Calgary Ambulance Bay Project -Original- 2012
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This report raises serious patient care and privacy concerns. For the patient's well-being and rights, medical treatment should not be combined with law enforcement activities like interrogation. The focus must remain on providing compassionate emergency care.
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Calgary Ambulance Bay Project -Original- 2012
- 1. Calgary Ambulance Bay Project Don Sharpe - Paramedic
- 3. Cluttered Ambulance Bay Stretcher Pathways
- 4. Hospital Equipment and Supplies Storage
- 5. Cleaning Supplies and Equipment Storage
- 6. Expensive Medical Supplies Wasted
- 8. Under the Clean Linen Cart
- 10. Stained Walls & Broken Equipment
- 14. Contaminated Stock costs $$
- 16. Entire pallets of $$ - Overstock
- 17. Contaminated Equipment & Garbage
- 18. It stayed clean less than One Day.
- 20. Was there nothing we could do about this?
- 21. AHS Improvement Way (AIW) A3 Template ! ! ManageChange ! ! ! ! Stakeholder & Communication Strategies: (Identify key groups or individuals who may impact, influence or be affected by the change and actions required to build their engagement and support.) DefineOpportunity ! "! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Background, Problem Statement, Goal Statement: (A good description of what the issue is – focused on the problem not blame or solutions. Include a concise description of the pain, gap, challenge including observable evidence and impact. Include the targeted benefit – “How much by when?”) !! BuildUnderstanding ! ! ! ! ! #! ! ! ! ! ! ! ! ! ! ! ! ! ! Process Assessment, Cause Analysis: (Understand current state to determine why the problem exists. Pictures, process maps, graphs, and data analysis are encouraged. Ask “why” enough times to establish root cause. Adjust goal as needed.) ! Improvement Selection & Implementation Plan: (Brainstorm potential solutions, evaluate and select options, create implementation plan, assess and plan for potential risk.) ! ! ! ! ! ! ActtoImprove Reinforce Ownership, Measurement & Continuous Improvement: (Include key performance indicators, visual controls, job descriptions, procedures, standard work, ownership clarification, etc.)! SustainResults ! Lessons Learned: (Identify and share with groups who may benefit from your experience – inside and outside of your team.) ShareLearning Title:Title: Owner:Owner: Date:Date: !
- 22. AHS Improvement Way (AIW) A3 Template ! ! ! DefineOpportunity ! "! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Background: A number of WHS and IPC concerns have been raised by EMS and ER Staff regarding cleanliness and supplies organization in the FMC Ambulance Bay, which is the busiest in Southern Alberta. On May 01, members of EMS, ICP, Emergency, and WHS met in the FMC Ambulance Bay to assess conditions. Problem: A review of the work area revealed: 1. The presence of safety hazards 2. Contaminated equipment 3. Excess equipment and supplies All of these were identified as negatively impacting the workflow and risking the health and safety of both patients and staff. We discussed the need for short term and long term goals and identified stakeholders who would be a necessary part of the solution. Some operational issues will require follow-up in a few week's time with a larger group of stakeholders (i.e. FMC Site Director, Environmental Services, Facilities Maintenance and Engineering, Planning, etc.) regarding ownership, allocation of resources and sharing of responsibilities for the Ambulance Bay. Other issues of urgent nature (i.e. contaminated equipment / workflow of clean & dirty) are being assessed promptly as these carry immediate risk to patient care. Goal: Improve EMS work flow, reduce safety hazards and maintain a clean Ambulance Bay at the FMC. AHS EMS goals of excellent patient care, timely and safe delivery of patients to the Emergency Department and then restocking the Ambulances in order to get quickly back into service would be greatly enhanced if the FMC Ambulance Bay was clean and well organized. ! ! BuildUnderstanding ! ! ! ! ! #! ! ! ! ! ! ! ! ! ! ! ! ! ! Process Assessment: EMS is now fully integrated into AHS, and is also busier than ever before. Where before each municipality had individual equipment and cleaning routines, we are now being asked to establish one standard system for everyone to use. Equipment and cleaning procedures that are in place to ensure various areas inside the hospital remain free of contamination and well organized are not readily transferrable to the Ambulance Bays. Immediate progress was seen with the initial effort; however we need to identify ways to make additional sustainable changes. Cause Analysis: There are specific risks to staff assigned to clean the Ambulance Bays that they wouldn’t encounter inside the Hospital, including vehicle traffic risks, and these need to be identified and mitigated. Identifying accountability for the workflow and cleanliness of the Ambulance Bay and EMS equipment is difficult, as it a shared space for several FMC departments and services. The Ambulance Bay is used to store many different kinds of equipment and supplies, and the volume and variety of workers using the space is large. You can help identify additional challenges and provide solutions. Ask yourself; Why is this area so challenging to keep clean? Provide your comments and suggestions on the page provided.
- 24. Shine Stations
- 25. Hospital Ambulance Bay: A Shared Space, With No Accountability.
- 26. 24 Stn EMS Office
- 27. 24 Stn EMS Dorm Rooms
- 28. Out of Service w/ 130 blankets
- 29. EMS Vehicles not being Cleaned
- 30. Friends in High Places
- 31. ! ! ! ! ! ! ! ! EMS Cleanatics! ! ! " #$%&' (!" #&)&*(+(,$*!- . /! ! ! " #$%&' () *$ " +#+0 &1,' ! 234!56 4! 7+89+#. !6 &(#$! ! :; *&!<=!>?@>! ! ! AHS Improvement Way (AIW) – EMS Cleanatics! ! EMS Cleanatics! 4 different EMS workspaces - identified as ‘could be cleaner’. 1 - EMS hall offices/dorms. 2 - Hospital ambulance bays. 3 - Hospital hallway waiting areas. 4 - K bldg. Goal: Develop an EMS ‘Culture of Clean’ to improve our workspaces. Canadian OH&S Guide to Workplace Housekeeping is attached (also here): http://www.ccohs.ca/oshanswers/hsprograms/house.html 5S’s for a clean workplace: Sort – Go through your work area - Remove what’s not needed. Set in Order – Organize your workspace – Improve efficiency & workflow. Shine – Regular cleaning & disinfecting. Standardize – Establish standards and maintain organization. Sustain – Maintain what’s been accomplished through: Systems - Training - Supportive Culture. Leading by example and teamwork is the essential strategy. Spring is decidedly the best time to implement a program that motivates workers to clean their workspace. Initial efforts to achieve a ‘Quick Win’ in these areas are possible. This project has been developed with the assistance of: THE AHS IMPROVEMENT WAY (AIW): Fundamentals of Improvement, Change & Problem Solving Program. Douglas Sinclair, Improvement Advisor with AHS. !
- 32. AHS Improvement Way (AIW) – EMS Cleanatics! ! DefineOpportunity j Background, Problem Statement, Goal Statement: 1. EMS offices/dorms - Leased space and stand alone stations - Often dirty and in disarray. Garbage’s full, blankets on the floor, drawers/cabinets filled with discarded and dirty equipment, floors not vacuumed, swept or mopped. Crews often collect 30+ blankets to return to the hospital linen supply. 2. Hospital Ambulance bays - already identified as chronically unclean, larger organizational issues are being worked on by another team. Keeping the bays free of garbage on the floor and clutter on top of cabinets and supply carts is needed. 3. Hospital Hallway waiting areas – Patient / Public traffic areas neglected by housekeeping in part because of soiled linen, trash and equipment left there by EMS 4. K Bldg – Being renovated, garbage / medical supplies on the floor – no regular cleaning. AHS Improvement Way (AIW) – EMS Cleanatics! ! ManageChange Stakeholders & Communication Strategies: Patients – Families - EMS – Housekeeping – Nursing – Security – Equipment Techs – Mechanics – Supply Vendors – Maintenance - CPS – CFD – Managers - Some of the efforts needed can be Peer Driven Peers taking initiative and leading by example can set new standards. Peer messaging by email and posters in workspaces to remind staff. With team support, peers actively engage staff participation. What else can Peers do to encourage all staff to keep the workplace clean? -- -- -- -- -- Would a new reputation as responsible stewards of these areas enhance our efforts? Once an acceptable standard of cleanliness is achieved, new goals can be set. BuildUnderstanding B Process Assessment, Cause Analysis: Infrequent cleaning of different workspaces. Varied cleaning requirements for different work spaces. CFD does not clean AHS leased areas. Medic crews often out working by the traditional 9 am cleaning. Accountability for cleaning workspaces is unclear. Adequate cleaning supplies not always available. Absence of inspection schedules. Obsolete furniture, absence of maintenance schedule or replacement date. Minor repairs required at different sites. What are the Root Causes of these dirty workspaces? ( 5 Why’s ) -- -- --
- 33. AHS Improvement Way (AIW) – EMS Cleanatics! ! Improvement Selection & Implementation Plan: Collect staff members who are proven leaders, with demonstrated skills in keeping their work environment clean. How many would we need? Ask only that these team members identify problem areas, provide solutions and encourage others to ‘pull their weight’. The team would share strategies, request support and document successes. What might these team members need to get started? -- -- Team members will begin to seek out and actively resolve problem areas. The team would lead by example, and encourage other staff members to follow. Are there any obstacles we need to consider? -- -- EMS Maintenance might see a spike in their call volume initially. ActtoImprove Reinforce Ownership, Measurement & Continuous Improvement Supervisors should see immediate results at the halls and in the hospital ambulance bays, Mechanics will see a difference at K bldg and Nursing staff will see improvements in the hospital hallways. Team members can be notified of problems in their zone by Supervisors, nursing or other staff members, act to provide a ‘quick fix’, and then notify the team for a long term evaluation and resolution. How else might team members hear about a problem area? -- -- -- How would success measurement and record keeping be accomplished? -- -- -- SustainResults AHS Improvement Way (AIW) – EMS Cleanatics! ! Lessons Learned: Can individuals within a group identify, bring forward and resolve cleanliness, safety hazards and any other issues with which we may not even be aware? -- -- If team members encourage others to identify slip, trip and fall hazards, will they be able to develop the ‘Culture of Clean’ that is the goal of this project? I believe developing staff interdependence and cooperation will strengthen our teams. AHS EMS Calgary Metro will again be identified as developing innovative programs that work, and are an example to the rest of the EMS community. What other benefits might happen as a result of a clean, well organized workplace? -- -- -- ShareLearning Thank you for taking the time to review this project proposal. These ideas will benefit from your input. I’ll make sure each of you get a copy of this session document by email. Don Sharpe 403 862-2598
- 34. Getting some ‘Buy-in’ from Crews
- 35. Shine Stations
- 36. Where’s the very BEST PLACE to put soiled PINK BUCKETS? We STERILIZE and RECYCLE all the PINK BUCKETS placed in the small container in the middle.
- 38. Disposal Station Prototype Designed for safe disposal of sharps, biohazard & regular EMS garbage, Includes feature for proper handling of recyclable containers. Provides portable, complete disposal service for EMS in any Ambulance Bay. Disposal Station Prototype Designed for safe disposal of sharps, biohazard & regular EMS garbage, Includes feature for proper handling of recyclable containers. Don Sharpe - Paramedic AHS EMS - Calgary Metro (403) 863-2598
- 39. Foothills Hospital – ER Social Club - Recycling Storage Box Contact ____________________ for more information. All bags with Pop Can / Bottle Recycling can be placed in the wooden bin in the Ambulance Parking Area behind Emergency. Thanks for your help! The money raised supports the Foothills Hospital Emergency Nurses Social Club. Foothills Hospital – ER Social Club - Recycling Contact ____________________ for more information. Please place ONLY your EMPTY De-Capped Bottles and Cans HERE The money raised supports the Foothills Hospital Emergency Nurses Social Club.
- 41. Both Ambulance Bays & Halls' ( "0#= , 0#9)( "- 6#.( )#QWR#+, 2.#N#F>O"0#, .#.( )#E; ; .( "%%0#"- #.( )#$3 9#Z, >8# # # # # ' ( "0#= , 0#9)( "- 6#.( )#QWR#+, /( )#+, 2.#, .#V#R.- 8## # #
- 42. November 19, 2012 • (E.) - Working to secure funding for floor upgrade and possible additional work (funding already secured for part of the work, but seriously under funded for the work required – (S.T.) involved; will be part of bi-weekly E&M meeting) • - Formal project to be developed to address the Ambulance Bay – patient movement, Human Factors for design & signage, (creative thinking, collaboration) • - Monitor via OHS committee • • (T.) - EMS site contact; will be taking over project liaison • • (S.) - highlighted concern with contaminated equipment being returned to bay without being cleaned first. Hoping that this equip can be cleaned before being sent back (i.e. ED NAs cleaning back boards) • • (R.Z.) CRSP • Manager, Workplace Health & Safety Services
- 43. Proposed Projects • Write: Proposal - Provincial Ambulance Bay Standards • Suggested Standards for Cleanliness, Equipment and Security. • Write: Proposal – EMS Accountability for Calgary Metro Ambulance Bay Project • Proposal for Managing, Cleaning and Stocking Metro Ambulance Bays. • • Continue: Hospital Ambulance Bay Project • Redesign Layout, Equipment and Procedures for this EMS workspace. • Continue: Liaison w/ Capital Projects group for Ambulance bay floor replacement • Inclusion of Sumps, Sinks, Decontamination and Safety items we require. • Continue: Liaison w/ Calgary Metro Hospital management and safety teams • Strengthen relationships w/ Hospital Staff involved in Amb Bay issues. • • Collect: Data on Hospital Turnaround - Ambulance Return to Service issues • Identify issues & provide coaching to shorten turnaround times to staff. • • Investigate: New funding opportunities specific to the Hospital Ambulance Bays • Raising Awareness isn’t enough, we need cash for projects. • • Develop: Protocols for disposal / return to service of contaminated EMS equipment • Spineboards and straps, garbage, biohazard, sharps, expired meds. • Develop: Protocols for EMS transfer of Patients when Ambulance Bay unusable • Prepare procedures for disaster or maintenance scenarios. • Develop: Check sheets and Hazard Reporting systems for Ambulance Bays • 5S model audit, problem identification and reporting documents.
- 44. Work to Prevent Problems Continues
- 45. Cleanatics! • The ‘Cleanatics’ are making a difference. • • Ambulance stations are cleaner, Hospital hallways are cleaner, and Ambulance bays are cleaner. Working together we’ve made real improvements where we work. • • I get phone calls and emails from people: • - “Hey, I was at the Foothills and I saw Paramedic T____ squeegee the floor….” • - “We were at __ stn and cleaned up the ____ room, it took 15 minutes…” • - “I got into an ambulance at K-bldg and it was cleaner than the one we brought in…” • • People are sending me before & after pics of areas they’ve cleaned, and I encourage you to do the same. Working a couple of extra shifts the past 2 weeks, I’ve had some great partners who’ve helped out while we’ve been stuck in the hallways. • • I’m calling January, ‘Clean behind that Cabinet & Couch’ month. • • Everywhere we go, we’re pushing furniture and cabinets aside to see what’s behind them. So far, I’ve found enough coins to buy lunch …. and a few dust-bunnies bigger than my dog. • • Let’s this month try to pull out a few more pieces of furniture and clean behind them. A quick vacuum and mop ‘round behind something that hasn’t moved in months can make a real difference to a room. Put a little water & bleach in the bucket and the whole room smells clean! • • Have some fun with this, and share your success w/ the rest of the ‘Cleanatics’! • Everybody loves a clean behind . .
- 46. Patient Safety Reports • We arrived as Medic 220 with Police who had the patient pinned on the ground. We cut open his jacket and shirt to expose the wounds as police finished searching him for weapons. Once inside the ambulance we continued treatment as the police conducted an interrogation of the patient. • We then transported the patient lights and siren with Police onboard to the Foothills Trauma Centre, calling ahead to advise the trauma team of his injuries, our treatment thus far and our expected time of arrival. • Then the call became difficult. I pulled up to the Foothills Hospital Ambulance Bay and couldn’t tell that the Bays were full until the automatic doors opened. Once I saw that, I had a choice: • Back up into one of the busiest pedestrian crosswalks on the Foothill Hospital Property, without a spotter, and hope everyone is courteous enough to stop for me. • Park the ambulance and take the patient out of the ambulance directly into the unsecured crosswalk, with people walking by, and roll the cot into the Ambulance Bay from there. • I chose the latter, and was faced with another dilemma. A Rural EMS Crew had parked their Ambulance not only at a slight angle, but also slightly too far over to the left within the bay. Please understand, the margin for error when parking Ambulances within the Foothills Hospital Bay CURRENTLY IS VERY SMALL. There is no other way to bring the patient into the TRAUMA BAY from the front, except to roll them in through the main emergency doors and through the main ER waiting room.
- 47. New Cleaning Policies Introduced • I've reviewed the Policy and Procedure and successfully completed the evaluations for the new PS-EMS-02 'EMS Cleaning and Disinfecting Medical Equipment and Vehicles'. • • Both mention medical equipment and facilities in the procedure, which comes into effect on Jan 21, 2012 with the following objectives: • - to reduce the risk of exposing all of us to infectious agents. • - to define a process for cleaning EMS vehicles, medical equipment and facilities. • - to define a process for reprocessing medical equipment. • • I don't believe continuing to allow contaminated EMS equipment, such as spineboards and straps to be stored as they are currently for several days at a time (as illustrated in the attached photo taken the week of Jan 7, 2013 at the Foothills Hospital Ambulance Bay) meets either the spirit or the letter of the new policy or procedure. • • Section 5.1 of the Policy states that: • Blood and Body Fluid spills must be cleaned as soon as practical. • Section 4.1 of the Procedure states that: Blood and body fluid spills will be cleaned as soon as is practically possible to prevent spreading or drying of biological material. Dried blood and body fluids can be difficult to remove.
- 48. 10 things you can do in the Ambulance Bay in 5 minutes. - Pick some garbage and paper up off the floor. Change the dirty water in the mop bucket. Help a colleague clean their truck. Clean a dirty Spineboard and green tag it. Sweep a section of the bay using the equipment on the Shine Station. - Clean and wipe the counter in the office using the spray bottle in the Shine Station. Clear extra stock and garbage from the top of the EMS cabinets and put it away. Check the garbages, dirty linen bags & sharps containers. Empty/Replace if needed. Squeegee extra water off the floor if required, sweep and shovel excess gravel. Introduce yourself to housekeeping staff; let them know you appreciate their work. (Housekeeping staff are always willing to assist you with a concern, if you ask!)
- 50. Project Objectives • Evaluate staff and patient flow in the FMC ambulance bay – Identify short and long term improvement opportunities – Focus on storage of equipment and supplies – Improve overall environmental design and space utilization Human Factors Evaluation of FMC Ambulance Bay
- 51. What is Human Factors? Human Factors is the study of how people interact with spaces, equipment, and others. For example: A perfectly designed space would be easy to use, safe, efficient, and no one would make mistakes with it. A poorly designed space would be difficult to use, inefficient, hazardous and prone to mistakes. Human factors provides methods to evaluate these differences and recommendations for improvement.
- 52. ENVIRONMENTAL USABILITY RATINGS – Spring 2013 • Amount of usable space - Poor • PARAMEDIC -PATIENT / STRETCHER PATHWAYS • BLOCKED WITH STOCK CABINETS & GARBAGE • Cleanliness - Poor • NO CLEANING ROUTINES/ ACCOUNTABILITY, • LACK OF SPECIFIC EQUIP, NO CHECKSHEETS • Clutter - Poor • LACK OF UNDERSTANDING • AN AMBULANCE BAY IS NOT A STORAGE FACILITY. • Lighting - Poor • LACK OF PARKING INDICATOR LIGHTS IN FRONT • Access to Supplies - Poor • WOULD RECEIVE A LOWER RATING IF THERE WAS ONE, ‘DANGEROUS’ . • EMS workflow in the bay - Poor • FORTUNATELY PARAMEDICS ARE, BY NATURE, PROBLEM SOLVERS. • Your overall satisfaction - Poor
- 53. Methods – Usability Surveys Cleanliness, clutter, supply access, and flow to ED are key improvement areas • Post interview surveys – 5 pt Likert scale Goal = Satisfactory (rating = 3) and above
- 54. Findings – Presentation Template • Driver must park precisely otherwise they can impact access route to the ED and also access to/from other ambulances (84%) – Can limit access route to ED – Impacts getting in/out of ambulances, especially passengers – Can result in damage to ambulances Description of ISSUE FREQUENCY of responses Description of IMPACTS Photos or Mock Up of issue (EVIDENCE)
- 55. Findings – Accessing the ED • Patient transport routes from the ambulance bay to the ED are congested (84%) – RECOMMENDATION 4: Install painted striping on floor along ED access paths to communicate that staff are to keep the area clear. Install appropriate signage to “KEEP THE AREA CLEAR” [SHORT]
- 56. Findings – Maintenance & Cleaning • Ambulance bay is dirty (84%) • Ambulance bay is cluttered (55%) – RECOMMENDATION 39: Encourage EMS staff to help keep the ambulance bay clean / de-cluttered. Use signage improvements and other communications [SHORT] Ambulance bay brochure with ‘10 things you can do in 5 minutes’
- 57. Findings –Wash Facilities • No staff washroom in close proximity to bay (48%) – Closest washroom is public washroom in ED waiting area – Biggest impact is on job satisfaction – Can delay return to service No sink to wash hands in close proximity to bay (6%) -Hand sanitizers have been installed but EMS is not using them -Staff MAY not be washing hands often enough = IP&C concern -Can delay return to service
- 58. TEMPLATE PICTURE OR DESCRIP-TION Consequence and/or Recommended actions April 2013 Trigger word (CAUTION, WARNING, DANGER, NOTE) or Thing (Shine Station, Garbage...) Picture (recommended) or short (2-5 word) description of Hazard / Thing Short (2-5 word) description of consequences and/or actions AHS logo and date of sign Change background colors as follows: NOTE/THING = Blue CAUTION = Yellow (with black text) WARNING = Orange DANGER = Red 58
- 59. 59
- 60. SHINE STATION Help keep this place clean Please put cleaning equipment back where it belongs when you are finishedApril 2013 60
Editor's Notes
- Good Afternoon. I am PLEASED to be here today to speak to you. This project grew out of one person’s desire to make 4 primary EMS workspaces cleaner. As a working Paramedic in a busy Urban Metro EMS Service, I had become increasingly dissatisfied with the amount of clutter, lack of general cleanliness and the reluctance on the part of anyone to do anything about it. For almost 2 years now, with the help of a growing number of interested people I’ve investigated, documented & catalogued the problem and the changes that I thought needed to be made. This presentation today will show the very small bit of progress I’ve been able to make, and at the end I’d like to discuss with you ways that we can improve the cleanliness and functionality of these areas, and also talk about how we can Change the current expectations around cleanliness in EMS for the better. Prior to 1990 I worked with Dr Jeff Clawson on the introduction of Emergency Medical Dispatch and served as the VP of the National Academy of EMD. Back then asking Fire Dispatchers to give life saving pre-arrival instructions over the phone was... Challenging, to say the least. In 1990 I presented a paper at the Canadian EMS Interphase Conference on Ambulance Fatality Accidents, for which I was given both the Interphase Physicians Award for Research and a whole lot of grief from some EMS practitioners who thought the presentation went too far. Now 25 years later, EMD is the standard of care for EMS Dispatch Centres and in most Provincial Ambulance Legislation there is language and law that helps lower the number of people injured and killed in collisions with EMS vehicles each year. This presentation today addresses what I think is a similar type of problem in our profession that I would like your help addressing. Let’s begin.
- The first area I’d like to talk about today is the Hospital Ambulance Bay. Contaminated EMS equipment being returned to the Ambulance Bay, without being cleaned, seems to be a standard problem in our industry. In Alberta, where “We Are Now One” with the Hospital Health Care System, this practice is still, right now TODAY, commonplace.
- Ambulance Bays are neither primary patient care areas for EMS, nor are they tertiary care areas like we find inside the Hospital. Ambulance Receiving Bays are sometimes called ‘Garages’ and are frequently used for storage of supplies, patient belongings and broken or contaminated hospital equipment. My goal became establishing a standard of care and performance for these busy, critical patient receiving and treatment areas.
- These Hospital Supplies, equipment, garbage and recycling are frequently found lining the stretcher pathways in our Urban Metro Hospital Ambulance Bays.
- Cleaning Supplies and equipment are stacked and hung in a variety of ways, accumulating for use by EMS and Hospital Staff without protocol or design.
- In every Hospital we surveyed, thousands of Dollars worth of medical supplies, when left on the floor or stacked carelessly, become contaminated and unusable.
- Cleaning routines Do Not Exist in many Ambulance Bays, and soon we discovered that both Large Urban and Smaller Rural Centres shared these same conditions.
- When the floor under your clean linen cart shows an accumulation of debris like we see here, it indicates that maybe your local Hospital needs to pay more attention to Cleaning Routines.
- When mop buckets are left to dry and garbage containers are overflowing, it’s a sign that systems for Cleaning and Garbage disposal need to be established
- Restrictions on what can and cannot be left in the Ambulance Bay often do not exist.
- Any piece of Carpet in an Ambulance Bay that itself is already this dirty, must be so contaminated that perhaps the Centre for Disease Control should be notified.
- Pull out any cart or cabinet in your local Ambulance Bay and look behind it. How long does this problem take to correct? 5 minutes? So, what exactly is the problem here?
- How much money is going to be wasted next week when all of this expensive medical equipment is covered in dust and diesel exhaust and has to be discarded?
- It happens time and time again, and since both EMS Staff and Hospital Supply Staff were guilty of leaving the overstock on top of the cabinets, their shared blame seemed to absolve each party from doing anything about it. This became part of a more obvious pattern throughout the Ambulance Bays as we studied them.
- In every Hospital Ambulance Bay we surveyed, the situation was the same.
- In this case, an entire pallet of EMS supplies was brought up from the stock room and left in the Ambulance Bay. It certainly saved the supply clerk from having to return the next day pushing the heavy cart, but otherwise there was no advantage to leaving these supplies out.
- Everywhere we went, conditions were the same. Contaminated Equipment stored carelessly for weeks at a time along patient pathways, as well as inconsiderate and even dangerous bio-hazard disposal conditions.
- Even when we cleaned up the mess, made laminated signs stating clearly to - PLEASE DO NOT PLACE ANYTHING ALONG THIS WALL - and hung them up (as you can see in the picture on the left) in less than one day conditions returned to exactly the way they were when we started.
- We made beautiful full color checksheets, and found that NO ONE FROM EITHER THE HOSPITAL OR THE EMS DEPARTMENT WAS INTERESTED IN FILLING THEM OUT.
- Was there nothing we could do about this? Were Ambulance Bays doomed to remaining a lawless town of contaminated equipment where the rules of Workplace Health & Safety did not apply? Would it be more appropriate to rename the Ambulance Bay ‘Tombstone’, after the Wild West town that had no Sheriff and everyone could do as they please?
- We used the A3 Template DESIGNED SPECIFICALLY by AHS to approach and solve these problems. I’m no expert, I took a one day course on my day off to learn how to fill it out.
- With pictures and careful analysis, I documented the current conditions and suggested solutions. I proposed that the Ambulance Bay be designated an ‘Intermediate Care Area’, with guidelines for cleaning, storage and conduct that would enhance workflow and productivity.
- I drew pathway maps using suggestions from Jason Laberge, a Human Factors Specialist working in our Patient Safety Department who I’d had the very good fortune to meet in that A3 Template course.
- I observed other industries, such as Manufacturing, for similar problems and what solutions they discovered. (Discuss Shine Station creation)
- We discovered in the end that our Hospital Ambulance Bays were: A Shared Space, With No Accountability. (BREAK – PAUSE - REVIEW)
- Leaving the Ambulance Bays behind for the moment, let’s move on to another area where Medics work that needed attention. This is a supply cabinet in a Medic office. It’s intended to store office supplies, however because of it’s proximity to the couch, it was being used to store discarded hospital linen as well.
- The same problem was found in both the Ladies Dorm, on the left, as well as the Men’s Dorm, on the right.
- One EMS Station - Medic Office and 2 Dorms - yielded 130 blankets. We were out of service transporting this load to the closest hospital for return to the Laundry system. Unfortunately, this was discovered to be all too common an occurrence.
- Another area for improved cleaning routines is the Ambulances themselves. I’ve been a preceptor for many students, and there has not been a single one who’s actually known how to clean an ambulance. They all have their WHMIS and WHS and other related training and certificates, however each one had to be shown how to clean. Most were much better at keeping their personal vehicles clean than they were keeping their work vehicle cleaned and maintained.
- After a few months of making noise about the cleanliness of the these areas, the Ambulance Bay portion of the project had attracted enough attention that friends started sending me pictures. Medics, Hospital Managers, even cleaning staff. Seems everyone wanted to help, but didn’t know quite what to do.
- We started a program called the EMS Cleanatics. I’ve provided a copy of the 2013 update for you in the participant binder. (OUTLINE – DISCUSS)
- Again using the A3 Template, we attempted to elicit support for a formal program of Peer Leadership to clean the four areas we work in.
- It was APPROVED, BUT WITH A LIMITED MANDATE: It was restricted to only one of the four platoons, and we were advised that all communication with staff had to be routed through the Supervisors. I had FAILED to effectively ‘SELL’ this program to my Managers.
- Much of the work done to publicize and promote the Cleanatics initiative was done ad-hoc, and without formal approval. Without the MANAGEMENT GAS to run this project, it wasn’t going to go very far down the road.
- Shine Stations were purchased and built without pre-authorization, with either our own money, or by the grace of the Hospital Facilities and Maintenance Staff. Each Hospital in our system is encouraged to run independently, which might be great for them, but doesn’t help an associated department like EMS. When I pull into an Ambulance Bay with a patient, I expect that everything will be the same. That limits the number of decisions and thus mistakes that can be made on this important portion of an EMS call.
- The independence of each hospital also made addressing the overwhelming amounts of garbage and poor biohazard handling at each site more difficult. We had to approach every member of the front line Hospital Cleaning staff and engage them individually. Repeated efforts to maintain an acceptable standard of cleanliness were fruitless, I was never going to accomplish my goals this way.
- To solve the garbage/bio-hazard problem, I designed a couple of mock-ups, one of which you see on the left. That design was eventually built as a prototype Disposal Station, however this concept design is still not approved for use in any facility.
- While the design may not be perfect, I believe we’re on the right track.
- Storage of recycling in the Ambulance Bays, especially pop cans and bottles by Hospital Staff, was a sticky problem. I solved it by building an outdoor storage box for the Hospital, using funds form their own social club for the wood. Both Emergency & Housekeeping staff were advised of the new procedure and the benefits, this year one particular Hospital ER Social Club is on track to raise over $2000.00 which they split with between a Charity and their Christmas Party.
- From one sticky mess on the floor to another, the problem of flooding and contamination due to inadequate floor drains was discussed, however funding that had been obtained to fix the problem was reallocated to another project. Having a large, poorly sloped floor with an inadequate drain placed right at the back of the ambulance rear doors is almost Machiavellian.
- As I stand here speaking with you, Ambulance Bays and EMS Stations, as well as the Ambulances themselves REMAIN DIRTY. This is not just due to the recent flood we had, either.
- After sending a written and signed complaint to the Alberta Government Workplace Health and Safety Office, there was finally a meeting of Senior Managers from the Hospital & EMS which I attended. Some important items were discussed, and decisions made.
- I approached Senior EMS Management with this proposal.
- Meanwhile, the Overstock and Maintenance issues continued. Remember, the whole time I’m conducting this project I’m also working as a Paramedic, on a busy Metro Emergency Ambulance. However these problems were just too pressing for me to ignore.
- The Cleanatics were achieving and modicum of success, however half the feedback I received was the result of misinformation. We simply weren’t getting the word out that the program was designed to enhance, not replace or interfere with present cleaning staff and their efforts. Add to that the problem of an increasing call volume in an ever changing large urban EMS system, and maybe it’s no wonder results weren’t what I wanted them to be.
- I continued filling out Patient Safety Occurrence Reports, such as this one.
- AHS EMS introduced a new ‘comprehensive’ cleaning policy that didn’t address or seem to apply to the problems we were seeing on a daily basis.
- Some of the EMS Staff ‘Got It’ right away, others found reasons to argue and seemed to resent the idea that they were being asked to help clean up their work areas. While no acts of actual ‘Sabotage’ occurred, the general level of apathy to the project was, at time, disheartening.
- Suddenly, I was nominated for the AHS President’s Excellence Award. My immediate Supervisor had filled out the paperwork, and I certainly wasn’t going to look this gift horse in the mouth. Maybe, finally, the project was going to get some traction.
- Jason Laberge, the Human Factors Specialist from the Patient Safety Department was assigned to the Ambulance Bay Project. Yeah!! I’d been meeting with him on my days off for several months by this time.
- What is Human Factors?
- Jason surveyed EMS staff right there in the Bay, asking the questions you see here, and asking Paramedics & EMT’s to fill out and submit evaluations.
- This information was charted and included in our final report on redesigning the Ambulance Bay as an ‘Intermediate Patient Care Area”.
- Jason brought a lot of structured assessment techniques to the process, as you can see here.
- These skills allowed us to present the information to Senior Hospital and EMS Managers in a structured and easily understood way.
- Our Findings and Recommendations were included in a 165 page report.
- They included everything from approach and access issues to revolutionary ideas like: There ought to be a bathroom and a sink!
- Signage – I had no idea how important and difficult the whole signage concept was! In one large Urban Ambulance Bay in Calgary, THERE WERE 78 DIFFENT SIGNS, ALL PUT UP BY DIFFERENT PEOPLE AT DIFFERENT TIME, SOME OF THEM WERE FROM THE ‘80’S!!
- The signs we proposed they put up are standardized and scientifically designed to be easy to read and follow.
- The work done in the Ambulance Bay Project was easily transportable to all other EMS workspaces. The Goal: To keep these 4 Primary EMS Workspaces clean – to develop policies, protocols and procedures that allow us to do so.
- This is our concept drawing of an ‘Ideal Ambulance Bay’. If you look on the ‘net, you’ll see there has been very little of this kind of work done.
- This final slide shows all the pathways for Paramedics, Patient Stretchers, Housekeeping, Supply Staff and Vendors. Seemingly simple concepts such as not wheeling patients past bio-hazard bins over-flowing with garbage, having water and snow drain away from the back of each ambulance and having resupply stock secured and placed close by have been incorporated. This is the end of my presentation, I welcome your comments and questions.