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

2. 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:

3. 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:

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

5. 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?

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

7. 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)?

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

9. 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?

10. 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?

11. 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?

12. 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?

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

14. Initial Improvement Plan