Information

  • Division:

  • Housekeeper Assigned to Area:

  • Room Number:

  • Conducted on:

  • 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?

  • Was your trash emptied today?

  • Was your floor mopped today?

  • Was your restroom cleaned and disinfected today?

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

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

PATIENT ROOM:

  • Overbed Table Cleaned?

  • Night Stand Cleaned?

  • Phone Cleaned?

  • T.V Cleaned free of Dust?

  • Picture Frame free of Dust?

  • Overbed Light Cleaned free of Dust?

  • Closet Cleaned?

  • Walls Cleaned?

  • Vents Cleaned free of Lint?

  • Ceiling Cleaned?

  • Door Cleaned?

  • Door Handle Cleaned?

  • Door Frame Cleaned?

  • Waste Can Cleaned?

  • Floors Cleaned?

  • Cubicle Curtain Cleaned?

  • Cubicle Curtain Functional?

  • Room Organized?

PATIENT RESTROOM:

  • Toilet Bowl Cleaned?

  • Sink Cleaned?

  • Shower Cleaned?

  • Shower Curtain Cleaned?

  • Shower Curtain Functional?

  • Supplies In Place?

  • Floors Cleaned?

AREAS FOR IMPROVEMENT:

  • Nursing?

  • Facilities Engineering?

  • Food & Nutrition?

  • 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?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.