Annual Performance Evaluation

Environment of Care Program: Utility Systems

Reviewer: ______

Review Date: <Date>

Review of Program Scope

The review of the scope is based on a comparison of actual operating experience to the program intent. . The scope defines the areas the program includes for management, and the kinds of services provided.

The Utility Systems Management Program is designed to assure design and installation of appropriate utility systems equipment to support the medical care processes of. The program is also designed to assure effective preparation of staff responsible for the use or maintenance and repair of the equipment. Finally, the program is designed to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planed maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff.

The program is applied to <Facility Name>.

After careful evaluation of the utility management program, no changes to the facilities served or the programs provided were made during the past year. The scope still accurately reflects the intent of the program.

Review of Program Objectives

Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate EC program manager(s) review the objective to determine what needs to be done to meet it during the next year. Objectives can be added, deleted, or modified. The action required to address each change is indicated in the last column of the table.

Objectives

/ Met / Not Met / Adjusted Objective / Action Plan
Operate utility to provide a safe, comfortable patient care environment. / √
Assure operational reliability of utility systems by performing recommended maintenance. / √
Reduce incidents that result in unplanned failures or interruptions. / √
Identify opportunities to improve utility system performance. / √ / Discovered that the medical vacuum is not operating to full capacity. The unit will be rebuilt by end of year <Year>.
Train all staff to use utility systems appropriately, including appropriate response to failures or disruptions. / √
Review all Engineering policies and procedures to assure compliance with all TJCrequirements. / √

Review of Performance

The review of performance evaluates the effectiveness of the current performance measures in providing EC managers with information that can be used to adjust program activities to maintain performance or to identify opportunities for improvement. The review also evaluates the effectiveness of any performance improvement projects related to the program.

*Current Performance Measure(s) (list)

  1. Percentage of completed PM’s
  2. Weekly test of the emergency generator
  3. Annual inspection of electrical panels

*Summary of performance reports for the last 12 months.

  1. The cumulative average for completed PM’s was 98%
  2. The cumulative average for weekly generator tests was 100%
  3. The annual percentage of completed electrical panel inspections was 100%

1.Performance is stable, sustainable, and acceptable: X

2.Performance is stable, sustainable, and unacceptable: _

3.Performance is unstable: _

*For 2 or 3 - identify major performance issues:

None Noted

Review of Program Effectiveness

Program effectiveness is evaluated by comparing the review of the program scope to current needs and stated objectives of the program with measurements made related to stated performance measures. Effectiveness is determined based on how well the scope fits current organizational needs and the degree to which current performance met those stated objectives.

This program was found to be fully effective.

Planning Objectives for <Year>

  1. Reevaluate current performance measures to determine new indicators of measurement.
  1. Replacement of filter core for main cooling tower.
  1. Receive approval for allocation of resources to replace he current medical vacuum pump.
  1. Revaluate all Engineering processes to ensure compliance / preparation for our next TJC survey.

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