TEMPLATE Results of Self-Assessment, and Initial Improvement Plan Environmental Services (ES) Optimization Project Kick Off and Site Visit Event Date: Presenter:

QUESTION 1: Please provide your average ES quality assessment metric(s) for the past 6 months: ATP results Glow Test results HCAHPPS score Other (describe) Response:

QUESTION 2: Do you have a clean accountability guide or checklist to ensure the right surfaces are cleaned and disinfected with the right products by the appropriate person with the right training and tools? Response:

QUESTION 3: What do ES Technicians use to guide their cleaning processes? Facility policy manual Protocol cards on cleaning cart Checklists Other Response:

QUESTION 4: How do you provide new ES Technician training QUESTION 4: How do you provide new ES Technician training? Response: QUESTION 5: How do you provide routine ES Technician training? QUESTION 6: How often do you provide ES Technician training?

QUESTION 7: How many of your ES managers are AHE certified? Response: QUESTION 8: How many of your ES Technicians are AHE certified?

QUESTION 9: Do you have a program or method for recognition of ES Technicians for excellent performance? Response: QUESTION 10: What chemical do you use to clean hospital room floors (e.g. quat, hydrogen peroxide, bleach)?

QUESTION 11: What chemical do you use to clean hospital and clinic room high touch surfaces (e.g. quat, hydrogen peroxide, bleach)? Response:

QUESTION 12: Do you use UV light as an adjunct to manual environmental cleaning? Response: QUESTION 13: What type of cleaning cloths and mops to you use? QUESTION 14: If you use microfiber do you use disposable or re-usable?

QUESTION 15: If re-usable, how are they laundered (what disinfectant QUESTION 15: If re-usable, how are they laundered (what disinfectant? Onsite or contract laundry?) Response: QUESTION 16: How do you clean privacy curtains? QUESTION 17: What resources were used to write your ES program policies?

QUESTION 18: What do you think needs improvement in your facility ES program? Response: QUESTION 19: What do you think your ES program excels at?

QUESTION 20: What are barriers to best practice in your ES Program QUESTION 20: What are barriers to best practice in your ES Program? Response: QUESTION 21: What type of report does ES department submit to Infection Control Committee and how frequently?

QUESTION 22: Do you have an ES Technician recognition program QUESTION 22: Do you have an ES Technician recognition program?? Response:

Initial Improvement Plan http://www.infectioncontroltoday.com/articles/2017/07/success-story-infection-prevention-and-environmental-services.aspx