EVS - Patient Visitation / Cleanliness Evaluation

• Division:

• Housekeeper Assigned to Area:

• Room Number:

• Conducted on:

  Date

• Prepared by:

• Script:
  Hello, My name is:____________________________, I am the, ________________________ of Environmental Services Department here at Barnes-Jewish Hospital. Our Department’s Goal is to deliver the Highest level of cleanliness and excellent customer service to our patients and there family members. If this is a convenient time for you, would you be willing to take a few moments and share with me your impression and experience of our service delivery.

CUSTOMER QUESTIONNAIRE:

• Have you seen your housekeeper today?

  Yes

  No

  N/A

• Was your trash emptied today?

  Yes

  No

  N/A

• Was your floor mopped today?

  Yes

  No

  N/A

• Was your restroom cleaned and disinfected today?

  Yes

  No

  N/A

• Did your housekeeper ask if there's anything I can do before I leave?

  Yes

  No

  N/A

ENVIRONMENTAL QUALITY EVALUATION: (E.Q.E.)

PATIENT ROOM:

• Overbed Table Cleaned?

  Yes

  No

  N/A

• Night Stand Cleaned?

  Yes

  No

  N/A

• Phone Cleaned?

  Yes

  No

  N/A

• T.V Cleaned free of Dust?

  Yes

  No

  N/A

• Picture Frame free of Dust?

  Yes

  No

  N/A

• Overbed Light Cleaned free of Dust?

  Yes

  No

  N/A

• Closet Cleaned?

  Yes

  No

  N/A

• Walls Cleaned?

  Yes

  No

  N/A

• Vents Cleaned free of Lint?

  Yes

  No

  N/A

• Ceiling Cleaned?

  Yes

  No

  N/A

• Door Cleaned?

  Yes

  No

  N/A

• Door Handle Cleaned?

  Yes

  No

  N/A

• Door Frame Cleaned?

  Yes

  No

  N/A

• Waste Can Cleaned?

  Yes

  No

  N/A

• Floors Cleaned?

  Yes

  No

  N/A

• Cubicle Curtain Cleaned?

  Yes

  No

  N/A

• Cubicle Curtain Functional?

  Yes

  No

  N/A

• Room Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• Toilet Bowl Cleaned?

  Yes

  No

  N/A

• Sink Cleaned?

  Yes

  No

  N/A

• Shower Cleaned?

  Yes

  No

  N/A

• Shower Curtain Cleaned?

  Yes

  No

  N/A

• Shower Curtain Functional?

  Yes

  No

  N/A

• Supplies In Place?

  Yes

  No

  N/A

• Floors Cleaned?

  Yes

  No

  N/A

AREAS FOR IMPROVEMENT:

• Nursing?

  No

  Yes

• Facilities Engineering?

  No

  Yes

• Food & Nutrition?

  No

  Yes

• Final Scripting:
  I would like to thank you for sharing your observations with me. We will use this valuable feedback to improve the quality of service we deliver to our patients and there family members. Before I go, is there anything I can do for you?