Urgent message: Every urgent care center must have a plan to clean and maintain its physical facility. In this JUCM-exclusive panel discussion, industry leaders share their insights on selecting an environmental services contractor, negotiating pricing, and maintaining service levels.
Urgent care is often considered a blind product because patients generally lack the formal training necessary to assess the quality of the actual medical services delivered. As a result, satisfaction or dissatisfaction is determined in large part by factors that patients can see, touch, and experience, including time spent waiting, the friendliness of staff members, and the upkeep and cleanliness of the physical facility. A facility that is dated, has heavy wear and tear, is disorganized, and/or appears unclean will likely be considered of poor quality regardless of the medical outcomes provided. Because urgent care centers routinely deal with infectious agents and other biohazards, the environment must not only be presentable; in addition, it must be compliant with regulations that protect patients and employees. Yet despite the importance of having a clean, well-maintained environment, many centers consider cleaning an afterthought or nuisance to be dealt with instead of a differentiator or benefit. This roundtable discussion provides insights on questions commonly asked by urgent care operators about cleaning and maintenance services.

Staying In-House Versus Outsourcing
Ayers: What are the advantages and disadvantages of contracting cleaning and maintenance services out to third parties versus hiring cleaning and maintenance staff or having the center’s nonmedical staff perform routine facility tasks?

Regna: Whether handling things in-house or outsourcing, the organization must understand what is needed to ensure that the cleaning and disinfecting process is completed and documented. The first priority must be providing a clean, disinfected, and safe environment for patients, visitors, and staff. Maintaining a clinical environment is not like cleaning your home. Environmental services (EVS) staff must understand and use disinfectants, equipment, and other supplies registered with the U.S. Environmental Protection Services (EPA) that require a higher level of training and education. The choice to use a contractor versus the center’s staff comes down to who is best qualified, who understands the requirements, and who provides services that assist in the reduction of health-care-associated infections.

Bailey: For multifacility companies, outsourcing services helps maintain a consistent brand image across all units via a standardized scope and chemicals. The scope of work is monitored by professionals and allows the centers’ nonmedical staff to concentrate on other important tasks necessary to run the operation. Outsourcing all facilities to one contractor is much less expensive than hiring individual cleaning companies for each center, particularly because of administrative fees and the rising costs of minimum wages and insurance.
Another advantage is additional layers of insurance and indemnity, which puts the center in the third position. A disadvantage I’ve noticed is when a manager asks a crew to complete a task that is outside the standard scope of work, there is often a delay because of the need for corporate office proposal and approval time, whereas if the service was done in-house, there would be no question and no delay.

Gottfried: An obvious advantage with the outsourcing model is having access to best-in-class providers or at least having the flexibility to change providers as quickly as needed. The primary challenge with this model, as we see it, affects companies that manage a number of different facilities in various locations. Just the act of sourcing the best providers in each location can be difficult. On top of that, there are the operational challenges in keeping track of project status, budgeting, and vendor performance. Overcoming these challenges is the immense market opportunity behind service automation technology.

Watkins: The greatest advantage of contracting with a third party is the ability to allow all clinic staff to focus on their main role and objectives—to ensure high quality patient care. The greatest disadvantage would be having nonemployee staff members managing a key component within the clinic that is a major focus on the environment of care in each center. Thus, ensuring that you have a top-quality and communicative vendor would be of the utmost importance.

Desirable Contractor Qualities
Ayers: What steps does the urgent care operator typically follow in identifying cleaning and maintenance contractors? What factors should an urgent care operator consider when evaluating a contractor?
Regna: Urgent care operators must first consider the level of risk posed by the environment and the community demographic. Next, they must walk the facility with key members of the organization and decide on the level of cleaning and disinfecting, the number of days needed, floor types, floor care, and the overall perception of the organization by the community.

Sidebar 1 lists the policies, procedures, and documents that should be brought to the very first meeting to establish the ability of the contractor to provide service in this environment.

Sidebar 1. Requirements and Credentials for HealthCare Environmental Services
According to Mark Regna, International Director of Jani-King Healthcare Services, urgent care operators choosing an environmental services contractor should ensure that competencies are documented for training to the level required to clean and disinfect the facility, and that the following items are documented as well:

  • Health Insurance Portability and Accountability Act (HIPAA) training
  • U.S. Department of Transportation regulated medical waste training
  • Blood-borne pathogens training
  • Background check to the level of the Federal Bureau of Investigation
  • No presence on the exclusions list of the Office of Inspector General (U.S. Department of Health & Human Services)
  • Tuberculosis skin test results; familiarity with tuberculosis policy and procedures
  • Influenza vaccine requirements
  • Uniforms
  • Identification badges
  • Proper use of personal protective equipment
  • Liability insurance
  • Designation of a local office to provide oversight and quality-assurance inspections
  • Cleaning schedules and checklist
  • Written policies and procedures
  • Compliance with regulations of the U.S. Environmental Protection Services
  • Compliance with regulations of the Occupational Safety and Health Administration of the U.S. Department of Labor
  • Compliance with the Chemical Right to Know Act
  • Professional references

To ensure compliance and continued success in the center, remember the Five R’s: Right Staff, Right Training, Right Chemical, and Right Equipment at the Right Time. If any one of these five fails, disinfecting will not occur and over time will become a quality issue.

Bailey: Operators should look at a company’s profile before even accepting a proposal. The nature of healthcare facilities requires cleaners to have a specialized knowledge of the way services are performed. An experienced company understands the guidelines of the Occupational Safety and Health Administration (OSHA) and Centers for Disease Control and Prevention (CDC) and trains its cleaners in the use of appropriate chemicals and methodology. They also should check on the references provided to see if they fulfill expectations. Other factors to consider: Do they offer 24/7 emergency response? Do they have a biohazard program? Are they capable of handling the entire geographic portfolio of your company to ensure brand consistency?

Gottfried: There was a time when it was the responsibility of each facility’s operations team to meticulously develop the relationship with qualified contractors one by one, site by site. But as an enterprise such as an urgent care company scales up, this individual sourcing becomes quickly untenable from a time and management perspective. However, with cloud, web, and mobile technologies, it is now possible to choose from a global network of qualified contractors at a moment’s notice from one platform. Further, having these networks in a consolidated platform also provides the means to objectively and quantitatively rate their performance and share other relevant data across the enterprise. We have obviously seen this work well in consumer applications such as Yelp, so it was only a matter of time before facility managers took advantage of these advancements. For example, in our own network, we have more than 50,000 qualified contractors that we make available to our customers. Multiply that by the hundreds of companies offering such services, and you have the means to completely transform how contractors are sourced.

Watkins: The biggest way in which a contractor can be an asset to an urgent care group is to be responsive to the evolving needs that can arise within multiple locations and clinics across various geographic areas. Although the cleaning side can be very specific and standardized, the maintenance side of things is an area that is not predictable. The steps to find a contractor must include reviewing the way(s) that the contractor will work alongside the urgent care facility to achieve the facility’s vision.

Pricing Options
Ayers: How are cleaning and maintenance contracts typically priced? Are they based on hours worked, or on services provided? What recommendations would you make to the urgent care operator who is negotiating the scope and pricing of a cleaning or maintenance contract?

Regna: EVS contracts for the most part will be different, and each will have specific needs to be addressed. An outsourced company with experience in health-care settings will use production rates to maintain the facility. For example, if you have a facility that has five examination rooms, and each examination room is 35 square feet, you would multiply the five examination rooms by 35 feet to get a total square footage of the examination rooms. In this case, you would have 175 square feet of examination rooms. A reputable contractor who is looking to truly clean and disinfect the examination rooms will use a production rate of 650 to 850 square feet per hour, depending on the acuity of the room (low, medium, or high). Once you have the total hours needed to service the facility, then you will add in the fully loaded labor rate to the daily hours and multiple that by how many days per month the organization is looking for service. From this, you get the price to clean and disinfect the facility, with the understanding that labor is the biggest expenditure for service providers.
As new laws are being passed by county, city, state, and federal governments to increase minimum wages and living wages, the cost of labor continues to increase. As wages change, you will also see changes for providing mandated health insurance. The key is to get creative, know your facility, and understand what is required to provide a clean, disinfected, safe health-care environment.
The question was asked whether to either contract for services or use the staff from the facility to do the cleaning and disinfecting. In some cases you can do both, if the facility staff members clean and disinfect their own nonclinical work areas four times per week and the contractor does a deep weekly or monthly cleaning of those areas. This would reduce the organization’s cost to clean and disinfect.

Bailey: Typically, pricing at urgent care facilities is based on hours worked for janitorial services (normal service frequency in urgent care ranges from 3 times a week to 7 times week), and square-footage pricing for floor-care services (strip and wax, auto-scrub, and so on). The more frequent the service, the lower the per-service cost. There are many studies in health care that support daily cleaning services and a scheduled recurring floor care maintenance program. Operators should also compare the cost of minimal cleaning with the value of customers’ reactions to visiting a clean clinical facility.

Watkins: In the urgent care market, winning the contract will often be based on price over value. The greatest success we have had is partnering with the urgent care throughout the bid process—even helping to create the scope of work. Ultimately our goal and model is to provide facility services at or below 2.5% of the projected annual budget of a specific clinic. Two percent of that is generally routine maintenance and janitorial services, and the 0.5% is long-term planning or capital improvements—painting, renovations, and so on. In our pricing model, we want to give the most value at the best price. Part of our process is having a greater facility management strategy and vision versus simply routine maintenance and janitorial services. A few of the things we do to ensure competitive value and cost are partnering with janitorial consultants, implementing FacilityDude.com (an online tool for requesting, managing and reporting work orders), and working toward establishing preventive maintenance on a monthly schedule.

Maintaining Quality Over Time
Ayers: A common complaint is that over time, cleaning services start to neglect minor details. How can an urgent care operator best keep its cleaning services accountable?

Regna: As the cost of labor increases, you have contractors starting to cut corners and not clean as thoroughly. Unfortunately, you have some contract providers who are not experienced in bidding or cleaning in health-care organizations. The contractor has misjudged the hours, pay rates, or requirements for training and compliance. The best way to keep the little details from becoming big issues is to do environmental rounds with the key contact from the EVS provider and to complete customer-satisfaction surveys. Make sure your contract has an out clause for poor performance; this is key to being able to switch providers if there is poor service.
Bailey: The best way to ensure quality is to have an effective communication and quality-control program in place. Service-based companies will inevitably run into poor-performance issues occasionally. The best ones will accept that fact and have a system to correct any defects in a timely manner.

Gottfried: Vendor performance management is one of the most vexing problems that our customers want to solve in deploying service-automation technology. The key issue is that the traditional method of managing vendor performance, if completed at all, was highly asynchronous—meaning it was done after the fact and often on the honor system. That is, the contractors provided performance updates and reviews, and the customers took the information on face value or not. Real-time performance management and project status updates were very difficult to achieve before service automation. Now it is second nature for contractors to check in to a project site (using mobile devices enabled for a global positioning system [GPS]) and providing real-time, blow-by-blow project updates, including sharing photos and other multimedia information to demonstrate progress. In addition, service automation now empowers facility-management teams with business intelligence analytics to give them a historic view of how any contractor performed over time, using key performance indicators such as reliability, time to case resolution, and costs. Having these data points is the ultimate tool for accountability, because there are hard metrics to back up performance evaluations, good or bad.

Watkins: You can hold contractors accountable to the extent you are holding staff members accountable. So much of what we run into is more on the customer-service and communication side than the cleaning side. Obviously as contractors, we must maintain excellence in our facility management, and that means hiring the best people to perform all types of work. However, the extent to which we are held accountable must be acknowledged by those on the corporate side as well as those within the clinic. So much of what we strive to do is work with our end customer—not necessarily the one who signs the check—so that we can address the little things that separate a good contractor from a great contractor.

Managing Risk
Ayers: Medical environments create unique risks, ranging from exposure to pathogens to protection of confidential health records. What steps should the urgent care operator take to ensure that individuals cleaning the facility are informed and compliant with all the regulations governing health-care facilities?

Regna: The biggest thing a provider can do is to ensure that the contractor has provided all documentation prior to starting the contract. The person who handles the contract and who is responsible for the cleaning and disinfecting of the facility should review who is in the facility and make sure that they have organizational clearance to work in the facility.

Bailey: Service-based companies emphasize the proper awareness and provide training to their cleaners on proper handling of pathogens and the privacy rules governed by the Health Insurance Portability and Accountability Act (HIPAA). Center personnel must be properly trained in handling pathogens and using proper chemicals to protect against the spread of infectious disease. Operators should always ensure that patient information is protected and out of plain sight. In most cases janitorial cleaning and floor care services are performed after hours, so HIPAA regulations do not come into play.

Gottfried: Again, for us, the how facilities and operations managers can fix this issue is just as important, if not more important, than the what they’re fixing. Managing compliance with the various regulations is a major operational challenge for urgent care providers or any large enterprise in general. And regulatory compliance is only one aspect—there are corporate compliance requirements dictated by corporate functions, such as procurement, that facility managers have to be mindful of. The problem can quickly escalate out of control. Consider one urgent care provider and the dozens to hundreds of contractors and suppliers they deal with.
Then multiply that by the increasingly number of compliance documents and items they have to manage, each with different deadlines and milestones. Having a global view of all the compliance status updates for all contractors and suppliers is now possible through service automation. This is “Uberification” in action, and one of the most important ways that facility management is transforming as a profession.

Watkins: We believe that staff engagement is necessary to achieving a high-level result. Thus, we operate under a methodology of continual education of our staff members about infection prevention, floor care, efficiencies, and so on, and we extend this to our entire client base as well. We contract with a third-party independent consultant to help us standardize our process of cleaning, and ultimately achieve the desired outcomes for our customers (and their clients, members, patients, etc). We base our training model on documentation and guidelines from the CDC, EPA, OSHA, Joint Commission, and other regulatory agencies in order to instill confidence in our customers that our process has been researched and proven to work effectively.

Janitorial and Maintenance Roundtable: Best Practices for Managing Environmental Services
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