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Maintaining a Clean and Safe Environment Using Reliable Processes During COVID-19

By IHI Team | Tuesday, February 16, 2021

Maintaining a Clean and Safe Environment Using Reliable Processes

Photo by Nino Maghradze | Unsplash 

Before you can keep residents active and engaged, enhance staff joy in work, or reduce wasted effort, it’s essential to have a sanitary nursing home environment, especially during the COVID-19 pandemic. High-touch surfaces need to be cleaned and disinfected regularly, and processes like appropriate personal protective equipment (PPE) donning and doffing need to be consistently followed.

IHI is a participant in the AHRQ/Project ECHO National Nursing Home COVID-19 Action Network, a partnership between the Agency for Healthcare Research and Quality (AHRQ), the University of New Mexico’s ECHO Institute, and IHI. The IHI Training Center is delivering the standardized curriculum to five cohorts of nursing homes based in Delaware, Florida, Georgia, Louisiana, and North Carolina.

The following ideas for maintaining a safe environment and ensuring reliability come from nursing home participants in the IHI Training Center, but may apply to other settings as well.

Engage and Educate Staff on their Role in Preventing Infection

  • Discuss best practices for being safe outside of the nursing home with staff. Provide clarity about expectations and activities, including avoiding buffets or large groups, and wearing masks in cars, public transportation, and other public spaces.
  • Ensure staff understand proper disinfection processes.
    • Use a multidisciplinary approach to planning activities and keeping everyone safe (e.g., activities, nursing, CNAs, and housekeeping).
    • Develop a plan for disinfection before and after resident activities.
    • Instruct and ask for a “teach-back” about how to clean and disinfect and where.
    • Use products to simulate the spread of germs to provide a visual representation of what can happen without proper hand hygiene and disinfection.
    • Check that staff know the name and contact information of the facility’s infection preventionist.
  • Help staff and residents understand how to prevent or control an outbreak.
    • Explain the importance of following infection control processes — Why is this step important? What can happen if it isn’t followed?
    • Support staff by asking what gets in the way when best practices are not followed.
    • Develop a culture where all support one another and hold each other accountable for following infection control protocols.
    • Empower and make it easy for staff members at all levels to report safety concerns.
  • Make education accessible and routine.
    • Provide laminated education cards to staff members to carry with their ID badges that review routine practices, like proper handwashing or PPE donning and doffing.
    • Consider cultural and language barriers in developing education and training materials at an accessible reading level. Are instructions clear and easy to understand? Are visual instructions available and helpful? What factors might get in the way of a process being followed?
    • Incorporate “teach-back” and “show-back” techniques in trainings to verify staff understanding (“Can you show me how you screen visitors?”)

Evaluate Standard Processes to Improve Reliability

  • Observe staff to see how they carry out tasks in real time. This observation will help you understand what steps matter most to staff and will indicate where lapses are occurring or where a process may need to be reformed. It will provide a real-time illustration of how the work as imagined compares to reality. Leaders who round multiple times per day can help evaluate what’s going well and where further support might be needed.
  • Establish reliable COVID-19 entrance screening practices.
    • Standardize the process of logging results of the screen (temperature, symptoms, etc.) at the entrance to the facility, and review the steps with screeners and their managers each day.
    • Have plans in place for solving issues in the moment and for time off for screeners.
    • Partner with contractors who regularly visit the facility (including transportation, home health, hospice, and vendors) to understand their screening/testing practices and coordinate having timely test results sent to the nursing home.
  • Check for improvement opportunities. Visiting the point of care will provide insights into how principles are put into practice in real time. A number of facilities use managers and multidisciplinary pairs to make “angel rounds” during each shift to check the availability of equipment and supplies, ask about needs and worries of staff, and observe spaces and staff as they conduct daily activities.
    • Avoid taking a punitive approach if inconsistencies are identified; rather, see these events as opportunities for education and improvement.
    • Look for environmental barriers, e.g., insufficient signage, lack of an easily accessible trash can, or furniture inhibiting mobility.
    • Assemble an interdisciplinary team for group rounds to obtain input from multiple units and roles.
    • When not available in person, have remote infection control professionals conduct room-to-room video observations.

Regularly Reassess the Physical Environment

  • Stagger the time of meal delivery and room cleaning. Plan accordingly to keep cleaning supplies or equipment from coming into close proximity to food.
  • Identify less obvious or new high-touch surfaces for cleaning. Examples include the undersides of tables and chairs, door keys, phones, and computer keyboards. If your facility recently added a sign-in station for screening, ensure that pens are regularly disinfected, and store used pens separately until disinfection.
  • Streamline and enhance cleaning processes for the “new normal.”
    • Replace a communal mop and pail with single-room floor cleaning pads.
    • Upgrade the air filtration system. Consider applying for a grant if the cost is prohibitive.
    • Use fogging units to disinfect large areas and reduce burden on cleaning staff.
    • Consider locations of trash receptacles to make disposal of potentially infected items easy for staff and residents.

As facilitators and staff members supporting the “all teach, all learn” work of the IHI Training Center, we are seeing firsthand how innovative, dedicated, and compassionate these nursing home staff members are, seeking to provide high-quality, safe care for residents while simultaneously supporting staff and creating a just culture.

Gail A. Nielsen, BSHCA, FAHRA, RTR, is faculty for the IHI Training Center of the National Nursing Home COVID-19 Action Network. Marina Renton, MPhil, is an IHI Project Manager. Becka DeSmidt, MPH, is Senior Manager of IHI Open School & Virtual Programs. Frank Federico, RPh, is an IHI Vice President.

You may also be interested in:

National Nursing Home COVID-19 Action Network details and registration

Video — COVID-19 Vaccinations: Perspectives from a Nursing Home CNA

Lessons from Nursing Home Staff to Address Burnout and Enhance Joy in Work

Driving the Urgent Need to Improve Nursing Home Care

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