Become a Part of Patient Care

Every weekday at 7:30 a.m., a small gathering on an inpatient unit shapes the fate of every patient on the floor.

The attending physician, charge nurse, pharmacist, case manager, and social worker cluster around the nursing station. They run the list. They discuss who is going home, who is not, who needs a family meeting, and who is stuck waiting on a bed.

If you have practiced hospital medicine for any length of time, you have watched that meeting grow. Pharmacists joined to catch medication errors. Case managers joined to coordinate discharges. Social workers joined to address what medicine alone cannot fix.

But according to Dr. Omrana Pasha-Razzak, MD, MSPH, an academic physician and epidemiologist at the City University of New York (CUNY), environmental services (EVS) has never been at that meeting.

That is a serious problem that Dr. Pasha-Razzak insists needs to be addressed.

"The person who spends the greatest number of minutes with a patient in their room is not a nurse. It is not a doctor. It is the environmental services worker. And they are not part of the interprofessional team," Dr. Pasha-Razzak said at the ISSA Healthcare Surfaces Summit on Tuesday, May 5, 2026.

The structure built-and left unfinished

The concept of interprofessional practice has been around since the 1960s, but it took recognition of a crisis to move it from academia into daily hospital operations. In 1999, the Institute of Medicine (IOM, now the National Academy of Medicine) published the report To Err is Human: Building a Safer Health System, documenting tens of thousands of preventable deaths caused not by clinical ignorance, but by the gaps between clinical silos. The IOM's response was to call for healthcare delivery organized around interprofessional teams, and hospitals responded.

First came pharmacists, inserted into the huddle to catch dosing errors. Then case managers. Then social workers. Each addition met resistance. Each eventually took hold. The 7:30 a.m. huddle is now recognized as a solid cornerstone of safe, coordinated care.

But EVS has not been brought into that structure. And the cost of that omission is measurable.

What your team knows that EVS does not

Consider the information that circulates inside your morning clinical huddle on any given floor. Your team knows which patient in room 817 has Clostridium difficile (C. diff). You know which patient coming up from the emergency department is neutropenic, with an immune system compromised by chemotherapy, and needs a specific room preparation before arrival. You know which patients have Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), or other contact precautions in place. You know who is being discharged that afternoon and who will be held until the following morning.

EVS workers, by contrast, often learn about isolation precautions only when they arrive at a room and see-or do not see-the sign on the door. They learn about discharges when the patient is being wheeled out. They have no advance notice of the infectious history of the room they are about to turn over, even though incoming patients face a 2.14 times greater risk of hospital-acquired infection when placed in a room previously occupied by an infected patient.

This is not a failure of EVS. It is a failure of the system that was never designed to include them.

"Better communication-not more staffing, not more money, not more people cleaning-drove a 25% drop in C. diff cases on two oncology units when the clinical team began sharing real-time feedback with environmental services workers," Dr. Pasha-Razzak said.

The patient flow problem

There is another dimension to this that hospital administrators understand in economic terms, even if they have rarely framed it as an EVS problem. Boarding admitted patients in the emergency department is not merely an inconvenience. For severely ill patients held there more than six hours, studies show a 10% increase in mortality rates, along with longer intensive care unit (ICU) stays and higher rates of adverse events. Emergency departments cascade delays from the top down; e.g., a patient waiting for a clean inpatient bed blocks a bed in the emergency department (ED), delaying care for the patient waiting in the waiting room.

The single largest lever in that equation, after clinical decision-making, is how quickly you can turn over a room once a patient is discharged. And turnaround time depends almost entirely on communication between the clinical team and EVS.

One Lean study found that turnaround time dropped from 130 minutes to 65 minutes when communication between the clinical and environmental teams improved. A study tracking charge-to-readiness time saw a drop from 149 minutes to 105. Perhaps most strikingly, one hospital found that 60% of delays in outflow from the emergency department were caused by communication failures between the clinical team and EVS. Providing both teams with walkie-talkies saved nearly 800 hours of boarding time over nine months.

The expected discharge date-known by your clinical team from the moment of admission and discussed at the huddle every single day-is routinely not communicated to the EVS team until the moment the patient is physically leaving the room. That is a structural problem, and it has a structural solution.

Respiratory risk and the room itself

Infection prevention is the domain where the evidence for EVS inclusion is strongest, but it is not the only domain.

Patients you admit for asthma exacerbations or chronic lung disease are sometimes exposed during their stay to cleaning products known to trigger or worsen respiratory symptoms. Your clinical team, which decided the patient needed hospital care for a pulmonary condition, never communicated that information to the team responsible for the products used in that patient's immediate environment. There is, at present, essentially no research literature on the effects of those exposures on clinical outcomes. The variable has simply never been measured.

Falls from wet floors represent another understudied intersection of environmental and clinical work. The contribution of EVS staffing models and workflow to fall risk remains largely unmeasured because EVS has been treated as an unmeasured variable across nearly every domain of clinical research.

The workforce that bears the burden

The medical literature has called hospital EVS workers "forgotten" and "invisible." The Journal of Hospital Medicine used that phrase in 2022. A Global Health Action (GHA) journal article used it in 2019. The demographics explain why: roughly 70% of hospital EVS workers are women, 75% come from minority communities, and 50% are foreign-born. Turnover runs between 40% and 60% annually.

These workers absorb real occupational hazards. Research on the cleaning workforce broadly, not only in hospital settings, shows a twofold increased risk of lung cancer, lung function decline equivalent to smoking 10 to 20 cigarettes a day among non-smokers, and exposure to an average of 110 kilograms of hazardous chemicals per year. Reproductive harms associated with specific chemical classes-parabens, phthalates, glycol ethers-are documented in the cleaning workforce literature.

The people who bear the greatest physical risk from the work of infection prevention are the same people who are structurally excluded from the clinical governance structures that define how that work is done.

Barriers that are not new

None of this should surprise you if you have watched interprofessional practice evolve over decades. Every time a new professional category has been brought into the clinical huddle, the same forces have pushed back: hierarchy, language, credentialing gaps, and the structural misalignment between teams.

Status is the most persistent barrier. Physicians-particularly a generation ago-were not accustomed to being challenged at clinical rounds. That culture has improved substantially. Today, a physical therapist or social worker can tell an attending physician that a discharge plan is unrealistic and be heard. But that cultural shift has not extended to environmental services, in part because EVS workers have never been given a seat at the table from which to speak.

Language is the second barrier. The clinical huddle operates in English. Medical records are in English. A workforce that is majority first-generation immigrants and frequently non-English-speaking faces an immediate structural disadvantage in any communication framework designed around English defaults.

Training and credentialing present a third challenge. Every other professional who joins your clinical team arrives with formal credentials earned before their first patient interaction. Job listings for hospital EVS positions routinely advertise that no prior experience or training is required. Workers may operate for years without a formal framework connecting their actions to a clinical context. They learn about isolation precautions by reading door signs, when the signs are posted, and when they have not fallen off.

Finally, there is the structural misalignment between clinical and facilities systems. EVS sits in the facilities hierarchy. Clinical teams sit in the clinical hierarchy. The two lines currently converge only at the C-suite level, at the point in the organization farthest from the patient room.

The governance gap

Since 2024, both the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission have issued updated regulations explicitly naming environmental services: EVS should do this. EVS will be monitored for that. But no parallel structure has been created to include EVS representatives in the governance bodies that set those standards and interpret their implementation.

Advisory organizations-the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO)-do call for EVS inclusion in clinical governance. They lack enforcement authority. The Joint Commission and CMS have enforcement authority and have been silent on questions, such as whether EVS should be a standing member of infection control committees rather than an occasional guest.

That gap between consensus and regulation is where reform is needed.

What evidence-based inclusion looks like

According to Dr. Pasha-Razzak, two pilot models are worth testing.

1. Unit-level: Place an EVS representative as a standing member of the daily huddle on one or more inpatient units, and systematically evaluate outcomes, such as turnaround time, boarding hours, adherence to isolation precautions, and fall rates. The intervention is not more money or more staff. It is communication that is structured and consistent.
2. Governance-level: A standing EVS seat on the infection control committee, analogous to the seats held by pharmacy, microbiology, and information technology. Not a guest. A member. With the authority to shape not only what gets monitored, but also how workers are trained, by whom, and to what standard.

You need to co-design both pilots with EVS workers from the start. Implementation science has a term to describe characteristics such as the quiet assumption that the judgment of the people doing the work is not worth seeking. It is called an inner context determinant-a property of the setting that will shape whether any implementation strategy survives contact with the real world. You must name that assumption and address it directly. Environmental services workers spend more time in a patient's room than any other hospital professional. Their knowledge of that room is clinical knowledge, whether your clinical team has acknowledged it or not.

"The person with the greatest authority in hospital decision-making is the one farthest from the patient. The person closest to the patient has the least authority. That is the paradox we need to address," Dr. Pasha-Razzak said.

The huddle you need

The morning huddle has been one of medicine's most consequential structural innovations of the past 30 years. It is where you coordinate care, surface delays, and name risks before they become harms. It was built incrementally, discipline by discipline.

The work of bringing environmental services into interprofessional practice is the same project, just decades overdue. The data supporting it is there, in quality improvement literature and in the practical logic of anyone who has watched a clean room sit empty while a patient waits downstairs.

What you still need is implementation: the pilot studies, the governance structures, the co-designed training frameworks, and the cultural work of recognizing that the person with the mop has clinical knowledge worth acting on.

And your huddle should include everyone.