The Blue Cottage Blog

Out of Sight, but Not Out of Mind – the Importance of the Basement Dwellers

by on June 4, 2015

In my experience working with different hospitals, I sometimes find myself wandering corridors where I get the feeling I’m somewhere I shouldn’t be – in areas with cinder block walls, very few windows, and usually concrete floors. Most commonly this happens when I’m in the basement on my way to meet with client team members who make up the departments commonly known as the “basement dwellers.” These groups may include facilities, nutrition, health information management, housekeeping/environmental services (EVS), or many other support services departments.

Although these groups often get placed in the subterranean areas of a health system, not in high-visibility real estate, it’s important to acknowledge their impact on a hospital’s ability to achieve its vision, mission, and bottom-line. After all, much of what hospitals provide to patients falls outside the realm of medical and surgical services, and patients and their families are beginning to have high standards for it all. By efficiently staffing and operating these services, a hospital keeps its clinical staff focused on clinical tasks and puts resources in place that specialize in delivering those services.

Let’s start with an example pertaining heavily to patient satisfaction. What comes to mind if you imagine the stereotypical hospital meal tray? For me, it’s some sort of unidentifiable, rubbery meat next to a clump of overcooked greens with a fruit cup or Jello® on the side for dessert. According to NPR.Org’s The Salt, hospitals world-wide are stepping up their food game thanks in part to social media outlets giving patients a platform to voice their opinions (read as: disgust) about their dining experiences while staying at the hospital1. Beyond patient experience, though, improving nutritional care is on the agendas of many hospital executives as a way to lower costs through better patient outcomes across the care continuum. One example cited a health system’s budget neutral strategy to replace meals with healthier options, and then implement discharge instructions that explained to the patient how to replicate those choices at home, aiming to decrease complications that may be partially exacerbated by unhealthy or inadequate diets2.

Food 1

Figure 1. Canadian hospital’s inpatient meal. Source: NPR.Org’s The Salt.

Nutrition services is just one way non-clinical services can actually make an impact on quality of care – Environmental Services is another. Patient expectations for a clean room and facility spaces seem pretty obvious, and there are several performance indicators tied to EVS that prove its value in ensuring better health outcomes by preventing hospital acquired infections, so this is clearly a service that needs to be executed successfully. It’s important to think about how staffing this particular service can impact a hospital’s operating budget. With labor being the biggest cost associated with environmental services, it is critical that the staffing model be carefully designed based on analysis of a hospital’s size and volume to ensure the optimal amount of staffing is budgeted. Using productivity benchmarks, cleanable square footage, and patient volumes, optimal staffing should be a clear cut mathematical calculation to get to that optimal number, avoiding emotional or qualitative opinions of hospital managers3. Taking an analytical approach such as this can help other support services departments as well to both justify and comply with a realistic budget.

HFM Stat

Figure 2. Environmental Services productivity benchmarks. Source: Health Facilities Management Magazine.

Some health systems have found cost savings by outsourcing these analyses and execution of support services operations; vendors who specialize in providing these services may be able to more efficiently deliver, cutting costs for the system. The trend makes a lot of sense, given current efforts in the industry to implement every conceivable cost savings mechanism in response to reimbursement incentives. And if a vendor can assimilate into the health system’s culture and adopt its values and mission as its own, all the better. I have worked with hospital support services groups for months before realizing that they were not, in fact, direct hospital employees. The sense of commitment and pride shown by a vendor working within the walls of a health system increases the overall culture of excellence in service for all staff, be they vendor or direct employees.

Some experts predict that this trend in increased outsourcing will not last. As the trend of mergers and acquisitions continues and systems grow into bigger entities, these experts claim that insourcing may come back into prevalence since bigger systems will have more resources to effectively run support services departments. Not only that, but they suggest that by investing in creating a state of the art internal support service department, a health system may find itself in a position to offer those services to other hospitals in its region – a different type of outsourcing performed by one hospital for another. If this hypothesis holds true, the hospital leadership of today cannot simply choose to ignore support services capabilities as indefinitely outsourceable, but must begin to think strategically about whether their organizations could fill a demand in the future marketplace of healthcare.

Take another walk down a basement hospital corridor with these concepts in mind – the windowless spaces and hidden wings these departments occupy don’t usually do justice to the value they bring to the system as a whole. Just because these departments are out of sight, don’t let them be out of mind.


1Wyckoff, Whitney Blair. “Around The World in 8 Hospital Meals,” NPR.Org. The Salt 19 September 2014. Web 4 June 2015. <>

2Vesely, Rebecca. “Hospitals Put Nutrition on the Front Burner,” Hospitals & Health Networks Magazine. Online Post 11 March 2014. Web 4 June 2015. <>

3Jensen, Rock. “Environmental Services Staffing Methodologies,” Health Facilities Management Magazine. Online Post 7 January 2015. Web 4 June 2015 <>

Tagged: , , , , , , ,

Leave a Comment