The Environment of Care and Positive Patient Care Outcomes

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The Environment of Care (EOC) is often a mysterious part of a regulatory survey.  The EOC surveyor is often spirited away during the opening session of a survey along with the facilities cadre of engineers and technicians never to be seen again until the closing session. Coupled with a survey’s final report with EOC findings that cite engineering regulations and descriptions of room pressure gradients, fire pump settings, and Ansul nozzle angles, it is easy to understand how the EOC can be confusing to the average health care facility leader at times.  Those staff members that specialize in the environment of care, maintaining a health care facility, its systems and structure, are critical in creating an environment that promotes patient safety.

What is most imperative is that the organization’s leadership team, especially clinical leaders, appreciate the influence that the environment of care has on patient safety, and ultimately positive patient outcomes.  This will require clinical leaders to recognize the physical environment and how it shapes every patient experience and the delivery of care, including those episodes of care that result in patient harm. Additionally, organizational leaders need to learn how to evaluate adverse events from a systems approach which includes considering environmental influences that may have played a part in setting the conditions that contributed to the event occurrence and/or outcome.

Lessons from the Past

The considerations of environmental influences on patient care have not been limited to the recent past. In the mid-1800s Florence Nightingale developed her Environmental Theory based on five points that an environment must have to influence healing:  clean air and water, basic sanitation, cleanliness and light.[1]  the elements of her theory are as applicable today as they were back in her time. Clean air can be associated with proper pressure gradients, air exchange rates, and maintenance of HVAC systems. Clean water has most recently been a focus by the CDC in regard to controlling the risks associated with waterborne illnesses such as Legionella. Basic sanitation is addressed in modern times through a focus on separation of clean and dirty items, effective waste disposal and addressing other environmental sources of infection. Cleanliness would be addressed through proper hand hygiene, sterile technique, and addressing other person centric sources of infection. The benefits of adequate lighting can influence patient mood, safety and security, and aiding staff in performing tasks such as reading medication labels and conducting patient assessments and procedures where visualization is critical to safe care.  Even though Florence Nightingale was limited in addressing her challenges without modern facilities, systems, and science, her recognition of environmental factors impacting patient care outcomes led to dramatic changes in the organizations where she worked which directly contributed to saved lives and decreased suffering.

Today, the condition of health care facilities in the U.S. have greatly improved since Florence’s days in the field. However, the risks that an unsafe environment poses to positive patient outcomes are very real as they were in her time.  Health care organizations are struggling with maintaining adequate staffing, including environmental services staff, which puts a greater strain on maintaining cleanliness and sanitation.  Short staffing of clinical resources has resulted in the development of shortcuts in patient care which often are associated with the environment putting patients at greater risk for infection or injury.  Additionally, the overall aging of health care facilities and the struggles with maintaining their infrastructure and systems can contribute to unwanted environmental influencers on safe patient care.   It's imperative that health care leaders recognize these struggles and implement mitigating actions to address them.  Accreditation organizations are increasingly citing the shortcomings of leadership teams in providing oversight and response to environmental risks.


  • Ensure that all staff understand and appreciate the environment of care’s influence on providing safe patient care. This could include a section in your onboarding and annual refresher training on the EOC, how it can impact on patient care, and how staff plays a part in supporting the EOC. Be sure to include the medical staff in this training, addressing their role as a clinical leader. Consider role-based training for the EOC especially for those specialized areas such as the OR, behavioral health, sterile processing department, and other areas that involve high risk patient care.
  • Establish an educational program for facilities teams as to the clinical aspects of the environment of care. For example, ensure building engineers understand what a ligature risk is and how that may be used by a patient for self-harm. Our Consultants have made numerous observations where facilities teams are the sole members of the ligature risk assessment group and there is no representation of clinicians who may have special insight into how patients may use environment risks to harm themselves.
  • Establish and maintain a robust EOC deficiency reporting system where staff can easily report concerns to the facilities team for mitigation. It's important that the health care team is provided feedback regarding time frames for repair or response. This will provide them confidence in the reporting system and help the facilities team in creating a cadre of staff members who will report building deficiencies.
  • Develop tools for clinical leaders and managers that provide guidance on EOC requirements for their specific clinical area. This could include job aids, signage, and environmental rounding guides. Ensure that clinical leaders and managers are provided education and training specific to their role in supporting the EOC. Building engineering teams should also consider including clinical leaders in discussions and rounding events regarding the EOC to both train them as well as to help support transparency.
  • Ensure that the EOC is considered as a factor in the prevention of hospital acquired infections, medication errors, and patient falls, just to name a few. According to the AHRQ, these patient safety issues were found to have been strongly influenced by environmental factors during their research into the EOC impacting on patient safety[2].  Ensure to include plant engineering/facility staff during root cause analysis events and other patient safety prevention or event discussions to ensure that influencing factors from the EOC are considered.
  • Include data regarding the EOC in your organizations quality assurance and performance improvement program. This could include trending and addressing risks discovered during environmental rounding, measuring responsiveness in addressing reported EOC deficiencies, and reporting status in maintaining proper air pressure gradients, temperature, and humidity levels in critical and semi critical areas.
  • Establish and maintain an organized EOC rounding program that includes participation by leaders and middle managers, clinical and non-clinical personnel. This program should be conducted with a degree and frequency that supports identification and mitigation of deficiencies. Rounding should ensure focus on those high-risk concerns in your critical and semi critical locations such as behavioral health, pediatrics, perioperative areas, and special procedure areas. Involve your infection control and prevention team during these rounds. Findings from your rounding data should be trended and tracked for both short term improvements and the development of long-term interventions.


The environment of care can present a clear risk to positive patient outcomes if not considered as an influencer on patient safety. Leaders, especially medical staff, must ensure that they educate themselves as to how the EOC plays a part with patient harm prevention.  With an organized and proactive approach to maintaining a safe environment of care, and shared understanding of what creates risk, health care teams will ensure that their patients are protected.


[1] McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p

[2] Joseph, Anjali & Malone, Eileen. (2012). The Physical Environment: An Often-Unconsidered Patient Safety Tool. AHRQ PSnet.

To learn more about the Environment of Care contact the C&A team at 704-573-4535 or email us at

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