Healthcare Competency Skills/Evaluation Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY EVS Type EVS Tech EVS OR Tech EVS Floor Tech EVS Supervisor Proficiency Scale1 – No Experience / NA 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWhat is the procedure for hand washing/hygiene? 1 2 3 4 What are Standard Precautions? 1 2 3 4 How do you protect yourself from blood/body fluid exposure? 1 2 3 4 What procedure do you follow if a patient asks for your assistance? 1 2 3 4 What procedure do you follow for a needlestick? 1 2 3 4 What should you do if you are cleaning a patient's room and a physician comes in to see the patient? 1 2 3 4 What protocol do you follow if you notice a suspicious person or activities? 1 2 3 4 What procedure do you follow if you find a piece of jewelry while cleaning? 1 2 3 4 What do you do if you miss a punch in the computerized punch time system? 1 2 3 4 What personal protective equipment do you wear when cleaning an isolation room? 1 2 3 4 What procedure do you follow for infectious waste? 1 2 3 4 Where would you find out how to clean up an ammonia spill? 1 2 3 4 How is waste transported to the designated storage areas? 1 2 3 4 What items are contained in the Spill Kit? 1 2 3 4 What procedure do you follow for a major spill? Minor spill? 1 2 3 4 What is the dress code for the Surgical Department? 1 2 3 4 What is the procedure for damp mopping? Dust mopping? 1 2 3 4 What procedure do you follow to clean a bed after a patient has been discharged? 1 2 3 4 What is the grievance process and where would you find it in writing? 1 2 3 4 What changes would like to see in the department/facility? 1 2 3 4 Demonstrates competency in the knowledge of the delivery of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. 1 2 3 4 Demonstrates the knowledge of proper identification and reporting of medical/health care errors. Protects the patient in the event of a medical/health care error resolution. 1 2 3 4 Environmental Services - Able to describe, demonstrate thorough knowledge of:Cleaning and disinfecting patient and non-patient areas 1 2 3 4 Removing regular and medical waste 1 2 3 4 Clean linen distribution and soiled linen pick-ups 1 2 3 4 Emergency housekeeping services 1 2 3 4 Monitoring the interior of the hospital for areas or items needing repair and reporting these items to the appropriate departments for repair 1 2 3 4 Cleaning supplies and chemicals, correct mixing ratios, all containers labeled 1 2 3 4 Proper body mechanics 1 2 3 4 Demonstrates/provides thorough knowledge of cleaning procedures for:Walls 1 2 3 4 Floors, stripping, sealing, buffing 1 2 3 4 Carpets 1 2 3 4 Windows and draperies 1 2 3 4 Beds 1 2 3 4 Furniture 1 2 3 4 Waste containers 1 2 3 4 Bathrooms 1 2 3 4 Equipment 1 2 3 4 Light fixtures 1 2 3 4 Stairs 1 2 3 4 Non-patient areas, i.e., lobby, waiting room 1 2 3 4 Patient care units and departments 1 2 3 4 Special Care Patient Departments (Surgery) 1 2 3 4 Special Care Patient Departments (Labor and Delivery) 1 2 3 4 Special Care Patient Departments (Emergency Department) 1 2 3 4 Special Care Patient Departments (Critical Care Units) 1 2 3 4 Special Care Patient Departments (Central Service) 1 2 3 4 Special Care Patient Departments (Others) 1 2 3 4 Demonstrates/provides thorough knowledge of:Cleaning and daily stocking of cleaning carts 1 2 3 4 Cleaning and daily stocking of linen carts 1 2 3 4 Cleaning of waste disposal carts and dirty linen carts 1 2 3 4 Demonstrates/provides thorough knowledge of cleaning equipment, use and maintenance:Vacuum cleaner and attachments 1 2 3 4 Carpet extraction machine 1 2 3 4 Fan dryers 1 2 3 4 Mop bucket with wringer 1 2 3 4 Facility Environment - Able to locate and/or demonstrate knowledge of:Facility directory 1 2 3 4 Fire Equipment (Alarms) 1 2 3 4 Fire Equipment (Extinguishers) 1 2 3 4 Fire Equipment (Exit doors) 1 2 3 4 Fire Equipment (Oxygen valves and shutoffs) 1 2 3 4 Fire Equipment (Emergency (red) outlets) 1 2 3 4 Department Resources - Able to locate and demonstrate the use of:Environmental Services Policy and Procedure Manual 1 2 3 4 Hospital Policy and Procedure Manual 1 2 3 4 Infection Control Manual 1 2 3 4 Material Safety Data Sheets (MSDS) Manual 1 2 3 4 Fire/Emergency Management Manual 1 2 3 4 Department Specific Reference Materials 1 2 3 4 PI Documentation 1 2 3 4 Others 1 2 3 4 Department Routines - Abel to describe, locate and/or demonstrate knowledge of:Communication System (Bulletin board) 1 2 3 4 Communication System (Logbooks) 1 2 3 4 Communication System (Meeting minutes) 1 2 3 4 Communication System (Ordering supplies) 1 2 3 4 Cultural Factors (Religion) 1 2 3 4 Cultural Factors (Food preferences) 1 2 3 4 Cultural Factors (Family/community relationships) 1 2 3 4 Cultural Factors (Healthcare attitudes/understanding) 1 2 3 4 Cultural Factors (Trust/privacy needs) 1 2 3 4 Cultural Factors (Socioeconomic environment) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Healthcare Competency Skills/Evaluation to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
