Location: Vanderbijlpark, South Africa

Work areas: Products, process.

Summary: The goals were to achieve an overall cleanliness score of above 90% during the National Core Standards Assessment, reduce cleaning chemical-related injuries on duty, and to phase-out cleaning products that appear on the Health Without Harm's Chemicals of Concern to Health and the Environment list.

Initial situation

All public health facilities including hospitals are experiencing challenges with both human and financial resources as a result of budget cuts and staffing positions left unfilled. This has led to a decrease in the number of Support Staff (General Assistants) being employed as well as a decrease in cleaning equipment and cleaning materials being procured. 

Sebokeng Hospital’s Environmental Health Department conducts environmental health inspections on a monthly basis as part of their duties. The department identified the following challenges affecting the cleanliness of the hospital: 

• Poor conditions of mops that were dirty and unhygienic.
• Infection Control standards not being adhered to that could lead to cross contamination, for example only one mop being used to clean the entire ward.
• Poorly labeled cleaning chemicals i.e. bleach dishwashing liquid held in the same container thereby creating toxic fumes which led to hospitalization of General Assistants.
• Decanting of cleaning chemicals into non-compliant, unsafe and unlabelled containers i.e. pine gel into a yogurt container.

Alternatives

• The Environmental Hygiene Checklist (a monitoring tool) was implemented to assess the condition of cleaning equipment and dilute cleaning chemicals
• Personal protective equipment was provided to staff to prevent exposure to hazardous chemicals.
• New mops were procured.
• Training was provided to staff to raise awareness on the hazards of chemicals, the need for dilution, and the safe decanting and labeling of products so that no unsafe mixing can occur.

Progress and benefits

In order to improve the cleanliness of the hospital as well as ensure compliance with the various standards and legislation, the Environmental Health Department reviewed the Environmental Hygiene Checklist (monitoring tool) and incorporated standards for assessing the condition of cleaning equipment, dilution of cleaning chemicals as well as the use of personal protective equipment by staff.

Environmental health findings and the conditions of the mops were presented to the Executive Management Committee as well as the Quality Assurance Forum of Sebokeng Hospital in order to measure the extent and level of non-compliance.

A budget was allocated and purchase orders were created for the procurement of mops as well as proper, compliant cleaning containers for the decanting of cleaning chemicals.

On-the-spot trainings were conducted by the Environmental Health Department during inspections in order to discourage the practice of mixing cleaning chemicals, the effects of inhaling toxic fumes and the importance of keeping cleaning equipment in a clean and hygienic state as a way of reducing cross contamination in a hospital environment.

A formal training session was conducted by Kiarah Chemicals (cleaning chemicals supplier) on safety precautions, dilution techniques and cleaning procedures for the General Assistants.

The Environmental Health Department developed and printed labels/stickers with dilution instructions, safety precautions and active ingredients for the cleaning chemicals

Human health benefits:

• The chemical safety training led to a decrease in the number of toxic fume-inhalation cases reported. They decreased in the monitoring period from 10 in the year 2016/2017 to 0 in the year 2017.
• There was also a reduction in the chemical safety incidents reported by General Assistants.
• Cleaning chemical store attendants have been informed and trained on the importance of active ingredients and the role they play in cleaning chemical formulations, ensuring that no unsafe mixing of cleaning chemicals is done, for example ensuring that a container used for one chemical is not used for another incompatible chemical
• General Assistants were also trained on safety precautions, dilution rates and personal protective equipment to be worn when cleaning
• A basin was installed inside the chemical storage area for the decanting of cleaning chemicals in a clean and hygienic manner
• Colour-coded mops were purchased for cleaning different areas of the ward to reduce cross contamination as Infection Control standards stipulate the different places where each mop should be used i.e. blue for cleaning of general ward, red for cleaning of toilet and bathrooms etc. 
• The following cleaning chemicals were identified as appearing in the Health Care Without Harm Chemicals of Concern to Health and the Environment:
• 1-Amino-1.4 dibromoantraquinone: which causes serious eye irritation and is suspected of causing cancer was identified in Handy Andy and Multibac
• 3.3-Dichlorobenzidine: which is harmful on contact with skin, causes allergic skin reaction, may cause cancer, very toxic to aquatic organisms with long lasting effects was identified in Deoblock
• Benzene which is a flammable liquid and vapour, may be fatal if swallowed and enters airways, causes skin irritation, may cause genetic defects, may cause cancer and causes damage to organs through prolonged exposure, was identified in Handy Andy and Multibac
• Chlordane which is harmful when swallowed, is toxic in contact with skin, causes skin and serious eye irritation, is suspected of causing genetic defects, suspected of causing cancer, suspected of damaging fertility in unborn children, causes damage to organs through prolonged or repeated exposure, is very toxic to aquatic life with long lasting effects was identified in Multibac.

Environmental benefits:

• The overall general cleanliness of the hospital has drastically improved according to Infection Control and Environmental Health Departments.
• Positive comments on the cleanliness of the hospital have been received and were noted by the hospital Chief Executive Officer, Hospital Board members, visitors and patients of Sebokeng Hospital Patient Experience of Care (PEC) survey March 2018.
• The chemical safety project has been sustainable as the hospital is able to reuse the compliant and labelled containers over and over again; therefore adhering to the principle of Reduce, Reuse and Recycle.

Financial benefits:

• There has been a decrease in the number of cleaning chemicals being ordered and used by the hospital as properly diluted cleaning chemicals are decanted into properly labeled containers
• Training on dilution and cleaning techniques has assisted in reducing the amount of cleaning chemicals being wasted as cleaners are aware of dilution rates.
• Since the commencement of the project the hospital has realized a savings of R 91211.20 as R 419767. 40 was spent in 2017 (before the project was implemented) and R 4105567. 20 was spent in 2018 ($224,849.85 US dollars.)

Implementation process

• Safe, suitable and compliant 1 liter containers with color-coded lids were procured and used during the decanting of cleaning chemicals.

• Labels/ stickers derived from the Material Safety Data Sheets were developed and printed by the Environmental Health Department with active ingredients, safety precautions and dilution rates which were pasted on the containers.

• Empty containers labeled with the printed stickers are kept in the chemical storage area for refilling and exchanging on a weekly basis.

• New color coded mop heads and new mop sticks were procured and all old mops were replaced. Cleanliness and hygiene of the mops is monitored during Environmental Health inspections and all non-compliant activity is reported.

• The distribution day for cleaning chemicals is every Tuesday and all departments go to the chemical storage area for the collection of different cleaning chemicals that are used. During collection; departments are requested to bring the empty containers so that they can be filled and re-issued.

• The initiative has assisted with stock management as well as with recycling as the same containers are reused.

• Supply Chain and Finance have noted a drastic decrease in the quantities of cleaning chemicals being ordered as more stringent stock control measures have been put into place. To date there has been a saving of R 9179.120 in 2018 when compared to 2017.

Next steps

• The procurement of 1 liter buckets for Pine Gel are still outstanding - to be procured in the 2019 financial year

• Roll out of Chemical Safety to all General Assistants including new appointees.

• Phasing out of all cleaning chemicals that appear on Healthcare Without Harm Chemicals of Concern to Health and Environment such as Mulitbac, Handy Andy and Deo-blocks and replacing them with environmentally friendly chemicals

Information about the organization
Sebokeng Hospital is a regional public hospital in the Emfuleni Local Municipality within the Sedibeng District in Gauteng.

The Hospital is equipped with 800 patient beds including operating theater, intensive care units and TB focal point and has a staff of 18,804. The hospital provides a variety of healthcare services to the surrounding community and it is the referral hospital for Kopanong and Heidelberg Hospitals as well as other Sedibeng local clinics. The area falls within Region B of Gauteng Province.