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Getting Survey-Ready in 2022: Water Management

Sandy Garcia, RN, BSN, MBA, NHA, CJCP, Certified Black Belt Lean Six Sigma, Certified Change Agent
Senior Director, Care Transformation

I’m writing a series of blogs about getting survey-ready in 2022. To read the first blog about 1135 blanket waivers, click here. To read the second blog about workplace violence, visit: https://qhr.com/resources/getting-survey-ready-in-2022-workplace-violence/. Stay tuned for future blogs on resuscitation and performance improvement.

Joint Commission Survey Readiness: Water Management

In reviewing recent surveys, I have noticed an increase in expectations on water management across all entities. The Joint Commission Standards/Elements of Performance related to water management were updated January 1, 2022. DNV and HFAP are increasing focus on water management, and CMS also requires that you have a water management program in place.

The most prescriptive accrediting body is The Joint Commission, so I want to outline water management requirements as they will explain much of what is necessary and can provide good tools and resources, regardless of which organization accredits your hospital.

Start by creating a diagram

Example diagram mapping water supply sources.

If you are accredited by any deeming authority, they do expect a designated person or team to provide oversight and drive implementation of the program from development through management and maintenance activities.

Your organization’s water risk management plan will be based on the diagram that you create, that includes an evaluation of the physical and chemical conditions of each step of the water flow. The diagram will also identify any areas where potentially hazardous conditions could occur. An example would be highlighting areas where slower or stagnant water may occur (e.g., sinks, showers or toilets that are routinely unoccupied or in temporarily closed areas).

You need to have a diagram that maps:

  • All of your water supply sources, treatment systems, processing steps, control measures and your end-use points and
  • The symbols showing sinks, showers, water fountains, ice machines and all plumbing that comes into the building.

This may be difficult to do internally, so you can opt to use a local agency to work with your facilities team to map this diagram for you.

Running a risk assessment

You will also need to do an evaluation of your patient population to identify patients who are immunocompromised and ensure that you have monitoring protocols and accepted ranges for control measures.

You may refer to the Centers for Disease Control and Prevention Water Infection Control Risk Assessment (WICRA) for Health Settings tool as an example of how to conduct a water-related risk assessment.

Water Management Committee responsibilities

If you are accredited by The Joint Commission, or even if you’re surveyed by another accrediting body or CMS, you’ll want to ensure you have an individual or team responsible for the water management program managing the following:

  • Documenting results of all monitoring activities.
  • Establishing corrective actions and procedure to follow if a test result outside of acceptable limits is obtained, including when a probable or confirmed waterborne pathogen(s) indicates action is necessary.
  • Documenting corrective actions taken when control limits are not maintained.

The key players are facilities, infection prevention and control, and the lab.

The individual or team responsible for the water management program reviews the program annually and also when any of the following occurs:

  • Changes have been made to the water system that would add additional risk.
  • New equipment or at-risk water system(s) have been added that could generate aerosols or be a potential source for Legionella. This includes the commissioning of a new wing or building.

Building the plan

It’s key that facilities come together with infection prevention and control and your designated water management team. Developing a committee charter is a good idea to define what you want to accomplish with assessments. Hospitals should consider incorporating basic practices for water monitoring within their water management programs. This includes monitoring temperature, residual disinfection and pH. Organizations can involve cleaning services and housekeeping staff in stagnant water checks of unoccupied spaces.

A sample table of contents may include:

Water management plan sample table of contents

Protocol should include parameters that are measured, and state what appropriate corrective actions are taken when parameters are out of range. Define what you are monitoring, and if it’s out of range, the plan should outline what you do about it and, as always, make sure it’s documented.

For more information about QHR Health's regulatory readiness services, click here.