Stephen P. Ashkin 812 / 332-7950 SteveAshkin@AshkinGroup

1. Green Cleaning in HospitalsCleaning to Protect Health Without Harming the Environment Stephen P. Ashkin 812 / 332-7950 SteveAshkin@AshkinGroup.com H2E Green Cleaning Presentation

2. The Ashkin Group • Mission: Green the cleaning industry • We do NOT see ourselves at advocates. Rather, we aspire to be “transformers.” • Clients include building owners, contract cleaning services, product manufacturers, policy makers, environmental organizations, and others. Voice:812 / 332-7950 Email: SteveAshkin@AshkinGroup.com Website: www.AshkinGroup.com H2E Green Cleaning Presentation

3. “Never doubt that a small group of thoughtful committed citizens can change the world. In fact, it’s the only thing that ever has.” Margaret Mead H2E Green Cleaning Presentation

4. Overview • The Process of Change • Defining Green and Green Cleaning • The Cleaning Plan • Green Cleaning Opportunities and Examples H2E Green Cleaning Presentation

5. Process for ChangeAdministrative Support • Essential to have top management support for implementing green cleaning • Recommend having a team to come together to make changes in cleaning products and practice • Administrator, president, marketing, community relations • Environmental services, purchasing, infection control, GPO, others What is the business case? H2E Green Cleaning Presentation

6. Process for ChangeRecognize Differing Agendas • Infection Control - cleaning, disinfection • Environmental Services – cost containment, ease of use, efficiencies • Purchasing – group contracts, cost containment • Risk Management – optimize environment, reduce risks, protect patients • Employee Health – protect healthcare workers • Administration – overall performance, community relations Recognize the competition for resources. H2E Green Cleaning Presentation

7. Process for ChangeCreate a Baseline • Who • What products are being used • What do products cost • When • Where are they being used (are the same products used everywhere?) • How • Frequency • Training and communications – how often, issues • Are there other opportunities for improvement H2E Green Cleaning Presentation

8. Process for ChangeWho Is Performing the Cleaning? • In-house Services • GPOs • Contract issues • Out-sourced Services • Contract language • How are supplies purchased • Unions • Different structures have different challenges Consider small, low-risk “pilots” H2E Green Cleaning Presentation

9. Defining Green Cleaning and Green Cleaning Products • Green Products: Products that reduce impacts on health and the environment when compared to similar products used for the same purpose. E.O. 13101 • Green Cleaning: Cleaning to protect health (patients/occupants, staff, administrators, and visitors) without harming the environment. AG H2E Green Cleaning Presentation

10. Define Green CleaningIt’s Not Just About Chemicals • Products • Disposable Janitorial Products (i.e. paper) • Equipment • Procedures • Source reduction and pollution prevention • Safe for patients • Safe for staff (especially product users) • Safe for environment (creates minimal amount of pollution, especially PBT’s) Encourage sustainability H2E Green Cleaning Presentation

11. The Impact of Cleaning on the Environment • 5.0 Billion pounds of Chemicals • 4.5 Billion pounds of Paper • 0.5 Billions pounds of Equipment • 35.0 Billion Plastic Liners H2E Green Cleaning Presentation

12. Impact of Cleaning on Staff (Product Users) Health • 6% of workers injured on the job • Occupational asthma on the increase • 20% are eye and skin burns (chemical exposures) • Muscular/skeletal injuries (ergonomics) H2E Green Cleaning Presentation

13. Impact on Patients and Staff • Nursing homes and assisted living • 3,350,000 residents • 2,000,000 staff (full and part time) • Hospitals • 660,000 patients (per day) • 4,535,000 staff (full time equivalents) • 100,000 hospital trainees • Visitors??? Many are exposed 24 hours per day H2E Green Cleaning Presentation

14. Impacts on PatientsSome Perspective • 50,000 Die in Automobile Accidents • 7,000 Drown • 5,000 Die of Burns • 70,000+ Die of Nosocomial Infections Nine People Every Hour H2E Green Cleaning Presentation

15. Nosocomial Infections • 2,000,000 (About 5.7%) of all Patients Admitted to U.S. Hospitals Acquire These Infections. • 3.8% of Nosocomial Infections are Fatal • 70,000+ People Die Every Year From Nosocomial Infections • Approximately one-third are preventable • $$$$$ This is NOT an indictment of the cleaning industry. We know how to clean. We just need the budget, time and tools to do the job right. H2E Green Cleaning Presentation

16. Cleaning Plans Matter • Evaluate how facility is defined for cleaning purposes • All one level? • Different standards for different areas? • www.astm.org (ASTM E1971-89 Standard Guide for Stewardship for Cleaning Commercial and Institutional Buildings) H2E Green Cleaning Presentation

17. Divide up facility by ‘risk areas” • Typically in a hospital….. • 45 to 65% are Non-critical (low risk) areas • 25 to 45% are Semi-critical (medium risk) areas • 10% are Critical (high risk) areas • An important first step is to evaluate how the “risk areas” are defined and identified. • You can probably reclassify many areas as low risk areas, which in turn can reduce resources, impacts and costs. H2E Green Cleaning Presentation

18. Divide up facility by ‘risk areas” • Non-critical (low risk) • Exterior maintenance • Administration Areas, accounting, records, HR, etc. • Patient registration and waiting areas • Shops, carpentry, mail, printing, materials management • Hallways • Semi-critical (medium risk) • Restrooms (public) • Nursery • Clinics, outpatients, diabetes, respiratory • Rehabilitation, physical therapy, cardiac rehab • Critical (high risk) • Emergency • Labor and Delivery • Morgue • Surgery H2E Green Cleaning Presentation

19. Exterior Building Maintenance(keep the contaminants out) • Monitor pests and weeds • Use local plants adopted for the site • Use mulches and replenish as necessary • Train weed-eater operators not to damage trees • Use ice melters before precipitation begins and use to break bonds to remove by shoveling and plowing (not intended to melt the ice or snow) • Consider closing redundant entrances • Switch from sodium and calcium chloride to potassium and magnesium chloride and don’t over apply • Use environmentally preferable exterior cleaning chemicals and dispose properly H2E Green Cleaning Presentation

20. Entryway Systems and Maintenance(capture contaminants at the entries) • Design all entrances with permanent entry systems or mats • Can be used inside and out • Should be appropriate for climate • Class 1 Fire Retardency • Size approximately 12 feet in length • Develop a plan to track cleaning H2E Green Cleaning Presentation

21. Janitorial Chemical Mixing and Storage Areas • Provide adequate and secure storage areas with appropriate plumbing and chemical dispensing equipment • Have a plan to maintain the dispensers • Provide training on appropriate chemical storage H2E Green Cleaning Presentation

22. Cleaning and Janitorial Maintenance Products • Use Green Seal Certified products • www.greenseal.org • Use low VOC products for other categories • MSDS – full disclosure • Use concentrates with dispensing equipment • Increase the “life” of finishes • Use metal-free floor finishes • Maintain a log of all cleaning activities • Train cleaning personnel H2E Green Cleaning Presentation

23. What About Disinfectants? • All microorganisms are not “bad” and we do not want to sterilize the world! • Some antimicrobial products may increase resistance • Good physical cleaning of environmental surfaces often is enough • All antimicrobials are not “bad” and they are an important “tool in the toolbox” Use disinfectants only where they are necessary and select the appropriate product. One size does NOT fit all needs. Cleaning personnel are smart enough to use multiple products. H2E Green Cleaning Presentation

24. High Risk Continuum Low Chlorine, Phenols, Quats & Peroxide • Chlorine / Sodium Hypochlorite • Very effective antimicrobial • Corrosive to eyes and skin • Damage floor finishes, carpets, clothing, etc. • Respiratory irritant • Environmental concerns from production, contaminants, byproducts • Mixing can create poisonous gas • Phenols • Effective against TB – HBV assumed • Corrosive to eyes and skin • Damage floor finishes and other surfaces • Strong pungent odor – respiratory irritant • Environmental concerns. Possible estrogen mimic. • Quats • Typically not effective against TB or HBV • Less toxic then Phenols – eye, skin and surface corrosivity • Toxic to aquatic life • Peroxide • EPA Sanitizer. Not a disinfectant. • Superior health & environmental profile compared to phenols and quats H2E Green Cleaning Presentation

25. OSHA Blood Borne Pathogen Standard & Body fluids • Fluids covered by OSHA • Blood, semen, cervical solutions, other • Excluded fluids include • Urine, stool, saliva, sputum (unless visible blood) • Must be cleaned with tuberculocidal or hepacidal disinfectant 29CFR 1910.1030 H2E Green Cleaning Presentation

26. EPA Approved Cleaning Solutions For Blood and Body Fluids • Must be hepacidal or tuberculocidal • Purpose of product is to kill hepatitis B, but there was no EPA approved testing methodology, so • Surrogate test is killing of M. tuberculosis - if solution can kill M. TB, it will kill hepatitis B • Chlorine / Sodium Hypochlorite can be used H2E Green Cleaning Presentation

27. Janitorial Equipment • Vacuums meet CRI’s Green Label Program • www.carpet-rug.com • Extraction equipment remove sufficient moisture to dry carpet in 24 hours • Buffers & burnishers with vacuum attachments • Propane equipment have high-efficiency, low emission engines • Auto scrubbers equipped with variable-speed pumps • Battery-powered equipment environmentally preferable batteries (gel batteries) • Ergonomic equipment • Maintain an equipment log H2E Green Cleaning Presentation

28. Janitorial Paper and Other Disposable Products • Comprehensive Procurement Guidelines • www.epa.gov/cpg/products.htm • Toilet tissue: 20% minimum PC content • Paper hand towels: 40% minimum PC content • Industrial wipes: 40% minimum PC content • Facial tissues: 10% minimum PC content • Plastic trash liners: 10% minimum PC content • Processed chlorine free • Large rolls • Hands-free dispensers that limit paper • Micro-fiber cloths, mops and bonnets • Recycled containers, buckets, carts, mats, etc. H2E Green Cleaning Presentation

29. Integrated Pest Management • Landscape to eliminate “safe havens” • Prevent pests from entering the building • Eliminate food and moisture • Monitor for pests before they become a problem • Eliminate clutter • Use the least toxic pesticide possible • Universal notification H2E Green Cleaning Presentation

30. Integrated Pest Management Pesticides are relatively unique toxic contaminants in that they are intentionally put into the environment to accomplish their deadly purpose. Therefore, all pest control programs have a special responsibility to be fully knowledgeable on the impact of these chemicals and through a hierarchy of practice, prioritize the use of preventive, nontoxic or least toxic alternatives. IPM is the process by which this is accomplished. It is also the law – Public Law 92-516, as amended, The Federal Insecticide, Fungicide and Rodenticide Act (FIFRA). The requirements for the management of hazardous materials and the release of chemicals, particularly pesticides, are becoming more comprehensive. These expanding requirements and increasing costs, are creating incentives to reduce the amount of hazardous materials used and wastes generated.   -excerpt from Integrated Pest Management, by Wayne Warren American Society for Healthcare Environmental Services Professional Development Series H2E Green Cleaning Presentation

31. Integrated Pest Management Public concerns, chiefly centering around the inappropriate use of pesticides and the generation of harmful or toxic by-products from waste treatment and disposal processes, clearly indicate the need for a more comprehensive environmental management technique known as Pollution Prevention. A well-managed facility Pollution Prevention Program should incorporate IPM, as well as other proactive opportunities, to address the potential for risk before the “accident” results in adverse environmental impact, cost and/or liability. The facility Pollution Program should seek to minimize the generation of wastes or environmental releases and provide conscious management of all environmental media (i.e., air, water, and land). -excerpt from Integrated Pest Management, by Wayne Warren American Society for Healthcare Environmental Services Professional Development Series H2E Green Cleaning Presentation

32. Occupant Recycling • Establish a waste reduction and recycling program that addresses the separation, collection and storage of materials for recycling including (at a minimum) paper, glass, plastics, and metals • Encourage a high level of recycling by building occupants The success of recycling programs is dependant upon ongoing educations H2E Green Cleaning Presentation

33. “Insanity has been defined as doing the same thing over and over and expecting a different outcome. Negligence is defined as doing the same thing over and over even though you know it is dangerous, stupid or wrong. Now that we know, it’s time for a change. Negligence starts tomorrow.” William McDonough Cradle to Cradle H2E Green Cleaning Presentation

34. Green Cleaning in HospitalsCleaning to Protect Health Without Harming the Environment Stephen P. Ashkin 812 / 332-7950 SteveAshkin@AshkinGroup.com Thank You H2E Green Cleaning Presentation