Chair Calvin.Clawson@va.gov Interior Designer James H. Quillen VA Medical Center- Mountain Home, TN

Anthony Curling IPT Co-Chair Anthony.Curling@va.gov Chief EMS Hampton VA Medical Center- Hampton, VA

Work Group Members Eugene (Tree) Hairston Eugene.Hairston@va.gov EMS Training Coordinator Bay Pines VA Medical Center- Bay Pines, FL

Ruth Keizer Ruth.Keizer@va.gov MDRO Program Coordinator Lexington VA Medical Center- Lexington, KY

Helen Rice Helen.Rice@va.gov Infection Control Specialist Lexington VA Medical Center- Lexington, KY

John Sheets John.Sheets@va.gov Assistant Chief EMS Lexington VA Medical Center- Lexington, KY

Brian Tallmadge Brian.Tallmadge@va.gov Health Administrator Ralph H. Johnson VA Medical Center- Charleston, SC

Chapter 1 Introduction

The intent of this Sanitation Procedure Guide template is to provide guidelines. The manual will not in and of itself serve in each and every situation that may arise in regards to Healthcare Sanitation. EMS leadership, in collaboration with Infection Control practitioners at each local facility, must work in unison to further SOPs and local policy when required. The manual is made available to managers and employees in electronic media for the convenience of both. The information provided may be changed from time to time.

Welcome to Employees

I wish to take the opportunity to welcome you as a member of the Miami VA Health Care System Environmental Management Service (EMS), which includes: Health Sanitation, Textile Management & Linen Distribution, Reusable Medical Equipment, Interior Design, Patience Assistance, Waste Management, Recycle Management and Integrated Pest Management.

You have been selected to fill a very important position on a team dedicated to providing the best possible healthcare to our patients. You can take pride in being a member of this team. You are important in preventing healthcare associated infections. This role requires a professional and patient centered attitude. You will acquire the skills and knowledge necessary to support the delivery of quality healthcare.

EMS was established in 1954 to provide support to the healthcare team in the following areas:

· Office of the Chief

· Environmental Sanitation

· Environment of Care Monitoring

· Interior Design

· Textile Care & Linen Distribution

· Patient Assistance

· Waste Management/Recycling

· Integrated Pest Management You are required to promote a positive and professional image for our facility and create a feeling of confidence for co-workers, patients and visitors.

The Environmental Management Service Sanitation and Procedure Guide will assist you in becoming a valued member of the healthcare team. Please read it carefully. The Guide covers the basic methods and techniques which will help you acquire the skills and knowledge required for your position. This Guide also provides general information regarding leave, employee responsibility, conduct, and tours of duty.

Again, welcome to EMS.

Passion Sullivan, Chief EMS

Functional Statement

The Environmental Sanitation Operation ensures that the facility will be maintained in a state of cleanliness by:

· Providing environmental cleaning for all patient units, clinics, public, and administrative areas within the Medical Center.

· Selecting appropriate cleaning procedures, controls and monitors to ensure that all sanitation requirements are properly and efficiently addressed.

· Conducting orientation and in-service training, including standard cleaning methods and procedures.

· Assisting in creation of sanitation standards and establishing effective staffing.

· Testing new products, equipment, and technology to ensure that such items meet industry standards.

· Provide necessary resources to meet job requirements.

· Obtain, store and deliver all necessary supplies used within the sanitation operation.

The effectiveness of the Sanitation Operation directly impacts patient outcomes and the positive image of a healthcare facility.

The full responsibility for the physical and biological cleanliness of the facility remains with EMS regardless of where sanitation employees are locally aligned.

Mission, Vision & Values

EPS Mission Statement The mission of the Miami VA Health Care System:

To honor, comfort and protect Veterans by developing, and guiding innovative improvements in healthcare Environmental Sanitation, Textile Care, Interior Design, and Waste Management programs that exemplify VA’s Core Values and Characteristics.

EPS Vision Statement The mission of the Miami VA Health Care System:

To continually enhance VHA’s ability to create healthy, healing environments for our nation’s Veterans and their families that inspire, enable and sustain health and well-being.

VA Core Values and Characteristics

Blueprint for Excellence

Blueprint for Excellence The four themes and ten essential strategies contained in the Blueprint for Excellence frame a set of activities that simultaneously address

1. Improving the performance of VHA healthcare now

1. Developing a positive service culture

1. Transitioning from “sick care” to “healthcare” in the broadest sense

1. Developing agile business systems and management processes that are efficient, transparent and accountable.

Ten (10) essential strategies

1. Operate a healthcare network that anticipates and meets the unique needs of enrolled Veterans, in general, and the service-disabled and most vulnerable Veterans, in particular.

1. Deliver high quality, Veteran-centered care that compares favorably to the best of private sector in measured outcomes, value, efficiency, and patient experience.

1. Leverage information technologies, analytics, and models of healthcare delivery to optimize individual and population health outcomes.

1. Grow an organizational culture, rooted in VA’s core values and mission, that prioritizes the Veteran first; engaging and inspiring employees to their highest possible level of performance and conduct.

1. Foster an environment of continuous learning, responsible risk-taking, and personal accountability.

1. Advance healthcare that is personalized, proactive, and patient-driven, and engages and inspires Veterans to their highest possible level of health and well-being.

1. Lead the nation in research and treatment of military service-related conditions.

1. Become a model integrated health services network through innovative academic, intergovernmental and community relationships, information exchange, and public-private partnerships.

1. Operate and communicate with integrity, transparency and accountability that earns and maintains the trust of Veterans, stewards of the system (Congress, Veterans Service Organizations) and the public.

1. Modernize management processes in human resources, procurement, payment, capital infrastructure, and information technology to operate with benchmark agility and efficiency.

Telephone Directory Environmental Management Service Telephone Directory

Background and Orientation

Prior to 1954, the Nursing, Registrar, Supply and Engineering Services were performing many of the cleaning functions currently assigned to Environmental Management Service. On June 24, 1954, specific functions related to cleaning, sanitation and interior design were transferred to the new service and placed under the direct supervision of an Executive Housekeeper. This transfer established the new service in VA’s healthcare system, and identified it as the Housekeeping Division.

The Housekeeping Division assumed the responsibility of the laundry operations in July 1961. Since the Housekeeping Division already had control of linen purchasing, distribution and repair, it was felt that it was also logical for the laundry to be included in this operation. At that time interior Pest Management was a well-established component of the Division, due to its relationship with sanitation.

A Directive in October 1966 advised a change in the title of the organization from Housekeeping Division to Building Management Service, which was again changed a few days later to Building Management Division. This title remained until December 1972, when Central Office in Washington, DC, sent a Directive to all stations indicating that only those departments dealing with Veterans’ benefits should remain as a Division. All other departments should be known as Services. Therefore, the organization was again known as Building Management Service.

On June 1, 1993, the name of the Service was changed to Environmental Management Service to properly identify responsibilities, other than just Housekeeping and Laundry. Many Environmental Management Services at other VA facilities have expanded their role to include related activities, e.g., painting, maintenance, signage and graphics, furniture repair, waste management treatment and incineration, recycling, exterior pest control, grounds and transportation.

The primary responsibilities of Environmental Management Service at all divisions of the (insert facility name) are:

· Environmental Sanitation

· Environment of Care Monitoring

· Interior Design/Way-Finding/Painters

· Textile Care/Uniforms/Patient’s Assistance

· Waste Management/Recycling

· Integrated Pest Management

A brief description of each of the operations of the service will help to understand the overall functions of EMS.

EMS Employee Training -- Establish policy & procedures for meeting training requirements for all employees in Environmental Management Services. Conduct service level training in a professional manner that meets the needs of the employees, training requirements and mandates governing Environmental Management Services, specifically new employee orientation Environmental Sanitation -- Sanitation is a necessary and important function in the total operation of the medical center. In a healthcare environment, concern must go beyond the dirt that is visible to the naked eye and extend to the organisms that cannot be visually detected, i.e., germs. Even if an area appears clean, it must be cleaned and disinfected with an Environmental Protection Agency (EPA) registered germicidal disinfectant in order to sanitize the area and to protect the patients, employees and visitors from spreading disease-causing organisms. After cleaning, disinfection methods such as ultraviolet disinfection or peroxide fogging may be employed to enhance sanitation.

Environment of Care Monitoring –Environmental Programs Service provides coordination, documentation, tracking, and trending of Environment of Care rounds.

Fleet Management -- The transportation section will have oversight of GSA fleet management, scheduling maintenance and management of GOV or GSA leased vehicles. This includes oversight of all fleet credit cards and ensures that users are properly trained. (Insert local policy / memorandum)

Integrated Pest Management -- The relationship of Environmental Management Service (EMS) to the discipline of Integrated Pest Management (IPM) is one of mutual importance. The EMS employee is to report any insects, pests or rodents they see to an EMS Supervisor or to the EMS main office, noting where they saw the insect, pest or rodent; the time of day; and, if possible, where it came from and where it went. All available information regarding such incidents will aid the pest control operators in tracking down and eliminating pests. Sanitation plays a critical role in integrated pest management. EMS involvement with an effective IPM program is outlined within VHA Handbook 1850.02.

Interior Design/Wayfinding, Painting -- Interior Design. Selecting materials, finishes and furnishings that are safe and supportive of patient care that can be properly maintained in the healthcare environment is the responsibility of the interior design program. The selection of both the material and color for window coverings, cubicle curtains, floor coverings, paint, furnishings and wall art all fall within the realm of EMS, and is the responsibility of the Interior Designer or designee. Selected materials and finishes should be aesthetically pleasing but the ease of care and maintenance must also be carefully considered when making the decision. EMS employees may play an indirect role and, therefore, should be aware of what is involved. The EMS role in this area might be to report any loose tile, damaged window coverings, loose rods, damaged paint or wall tiles or other things of this nature to the Interior Designer, thus ensuring immediate attention to correct any deficiencies. EMS involvement with an effective Interior Design program is outlined within VHA Handbook 1850.05.

Wayfinding (Signage). The wayfinding function covers a wide variety of methods to move Veterans and visitors to and through space to the appropriate location. The sign program is responsible for ensuring correct and appropriate interior/exterior signage. The VA Signage Design Guide further outlines information and suggestions for the development of sign programs at Veterans Affairs Facilities. The guide provides detailed guidance for the development of a sign system that assists VA customers and staff as they approach the property, locate buildings and services within the facility. Some facilities may include painting, carpentry or other duties within the scope of this activity.

Textile Care Management -- EMS involvement with the use of textiles; and procedures and reporting requirements concerning textile management costs attributed to the procurement, distribution, and processing of textiles is outlined within VHA Handbook 1850.03.

Linen Distribution -- EMS involvement with the linen distribution activity may include shelving, clean linen, picking up soiled linen and distribution of clean linen. Each ward requires a set quota for each item of linen used on a daily basis. The linen carts from the Linen Distribution Section are brought to the facility, and linen closets are restocked with an established quota for that particular area.

Uniform Issue -- This program involves the issuing, marking, repairing, tailoring and laundering services to Service employees that are required to wear uniforms.

Patient Assistance Program -- At this (insert facility name), responsibility for this function falls under the EMS; at other medical centers, the Health Administration Service may be tasked with this responsibility.

This activity involves the inventory, storage and re-issue of a patient’s personal effects while the patient is hospitalized. This program also provides clothing, shoes and personal hygiene items to indigent patients, as well as haircut vouchers, if applicable to facility.

Waste Management -- Waste management includes collecting waste and recyclable materials generated in the facility and transporting waste to designated locations.

Employee Orientation Checklist

The following information will be provided/discussed/reviewed with new employees:

· Age-Specific Training

· Alternative Dispute Resolution (ADR) Program

· Attendance, Scheduling of Leave, Types of Leave

· Automated Safety Incident Surveillance and Tracking System (ASISTS) Program/Rights/Responsibilities

· Basic Procedures and How to Use this Manual in the Performance of your Duties

· Basic computer skills

· Bed Management System (BMS)

· Chemical Inventory Sheets and Location

· Compliance with JC, OSHA, EPA, CDC, AORN, APIC, DOT, VHA Program Guides, Local, State and Federal Regulatory Agencies.

· Computer Access Codes and Training

· Conduct, Manner, Attitude, Customer Service

· Customer Service (KAIDET/HEART Models)

· Disaster Plan & Emergency Operations Procedures (EOP)

· Employee Identification (ID) / PIV Badge Provision and Display

· Employee Responsibilities

· Ethics Policy

· Fire Regulations/RACE (Rescue, Alert, Confine, Extinguish)/ PASS (Pull, Aim, Squeeze, Sweep) Procedures

· General Safety Procedures/Regulations

· Handling of Spills

· High Performance Development Model (HPDM)

· Hazardous Communication Policy/Rights/Responsibilities

· Infection Control Procedures

· Information Security Officer (ISO) Confidentiality

· Job Description/Performance Standard/Competency/Performance Appraisal

· Keys and Access Regulations

· Safety Data Sheets (SDS) and their location

· Medical Center Brochure

· Medical Center Customer Service Requirements

· Medical Center Policy for the Prevention of Sexual Harassment

· Mission/Vision/Value Statement/Goals

· MyVA Website : http://www.va.gov/opa/myva/index.asp

· Occupational Safety and Health Administration (OSHA) Blood Borne Pathogens Standards; Employee’s Right to Receive Hepatitis B Vaccine; Occupational Health/Employee Healthcare

· Parking Regulations and Registration

· Patient and Family Centered Care (PFCC)

· Performance Appraisal/Competency (inclusive of rating factors)

· Policies and Procedures and Employee Responsibilities (Laundry, Linen and other)

· Probationary Period

· Professional Appearance and proper wear of uniform.

· Personal Protective Equipment (PPE) Procedure

· Restrictions for Use of Cell Phones within the Medical Center

· Service-Specific Orientation/Checklist

· Smoking Policy

· Standard Precautions and Transmission-Based Precautions

· Time and Leave and Pay Scale Information

· Tour of Duty, Breaks, Lunch, Dinner

· Tour Changes and Rotations, if applicable

· Transport Cart Training and Competency Certification

· Tuberculosis Control Plan

As set forth in this orientation guideline, I have reviewed, discussed and fully understand the requirements of my position and performance, position description, performance requirements and procedures manual. I understand that I may receive the Hepatitis B vaccine from Occupational Health. If I choose not to receive the vaccine, I must sign a declination form.

Employee Signature Date

Supervisor’s Signature Date

The Department of Veterans Affairs National Sanitation Manual consists of necessary policies, procedures and training applicable for any sanitation section within VHA. Policies and procedures within this Guide were last reviewed on June 6th, 2017 and accepted as written and/or edited by Charles A. von Goins and supersede manual dated 2016.

Chief, Environmental Management Service Date

Infection Control Representative Date

Back to Table of Contents

Chapter 2 Overview

Core Principles

Each employee will develop skills for effective job performance. This begins with facility and department orientation, personal education, and learning from peers and supervisors.

1. Understands mission and applies to daily work.

2. Understands chain of command, policies, and procedures to reach work goals.

3. Shows leadership, teamwork, ethical behavior, fairness, concern for others and accepts cultural differences.

4. Communicates with patients, the public, and employees.

5. Gives and accepts feedback about job and behaviors.

6. Accepts changes.

7. Gives ideas and suggestions.

8. Responsible for actions and final results.

9. Keeps a positive outlook.

10. Problem solves and suggests ways to improve work area.

11. Plans and acts to improve self and job growth.

Personnel Polices and Employee Conduct

1. Purpose: To provide guidelines and standards pertaining to Environmental Management Service Sanitation Section job-related issues.

2. Policy

· Personal Appearance - All employees are responsible for presenting a professional appearance by being neat and well-groomed while on duty. Employees must properly wear a clean uniform daily in accordance with service standards (i.e. shirt tail tucked, unwrinkled, etc.). All shoes must be clean and serviceable; for safety reasons, no canvas shoes, sandals, dress shoes, etc., will be permitted. Choices of work shoes will be either work boots or athletic tennis shoes (station provided where applicable). Good hygiene (clean hair and body) is a daily requirement.

· Uniforms - Employees will be issued government-owned uniforms, sufficient to allow them to wear a clean uniform every day. Laundry service will be provided if required. You may wear your uniform to and from your residence. Refer to blood borne pathogen plan if uniform becomes soiled with body fluids.

· Name badges- are to be worn and be clearly visible at all times while on VA property. If name badges are lost, employee must make arrangements for replacement at the earliest opportunity. Name badges are to be worn with picture facing outwards to make identification easy.

· Miscellaneous- Sunglasses are not to be worn inside, unless required by physician. Hats are not to be worn unless approved by management. Cell phones, earplugs, IPods or other electronic devices are not to be used while on duty except for official government use.

· Speech - Use a pleasant tone of voice, and avoid loud or boisterous talk or conduct at all times in the hospital and on the campus. Always remember patient privacy standards and principles.

· Manner - Be alert, courteous, helpful and brief. Employees should report any problems or issues to their immediate supervisor. Avoid showing irritation with patients and staff members. Show job interest and willingness to learn. Take pride in job. Be considerate of patients and the staff responsible for their care. Always utilize the KAIDET model. Knock, Announce, Identify, Duration, Engage, and Thank when entering and working in a patient room. If asked to leave, do so graciously and return another time. Be willing to assist each other and help employees of other Services, as needed. It is vital in to show cooperation and enthusiasm while on duty. When dealing with a patient remember the HEART model. Hear, Empathize, Apologize, Respond, and thank the patient for understanding.

· Conduct - Your actions and behavior on or off duty reflect upon you, this service, the facility and the Department of Veterans Affairs.

· Use of Drugs and Alcoholic Beverages - The use of drugs (except those prescribed by a physician) and intoxicating beverages are strictly prohibited on duty and on VA property. For patient and employee safety, Police Services will be contacted for an employee reporting for duty with an odor of alcohol.

· Obscene Language/Gestures - Vulgar or obscene language/gestures are prohibited, and will not be tolerated.

· Smoking - Do not give smoking materials or matches to patients at any time. Smoking as well as vaporizing units and smokeless tobacco products is to be used during official breaks and in designated areas. Smoking is permitted only in accordance with the Medical Center Policy (insert MCM# here).

· Protocol/Chain of Command - Following the proper chain of command is fundamental to ensuring continuity between upper management, supervisory personnel and EMS employees. It is important that all operational issues be addressed on the appropriate level of supervision first.

· Attendance - Regular attendance on the job is essential. Excessive missed days could be a cause for appropriate disciplinary actions

· Tardiness – Employees are always expected to arrive to work on time. Tardy is defined as not reporting to work on time, Tardiness will be documented. Repeated tardiness will not be excused and employee will be charged leave in 15 minute increments if approved by the immediate supervisor or other leave granting authority within the employee’s chain of command. Excessive tardiness could be a cause for employee to be charged absent without official leave (AWOL) and may lead to formal disciplinary action.

· Reporting On or Off Duty – All employees are expected to be ready, willing, and able to work during their tour of duty. Each employee is required to report for duty on time, fully dressed in their uniform and ready for work. The employee uniform includes clothing, name badge(s), and hospital issued communication devices such as pagers or Vocera as applicable. Employees not in full uniform will be sent home with instructions to return to work in the proper uniform. Employees shall not leave before the end of their shift. Employees will check in and out with their immediate supervisor or designee at the beginning and end of their tour.

· Schedules/Tour Changes - Schedule/tour changes will be addressed according to local labor/management agreements and medical center policies.

· Leave (Time Off) - Leave is granted according to national and/or local negotiated agreements and medical center policy.

· Breaks, Lunch Periods and Absences from Assigned Area - Except for designated breaks and lunch periods, employees will remain in their job area at all times. When an employee must be absent from the assigned area, approval from their supervisor will be obtained. Employees are reminded to remain in their assigned work area until the end of their tour of duty.

· Work Assignments - Employees are to receive work assignments from their supervisors and/or work leaders - During emergent situations, employees may be asked to perform housekeeping duties by other facility personnel and may be required to become part of the facility labor pool.

· Probationary Period and Performance Ratings

· Career appointment type will determine the probationary period. At minimum, an employee will be subject to a one year probationary period. Consult your local Human Resources for job specific probationary periods.

· Your supervisor will keep you informed on a continuous basis throughout this first year as to how you are performing your work and job assignments. He/she will point out your strengths, weaknesses and particular areas in which you need to make improvement, and provide assistance toward improvements.

· Each year all employees receive a mid-term rating and annual rating of their work performance. All employees are encouraged to submit a self-evaluation at the end of each annual rating period. Employees will be given advance notice for the submittal dates of these evaluations.

· Change of Address or Telephone Numbers - Any change of street address, telephone number or emergency address is to be reported to your supervisor on the day following the change. These records must be kept accurate at all times.

· Communication - There are several methods that can be used to communicate information to employees. These methods include, but are not limited to, mail boxes, bulletin boards, electronic mail (e-mail), staff meetings, verbal conversations, etc.

· Care of Tools and Equipment - Each employee is expected to use tools and equipment properly and to keep them in clean and good operating condition. Tools and equipment will be properly stored at all times when not in use. At no time should equipment be left unattended in hallways. All supply rooms, housekeeping aid closets, work carts, storage areas, etc., are to be maintained in a clean and orderly manner. No food, drinks and/or eating utensils or personal belongings are to be stored in these areas (OSHA AWE Infection Control and The Joint Commission requirements).

· Reporting Discrepancies/Work Orders - If an employee discovers that repairs to equipment, tools, furnishings or other items are needed, they should report the needed repairs to their supervisor for work order submission.

· Accidents - If an employee is involved in an on-the-job accident, whether or not they are injured, they must report the incident to their supervisor as soon as possible. First aid and medical attention are available for employees injured on the job. Light duty and accommodations for job related injuries maybe appropriate if required.

· Conserving Utilities - Employees are expected and encouraged to turn off unnecessary lights and turn off water faucets to help conserve utilities in their areas.

· Financial Dealings - Employees will not engage in financial dealings with patients, volunteers, students or staff members while on duty or on VA property.

· Indebtedness - The VA does not normally become involved in the financial affairs of employees; however, if repeated complaints of non-payment of justifiable financial obligations are received from creditors, action will be taken as authorized by applicable regulations.

· Reporting Fires - Any employee who discovers a fire should immediately implement RACE (Rescue, Alert, Confine and Extinguish) procedures and other local reporting requirements.

· Patient/Employee Interactions - For the safety of patients, employees are not permitted to give food, drink (including water) or cigarettes to any patient at any time. Be courteous and assist patients or visitors who are in need of help going through doors or into elevators or who need directions. Maintain patient privacy standards at all times.

· Aesthetics - All Medical Center employees should focus on providing a pleasing environment, regardless of the position they hold. When any employee notices litter, trash, etc., on floors, counters, stairwells, etc., he/she should dispose of such items in the closest waste receptacle. We must all work together (team work) to ensure that this is the cleanest medical center in our VA System. All employees, not just EMS employees, are expected to dispose of waste when visible; this includes interior and exterior areas.

3. Responsibility - It is the responsibility of all EMS employees to adhere to the above policies and standards.

Employee Signature Date

Supervisor’s Signature Date

Environmental Management Service Operations

The following schedule of cleaning will be followed in patient care areas. Environmental Protection Agency (EPA)-registered hospital disinfectant will be used, unless otherwise indicated. Surfaces must be cleaned of any dirt/debris before they can be properly disinfected.

1. Floors are vacuumed or dust-mopped and wet-mopped daily.

2. Wastebaskets are cleaned as needed (clean interior and exterior of receptacle). Waste disposal receptacles are emptied and re-lined twice a day as necessary in acute care areas. Waste receptacles in clinic areas and non-patient care areas are emptied daily. Filled trash liners are tied closed, placed in a collection cart and transported to the waste disposal site. Never use hands or feet to compress waste in receptacles.

3. Regulated Medical Waste (RMW) containers with a red liner are placed in each ward’s soiled utility room and other secured areas as appropriate, they are to be covered and collected daily.

4. Bathrooms, showers, utility rooms, toilets, urinals, sinks, mirrors, bathtubs and shower stalls are cleaned daily. Paper towel dispensers, toilet paper, sanitizer, and soap dispensers are checked daily and refilled as needed. Doors and doorframes are cleaned weekly and as needed. Shower curtains are inspected daily and cleaned as needed.

5. Furniture, window sills, ledges, radiators, fire extinguishers, external light fixtures, cubicle curtain tracks, mini-blinds, vents, light covers and horizontal surfaces are cleaned weekly by dusting with a vacuum cleaner or specially-treated dust cloth.

6. Ultra-violet (UV) lights are turned off and cleaned weekly with a specially-treated dust cloth.

7. Furniture in patient rooms is washed with an EPA-registered hospital disinfectant solution as part of the patient discharge procedure and as needed.

8. Handrails in corridors are cleaned with an EPA-registered hospital disinfectant solution weekly and as needed.

9. Horizontal surfaces including counter tops, over-bed tables, bedside tables and bed rails are cleaned as per local policy.

10. Rolling stock and Non-Critical Reusable Medical Equipment (RME) (wheelchairs, IV poles, etc.) is cleaned periodically or as part of terminal cleaning.

11. Drinking fountains are cleaned daily and as needed. The exterior and drain tray of ice machines are cleaned as needed.

12. Patient beds are cleaned upon discharge or transfer. Ambulatory Care exam tables and hemo-dialysis treatment chairs are cleaned as needed. Negative air isolation rooms - refer to local policy to timeframe on room closure to allow airflow exchange.

13. Bed Management System (BMS) program is monitored and updated by Housekeeping Aid or supervisor on a regular basis to ensure proper bed flow data.

14. Long-term care beds are cleaned monthly when Nursing Service notifies EMS that the patient is out of bed.

15. Cubicle curtains are changed quarterly and as needed. Draperies, shades, and blinds are washed as needed. Damaged curtains, blinds, shades or draperies are repaired or replaced.

16. Walls and ceilings are cleaned when visibly soiled.

17. Ceiling Tiles showing visible signs of mold, stains, cracks or holes are to be reported to your immediate supervisor who will coordinate replacement with Engineering Service.

18. Isolation rooms are cleaned according to the protocol found in the EMS Manual.

19. Fans, vents and lights are cleaned as needed.

20. Sharps containers are monitored daily and changed as needed by EMS personnel or contract personnel as dictated by local station. When boxes are ¾ full, they are securely sealed and disposed of as Regulated Medical Waste.

Position-Specific Competency Assessment Checklist

Competency Validation Record Competence is the ability to perform procedures safely, correctly and legally.

Category of Staff

· Permanent

· Temporary

· Contract

· Other Competency Validation

· Initial (Within 30 Days)

· Reassignment (Within 30 Days)

· Annual Review

Original of this form to be forwarded along with annual Performance Appraisal to the Human Resources Management Office

EMPLOYEE NAME:

SERVICE/SERVICE LINE:

CURRENT POSITION:

DATE ASSIGNED TO CURRENT POSITION:

DATES/PERIOD COVERED BY THIS RECORD:

USE THE FOLLWING METHOD OF VALIDAITON (MOV) CODES (DO NOT USE CHECKMARKS):

D-DEMONSTRATION

DR- DOCUMENT REVIEW

I- INSERVICE

C- COURSE/CLASS

USE THE FOLLOWING COMPETENCY CODES: S = SATISFACTORY; N = NEEDS IMPROVEMENT (PROVIDE EXPLANATION OF SPECIFIC IMPROVEMENT STEPS TAKEN. USE A SEPARATE SHEET IF NECESSARY.)

(MOV)

COMPETENCY CODE

N/A

VERIFIER’S INITIALS/

DATE

A. SERVICE/UNIT/POSITION SPECIFIC COMPETENCIES (SPECIFY) (Initial, High risk, problem prone, and/or seldom performed)

1. Ability to describe proper housekeeping procedures for assigned area.

2. Understand the EMS organization and business. Build trust relationship to provide services that meet the customers’ needs.

3. Communicates effectively with co-workers, customers, staff, patients and officials at all times. Demonstrates interpersonal skills that support an environment in which good communication takes place.

4. Demonstrates the KAIDET and HEART model

5. Describes working knowledge and proper use, handling, and proper labeling of all housekeeping chemicals.

6. Demonstrates the ability to change and/or refill any dispenser (paper, soap, etc.).

7. Demonstrates the use of all mops (dust and wet).

8. Knowledge and demonstration of all housekeeping cleaning procedures.

9. Can verbalize the proper dwell time for each disinfectant used to complete assigned tasks.

10. Demonstrates the proper use of Standard and Transmission Precautions to include proper PPE utilization.

11. Can verbalize and demonstrate the proper 2 Step cleaning process for cleaning/disinfecting a patient's room that has had a Multi-Drug Resistant Organism (MDRO) (for example, Methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile(C-diff).)

12. Can verbalize and demonstrate the proper techniques for handling trash, bio-hazardous waste and sharps containers.

13. Can demonstrate the proper use of Wet-Floor signs and proper mopping technique to ensure a safe walkway (I.E. half and half method).

14. Can verbalize and demonstrate the proper cleanliness of the housekeeping closet and housekeeping cart.

15. Can demonstrate how to secure the housekeeping cart and chemicals during the assignment (including while on breaks and lunch).

16. Teamwork: Encourages and facilitates cooperation, pride, trust, group identity; fosters commitment and team spirit; works with others to achieve goals.

17. Attention to Detail: Is thorough when performing work and conscientious about attending to details.

18. Can demonstrate proper safety mechanics in lifting, pulling, pushing, etc.

Can demonstrate the following procedures:

19. Bed-making and cleaning

20. Patient room-cleaning (terminal, isolation and daily)

21. Use of double-bucket mopping system

22. Use of microfiber system

23. Restroom cleaning

24. Floor care

25. Housekeeping Aid Closet (HAC) cleaning

B. AGE-SPECIFIC COMPETENCIES UNIQUE TO POSITION

1. Avoids being judgmental or condescending.

2. Conversations match customer level of understanding.

3. Ensures that environment remains safe.

C. POSITION SPECIFIC EQUIPMENT

(High risk, problem prone, seldom performed – Specialized position-specific equipment should be added in this section if it presents identifiable risks/special concerns)

1. Demonstrates the ability to use a computer.

2. Demonstrates the use of the Bed Management System.

3. Demonstrates the understanding and application of VISTA computer database.

4. Can demonstrate the proper use and cleaning of the following equipment:

A. Buffer B. Burnisher (both riding and stand behind) C. Scrubbers (both riding and walk behind) D. Carpet extractor E. Vacuums (both wet and dry) F. Blowers

D. LIFE SAFETY/ENVIRONMENT OF CARE/EMERGENCY PREPAREDNESS/HAZADOUS MATERIALS/UTILITY SYSTEMS

1. Life Safety to include:

A. RACE

B. PASS

C. Location of fire alarms and extinguishers D. Fire drills and smoking policy

2. General Safety to include:

A. Wearing of Personal Protective Equipment B. Keeping corridors unobstructed C. Securing housekeeping cart when not in use D. Familiarity with the Safety Procedures Manual E. Accident Reporting Procedures F. Electrical Safety

3. Hazardous Materials and Waste to include:

A. Hazard Communication Program B. Safety Data Sheet (SDS) C. Spill Response Procedures D. Knowledge of Radiation Safety

4. Emergency Preparedness Plan and Procedures (Employee verbalization of his/her role)

5. Utility Systems Procedures(if applicable) to include:

A. Emergency Procedures in case of loss of utility(s) B. Location of emergency shutoff controls

E. INFECTION CONTROL

Annual mandatory education has been completed. Demonstrates proper procedure and is able to explain where to find policies related to the following:

1. Hand hygiene (alcohol rub and hand washing)

2. Use of Personal Protective Equipment (PPE)

3. Standard and Transmission Precautions (Isolation categories)

4. 2 Step Cleaning Process (Clean and then disinfect)

5. Tuberculosis (TB) Exposure Control Plan

6. Blood borne Pathogen Exposure Control Plan

7. Has completed annual mandatory education for:

A. Blood borne Pathogen Training B. Multi-Drug Resistant Organism (MDRO) training C. Influenza Training

F. CPR

Demonstrates proper procedure in initiating CPR

1. How to Call a Code

2. Role in Code Blue

3. Knowledge and Skills of Basic Life Support (CPR)

G. INFORMATION MANAGEMENT (Employee Verbalization)Computer security and procedures to include:

1. Access codes

2. System Log on/off

3. Patient/Staff Sensitive Information/Information Confidentiality

4. Appropriate use of e-mail & computer use

H. PERFORMANCE IMPROVEMENT

1. Verbalizes PI process

2. Verbalizes role in PI process

3. Verbalizes examples of PI initiatives in the facility.

4. Knowledge of Mission and Vision

Chapter 3

Infection Prevention and Control Program

1. Purpose

To establish policies, procedures and guidelines to provide a clean and sanitary environment for patients, staff and visitors in order to prevent cross-contamination and transmission of hospital-acquired infection (HAI).

Proper sanitation is an important facet of infection prevention control. The relationship between sanitation of a healthcare facility, and HAI rate is hard to quantify. However, sanitation is an integral component of infection prevention and control.

The EMS Chief is a member of the Infection Control Committee. The chief is responsible for recommending policies, procedures and products through the Infection Control Committee.

2. Responsibility

· EMS employees receive initial orientation, as well as annual updates in infection prevention and control.

· EMS Chief and supervisors will ensure employees comply with hospital infection prevention and control policies and procedures.

· EMS employees are required to use standard precautions when handling body fluids, excretions, secretions and contaminated equipment. Standard precautions mean that each employee selects the proper personal protective equipment (PPE), based on anticipated contact.

· EMS employees are required to follow transmission-based precautions when posted. These include airborne, droplet and contact precautions or a combination of the three.

· EMS employees are responsible for compliance with the Blood borne Pathogen Exposure Control Plan, which describes measures designed to protect employees from such exposures and provides evaluation and follow-up of employees, should such an exposure occur. The purpose of the plan is to minimize or eliminate occupational exposure to blood borne pathogens by utilizing a combination of engineering and work practice controls, PPE, education, medical follow-up of exposure incidents, vaccination, and other provisions.

· EMS employees are responsible for compliance with their institution’s Tuberculosis Control Plan, including tuberculosis testing and fit-testing or particulate respirator training, as required by the facility.

· EMS employees are responsible to keep current with required immunizations and comply with the facility Occupational/Employee Health policy.

3. Responsibility

a. Standard Precautions

1. Standard precautions are used in all patient care areas to reduce transmission of organisms from known and unknown sources of infection. The blood, body fluids, secretions, excretions, non-intact skin and mucous membranes of all patients are considered potentially infectious. Examples include urine, feces, sputum, blood, and saliva in dental procedures, emesis, pus, drainage and any aspirate. All EMS employees are required to practice standard precautions when handling/touching blood, body fluids, excretions, secretions, and equipment or environmental surfaces contaminated with blood, body fluids, excretions, secretions.

2. Infection prevention and control measures are used to reduce the risk of transmission of organisms.

a. Hand hygiene is the single most important way to prevent the spread of infection in the facility. The purpose of hand hygiene is to remove potentially harmful organisms. Hand hygiene with soap and water or use of alcohol based hand sanitizer must be performed prior to the start of cleaning procedures; before and after using gloves; immediately after contact with blood, body fluids, excretions, secretions and contaminated equipment/surfaces; and, after completing cleaning activities. Hand hygiene with soap and water is used if hands are soiled.

b. The proper procedure for hand washing is: wet hands; apply hand washing agent; rub all surfaces of hands and fingers vigorously, paying particular attention to the areas between the fingers, under and around the nails, and around the wrists for at least 15 seconds; rinse thoroughly under running water. Before turning off the faucet, dry hands with paper towel, use a dry paper towel to turn off the faucet and discard.

c. An alcohol based hand sanitizer containing at least 60% isopropyl alcohol may be used for hand sanitation when hands are not visibly soiled. The proper procedure for using alcohol based hand sanitizer is: Ensure all organic matter is removed from hands. All visible organic matter (for example: dirt) must be removed from the hands prior to applying alcohol based hand sanitizer. Apply a dime sized amount of alcohol based hand sanitizer to the palm of one hand. Rub hands together covering all surfaces of hands and fingers. Rub until alcohol based hand sanitizer is absorbed.

3. PPE is used with standard precautions, based on potential exposure to infectious materials. PPE is intended to protect the employee from contact with possible infectious materials. PPE includes gloves, eye protection, gowns, masks and masks with face-shields. All PPE used in the facility will be provided to employees without cost, and will be readily accessible to employees. All garments that are penetrated by blood or body fluids should be removed as soon as possible. Refer to facility blood borne pathogen policy. All disposable PPE will be removed and discarded promptly and appropriately after use, and hand hygiene performed prior to leaving the work area.

4. Gloves are worn when…