Sustainability and the bottom line

The health care environmental services (EVS) profession has been challenged to embrace sustainability as one of its quality management goals. 

EVS professionals have been excited to lead other departments in finding and implementing opportunities to address the environmental, economic and social issues that are the foundation of sustainable health care operations. 

Many departments chose to reduce chemical use and to use environmentally friendly chemicals. They explored opportunities and technology to make energy use not only lower but more efficient. They worked with supply chain departments to find lower costs and lower environmental impact of expendable supplies. They were forging paths to reduce solid and liquid waste streams and opportunities to affect water use reduction positively.

But it is with a certain trepidation that EVS management has approached the topic of sustainability in their laundry operations. Although EVS management is comfortable with the specifics of their job and their wheelhouse, most have minimal comfort in the arena of health care linens, laundry and textiles. 

Health care EVS directors may not recognize the enormity of the size or responsibility of overseeing so many millions of dollars in health care textiles (HCTs). Ask a health care EVS director what the most expensive textiles they control are, and the answer may be microfiber products; but the real textile expense is in patient-use HCTs.

Whether HCTs are used directly by patients, as infection prevention textiles (IPTs) by EVS, or gowns for privacy and warmth during dialysis or chemotherapy treatments, staff must treat HCTs as an investment in patient outcomes.

Cost, quality and outcomes

The style of investment that EVS makes can be broken down into two dimensions for sustainability: 

Active versus passive management. Active management measures success by how much the portfolios (inventory, replacement cost, life expectancy and cost per pound) exceed or fall short of the performance of an established baseline, a comparably managed hospital laundry, the health care laundry industry or the market sector/region in which they’re operating. 

Active management requires constant monitoring and frequent product inventory for both quality and quantity decision-making to maximize the cost of goods and patient satisfaction. In addition, it seeks returns that exceed the anticipated performance of health care laundry markets, such as longer life cycle expectancy, a lower use per cost, a lower replacement cost and a lower laundering cost per pound. 

On the other hand, passive management can be problematic for health care laundries. Assuming that operations have been rolling along with smooth results means that management has been making sound operational judgments and staying the course will lead to continued operational smoothness and success; however, it is a sure sign of stagnation and ruin. 

A passive management style for EVS directors is to leave the whole operation to a service laundry contractor and trust that it has the hospital’s best interests at heart. That may be the case, but laundries have their challenges and problems, too.

Growth versus value investing. In growth investing for sustainability for HCTs, one must keep two things in mind: textile prices ebb and flow, and quality follows them. 

Oftentimes, a vendor may be faced with an overstock of higher thread count flat sheets that may not typically be introduced into health care. Due to the overstock situation, the vendor may be willing to offer a lower cost per unit than normal. Or a vendor may be holding a higher inventory of specialty items for areas such as burn units, bariatric units and neonatal intensive care units, but the demand has decreased so the price is lower. 

In both instances, the facility must be willing to invest in growing its inventory to benefit from a lower price. The growth in inventory will allow the facility to have a higher rotation inventory level, which will result in longer life for the textiles — the less frequent the laundering cycle, the longer the life of the textile. Additionally, if the facility has been maintaining a lower par level to save money, yet laundering their specialty textiles more often, the higher par level will lengthen the specialty textile life, thus improving the sustainability of the par level.

On the other hand, the value style of investing focuses on buying high-quality, comfortable and long-lasting textiles at a fair market price. A value style looks to a low price-to-use ratio, low price-to-long-life ratio and, generally, a higher yield (lower lifetime cost per item). 

Growth and investing are two different things entirely. Growth is preparing for the future through wise investments into the inventory to increase the sustainability of the textiles. Investing is essentially maintaining textiles to ensure quantity, quality and patient satisfaction. 

Addressing HCTs as perhaps the most critical part of sustainability for EVS is something new. Still, hospitals nationwide have been able to shrink this percentage through various cost-reduction methods versus elevating the sustainability of HCTs to the forefront.

Health care textile sustainability begins by recognizing that HCTs are an investment in a limited-life product. Therefore, active, growth and value operations management are most effective. HCTs are a commodity. They have a limited life expectancy and must receive the proper care.

Maintaining HCTs increases the life cycle and prolongs their effectiveness, quality and appearance. Therefore, operational knowledge of inspection and inventory practices is essential.

EVS management must do all that is possible to extend the useful life of textiles. There are four essential formulas to keep in mind in doing so:

• The life cycle expectancy.
• The use per cost.
• The replacement cost.
• The laundering cost per pound.

Knowing these formulas will have a direct impact on a hospital budget and textile sustainability.

An avoidable outlier

What is EVS supposed to do when a nurse or patient-care assistant throws a soiled washcloth into a waste bin or flushes it down a toilet? What if they wipe up a urine or blood spill with a towel and dispose of it in a waste bin? What about when the transport staff gifts a discharged patient with a bath blanket or bedspread to keep them warm? What is one to do when ambulance drivers remove sheets and blankets without a one-for-one exchange? What is EVS to do when things outside of their control happen? 

In these cases, sustainability takes a nosedive and the HCT investment increases due to shrinkage without any return on the investment. Some health care staff may dismiss the value of a textile item by calling it a “rag” or viewing it as an “old, used cloth.” 

EVS managers should ask two questions: 1) If the textiles are just a rag or just a used, old cloth, why are they being used for patient care? and 2) Does the staff realize that the hospital incurs a replacement cost for every missing or damaged textile?

Whether the materials are customer-
owned, rented or part of a full-service contract, there are replacement costs, and the hospital will pay the fees. Again, education is the key, and the loss of potential bonuses helps turn the key.

EVS, materials management and financial departments often concentrate on the cost per pound of laundering HCTs, but this is a blinkered approach. Focusing on price per pound is a budgetary process providing an immediate budget expense and a quick view. 

EVS managers should remember that sustainability focuses on meeting the needs of the present without compromising the ability of future generations to meet their needs. Likewise, sustainability focuses on meeting the needs of the current expenses without compromising the ability of future operations to meet their needs.

Two critical calculations to keep in mind in health care textile sustainability or life cycle of HCTs are the cost-per-use formula and the life expectancy formula. 

The cost-per-use formula uses the price of the product, life expectancy of the product, weight of the product and laundry cost per pound (COP) to process the product in the following equation: price of the item divided by life expectancy plus laundry cost per pound (weight times COP).

The cost per use for HCTs is tremendously valuable to health care facilities. It is a useful tool in helping facilities determine whether disposable or reusable items will provide the optimum value and lowest impact on the operating budget.

When developing a cost per use for comparison to a disposable item, it is essential to use the average weight of the HCT item after it has been in use for a while and is not new. The explanation for using a not-new item is because when the HCT is a used item, the hospital incurs a cost on a per-pound basis. So, it will be for the average weight of the HCT in use, which is generally lower than the weight of the item when it is new (unwashed). That will be a more accurate comparison to the cost of a similar disposable item. 

The life expectancy formula uses the number of pieces received over a fixed period and the number of articles purchased (replaced) over the same period in the following equation: number of pieces used per year divided by the number of pieces replaced per year.

Every EVS manager having oversight of a laundry department must know the price per item, the life expectancy of each article (washcloths have a lower life expectancy than pillowcases) and the new weight of each item. 

Cost of disposables

The cost per use for HCTs is a beneficial tool in determining whether disposable or reusable items will provide the optimum value and lowest impact on the operating budget. Sadly, too many purchasing decisions are convenience based rather than cost, quality and outcomes (CQO) based.

During the height of the COVID-19 pandemic, the U.S. was critically short of personal protective equipment (PPE). Many hospitals turned to their health care laundry or rental services for reusable isolation gowns.  

Many hospital EVS departments that had been using disposable wipes found themselves without inventory. They turned to manufacturers, retailers and rental companies supplying microfiber. Many of these facilities settled for inferior microfiber products that are inappropriate for health care facilities. 

Those products do not trap, capture and remove the smallest of pathogens: viruses. In addition, they could not withstand the Centers for Disease Control and Prevention (CDC) laundering guidelines of washing at 160 F for 25 minutes with at least 125 to 150 parts per million of bleach and 160 F drying until dry. The microfiber textiles most hospitals purchased were ineffective and could have potentially contaminated the health care environment due to ineffective laundering.

EVS purchases must follow the CQO purchasing movement. The CQO movement is a positive effort to bring effective methods of purchasing to all disciplines. The campaign does not require that a product be the highest cost or provide the highest rebate if purchased from a group purchasing organization. 

Although listed in CQO format, it is up to each CQO committee to make their recommendations for products based upon their needs, which may be outcomes, quality and cost (OQC), or quality, outcomes and cost (QOC). Although sustainability is not a listed option in making selections (i.e., sustainability, cost, quality and outcomes), it must always be paramount in product and service selections.

The use of disposable incontinence bed pads, disposable pillowcases, and replacing reusable washcloths, warm water and soap with high-cost prepackaged bathing wipes for convenience can lead to problems. 

Typically, one package contains eight disposable wipers — one for each body area to be bathed. At an average cost of 32 cents per wiper, a patient bath will cost a facility a minimum of $2.56. If more disposable cloths are needed, the bathing cost increases by a factor of two because, even if only one other wiper is needed, hospitals typically dispose of opened containers. 

EVS has always agreed with the authorities having jurisdiction that have looked favorably on microfiber flat mops, wipers and dusters, but balked at the perceived cost disparities. Now, based upon flawed reports, many EVS departments are using disposable wipes rather than reusable health care-grade ultramicrofiber (HGUM). Reusable ultramicrofiber wipers and mops are most appropriate and cost-effective for processing an entire patient room. Unfortunately, misinformation has led many EVS departments to use disposable mops and wipes.

Research by the Environmental Services Optimization Playbook (EvSOP^©) indicated disposable wipes cost more to process patient rooms than rental HGUM. They have a much lower efficacy in removing pathogens and cannot trap, capture and remove contaminants as effectively and efficiently as HGUM. 

Disposables are not sustainable; once used, they are discarded. Additionally, the dense plastic containers in which disposable products are packaged are rarely recycled, meaning they too are not sustainable. 

When developing a cost per use for comparison to a disposable item, it is essential to use the average weight of the HCT item after it has been in use for a while. That is because when the HCT is not new, the hospital will be charged on a per-pound basis. It will be for the average weight of the HCT in use, which is generally lower than the weight of the item when it is new (unwashed). That will be a more accurate comparison to the cost of a similar disposable item. 

Sustainable challenge

EVS departments must manage laundry expenses with the goals of sustainability in mind. Sustainability is not just saving cans or cardboard. For EVS departments, it’s a multimillion-dollar challenge that they must face head-on with determination, knowledge and training. 

---

Annual processing cost analysis

The chart above, courtesy of the Environmental Services Optimization Playbook (EvSOP^©) and supplied by the author, is an analysis of the annual total material cost to process each patient room to a hygienically clean state by number of patient rooms (average 296 square feet) within a hospital. 

Disposable products are three times higher in cost than rental of health care-grade ultramicrofiber (HGUM). This does not include the negative impact of increased labor, room turnover time or slower patient progression (throughput). This is due to increased processing time (cleaning and disinfection), wasted steps, effort, energy going back and forth to the environmental services cart, waste containers and need to remove residue left on surfaces from the use of disposable wipes, which negatively impact patient perception of cleanliness. 

Also, according to a study conducted by Daniels Associates Inc., Toronto, disposables increase the amount of physical exertion and energy needed to achieve adequate log reduction because of the wipes’ inability to trap, capture and remove contaminants. They proved a lower exertion rate, less fatigue and muscle strain, and increased productivity with HGUM.

---

John Scherberger, FAHE, T-CSCT, is president and founder of Healthcare Risk Mitigation, Spartanburg, S.C. He can be reached at jfscherberger@me.com.

---

Benefits accrue with reusable textiles

Health care products range from ultra-fine microfibers to comfort in surgical gowns to complex structured incontinence underpads. When these products are available in reusable or disposable alternatives, the well-structured, peer-reviewed data show substantial environmental savings with reusables. 

Across five personal protection equipment (PPE) and related health care products (i.e., surgical gowns, isolation gowns, surgical drapes, cleanroom coveralls and incontinence underpads) the reusable choice savings include 27% to 66% savings for carbon footprint (climate change benefit); 23% to 64% energy savings; and 80% to 96% solid waste (landfill) reduction at the facility. Furthermore, a peer-reviewed published report on 20 other products shows, in all cases, the disposable products create a higher impact on the environment.

An added benefit in decisions to select reusables is that they have a lower annual cost, another significant health care objective. In one recent PPE study of cleanroom garments, this economic savings was about 47%, regardless of facility size or regional location. At the national level, these economic savings would be about $1 billion, directly to the cleanroom bottom line. 

Finally, a recent study by the author of this sidebar article in collaboration with Lynne Sehulster, Ph.D., on the 50-year health care-associated infections (HAIs) safety record for reusables (1970-2020), showed the decision to select reusables had an inconsequential impact on HAI rates. 

In fact, the risk of HAIs from laundered reusables versus all other HAI causative factors was one in 14,900, compared to one in 9,000 chances of being hit by a meteor. For these reasons, the Centers for Disease Control and Prevention concluded the need to establish a health care laundry certification program based on microbiologic testing of cleaned, reusable health care textiles (HCTs) did not appear to be supported by epidemiologic data.

The combined environmental improvement, economic savings and safety record of reusable health care textiles continue to grow in documentation. A better understanding of these benefits should now be more transparent and used in decision-making. In the COVID-19 pandemic, the confidence in reusable HCTs based on these results is important as the demand for reusable HCTs is increasing substantially. 

---

Sidebar by Michael Overcash, Ph.D., co-founder of Environmental Clarity, a firm that has conducted life cycle assessments on incontinent pads, isolation gowns, surgical gowns, surgical drapes and cleanroom coveralls.