<p> Page 1 of 5</p><p>Title: Utility Systems Annual Evaluation</p><p>Effective Date: Reviewed : Revised: Function: Environment of Care</p><p>Annual Performance Evaluation Utility Systems Management Plan 2009</p><p><<This is a sample format and text for the conducting the Annual Evaluation for the Utility Systems Management Plan (EC.04.01.01). The Reviewer should evaluate the Scope, Objectives, Performance, and Effectiveness of their program based on the information for the previous year. Use this Evaluation to develop the Management Plan for the next year. Be sure to give an “evaluation statement” for Scope, Objectives, Performance, and Effectiveness >></p><p>Reviewer: <<assigned person >></p><p>Review Date: <<Date>></p><p>Review of Program Scope </p><p>Scope Statement {Include Scope Statement from the Management plan being evaluated}</p><p>The Utility Systems Program is designed to assure design and installation of appropriate utility systems equipment to support the medical care processes of Facility Name. The program is also designed to assure effective preparation of staff responsible for the use or maintenance and repair of the equipment support a safe patient care environment at Facility Name by managing risks associated with the operation and maintenance of utility systems. The plan includes processes for selection, operation and maintenance, and training designed to assure safe, effective performance of utility systems. 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.</p><p>The program is applied to the Main Campus and area clinics of Facility Name.</p><p>Evaluation: {include statement of scope, such as below}</p><p>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 </p><p>0ddea868224f71bef20d055012b3dbce.doc Page 2 of 5</p><p>Title: Utility Systems Annual Evaluation</p><p>Effective Date: Reviewed : Revised: Function: Environment of Care</p><p> program.</p><p>0ddea868224f71bef20d055012b3dbce.doc Page 3 of 5</p><p>Title: Utility Systems Annual Evaluation</p><p>Effective Date: Reviewed : Revised: Function: Environment of Care</p><p>Review of Program Objectives {Include “Objectives” listed in Management Plan. Indicate if the Objective was “met” or “not met” with a √. These are a few examples}</p><p>Not Adjusted Objective / Objectives Met Met Action Plan</p><p>0ddea868224f71bef20d055012b3dbce.doc Page 4 of 5</p><p>Title: Utility Systems Annual Evaluation</p><p>Effective Date: Reviewed : Revised: Function: Environment of Care</p><p>Review of Performance</p><p>Performance Measures {List performance measures identified in Management Plan}</p><p>1. <<performance measure>> a. Year average is __ % b. Threshold is __% c. Performance is <<acceptable or unacceptable, and stable or unstable>></p><p>2. <<performance measure>> a. Year average is __% b. Threshold is __ % c. Performance is <<acceptable or unacceptable, and stable or unstable>></p><p>See attached data {Insert data or attach Spreadsheet of data at the end of Evaluation}</p><p>Evaluation of Performance Measures {Analysis of performance such as follows}</p><p>The performance measure were <<List>></p><p>Review of Program Effectiveness</p><p>This program was considered generally effective, but the citation found during environmental tours needs to be improved.</p><p>Planning Objectives for 2010 {Include some goals for next year that could become “Objective” in the revised Management Plan}</p><p>1.</p><p>2.</p><p>3.</p><p>0ddea868224f71bef20d055012b3dbce.doc Page 5 of 5</p><p>Title: Utility Systems Annual Evaluation</p><p>Effective Date: Reviewed : Revised: Function: Environment of Care</p><p>Planning Performance Measures for 2010</p><p>0ddea868224f71bef20d055012b3dbce.doc</p>