Mervyn Phipps, an IHEEM Registered Authoring Engineer and Director of Synergistic Solutions Consultancy outlines some of the grey areas around the issue of water safety that might lead to potentially serious and life-threatening breaches on a healthcare estate.
There is no shortage of published articles that repeatedly inform the reader of the statutory and mandatory requirements for managing the safety and hygiene of water systems in our healthcare estate. Yet we all too frequently hear and read of lapses in the adoption of these requirements leading to Legionellosis outbreaks and/or cases of high legionella bacterial counts.
The Health and Safety Executive’s Approved Code of Practice (ACoP) L8 was published in 2013 and was followed by the publication of the Department of Health’s Health Technical Memorandum 04-01 ‘ Safe water in healthcare premises’. These documents provide a mass of information and best practice guidance to enable the Estates and Facilities Professional to understand the requirements of the law and how best to achieve compliance whilst keeping the safety of service users, staff and visitors firmly front of mind.
Ultimately, the duty holder, as defined in both sets of documents, is responsible. However, L8 makes it quite clear that the duty holder should appoint, in writing, a ‘responsible person’ to ensure the water system is operated, and maintained, in compliance with the ACoP. This begs the question; what governance and assurance is provided to the duty holder to enable them to assure the board and service users that the risk is being appropriately managed?
The requirements of ACoP L8 and the technical guidance, HSG 274 should be well understood by now. The more recent HTM 04-01 (2016) may present a different challenge.
This document introduced the concept of the Water Safety Group (WSG) and the Water Safety Plan (WSP). These concepts are not new - The World Health Organisation published documents and guidance on WSPs back in 2011 - and yet some organisations appear to find them a challenge. Is this because they don’t care; consider guidance as a take it or leave it option; or simply don’t understand what is required and how to go about it? My personal experience suggests the WSG and WSP are more widely adopted in the acute sector and not so widely adopted elsewhere.
Joined-up thinking
Recently we have seen the publication of a Memorandum of Understanding (MoU) between the Care Quality Commission (CQC) and the Health and Safety Executive (HSE). The MOU sets out how the CQC and HSE will ensure there is effective, coordinated and comprehensive regulation of health and safety for patients, service users, workers and members of the public.
This document provides clarity on the respective responsibilities of the HSE, CQC and other organisations, such as Local Authorities, with regards to health and safety incidents in health and adult social care services. In setting out typical examples of incidents the MoU clarifies who will take the lead role for incidents involving scalding, cases of legionnaires disease and where there is a complaint that a hot and cold water system is not being properly maintained and there is a risk of the proliferation of legionella bacteria.
It is, as they say not ‘rocket science’, and yet there are organisations who thus far seem unable - or perhaps unwilling - to comply and conform. That is not to say they are not managing their water systems correctly, but inevitably should an incident occur, they will struggle to defend their approach to managing the safety of their water systems.
No silver bullet
The link between temperature and pathogen survival/proliferation is well documented and scientifically proven, thus an engineering solution is clearly efficacious and does not require additional chemicals or complicated equipment to achieve the required outcome.
But what of specialist water treatment systems? What role can they play and what is the best system to ensure water safety?
Whilst every manufacturer or supplier of a water treatment system will extoll the virtues of their particular offering, the reality is that there is no one universal system that can provide a 100% guarantee of efficacy.
Of course, in the right application these systems can help with the control of microbiological pathogens, however, what works in one application may not work in others. The potential impact of using a water treatment system should be carefully considered, particularly if applied to extant installations where there may be material incompatibilities.
There is no doubt that manufacturers of equipment are constantly striving to develop products that help to prevent bacterial contamination and proliferation within water systems. For instance, many modern outlets have the ability to thermally disinfect the cold feed side of the outlet - some are capable of being put through a steam sterilisation process, whilst others have copper or silver coated surfaces.
Some of these solutions result in complex product structure and design, often comprising many individual components. Other manufacturers are moving towards simpler offerings that achieve the same end. Presented with such wide and diverse choice of equipment and solutions, how can the responsible person make a sensible and appropriate decision about what to use for the water systems under their control?
A thorough understanding of the water systems that are installed and operated across the estate is necessary in order to make suitable choices. Attaining an appropriate compromise between user requirements and safety of water systems will continue to be a challenge.
Training
Having access to suitable training is key to understanding the challenges involved. However, the focus of any training provision has to be the required outcome of the training – sufficient knowledge and understanding of the risks associated with water systems in healthcare environments – and not the financial and resourcing input to any training package.
What it should not be is a ‘tick box’ exercise that provides nothing more than a training certificate at the cheapest price and within the shortest timeframe.
HTM 04-01 does not provide clarity in respect of designated roles for the management of safe water systems in healthcare buildings; HTM 00 provides guidance for establishing a suitable management structure and also includes some guidance on training. HTM 04-01 provides detailed guidance on the requirements for training provision for all staff in respect of water hygiene and microbiological control. This includes the need for assessment following suitable training.
Advisors – friend or foe?
HTM 04-01 also provides clarity in relation to the constitution of the WSG. The role of the Authoring Engineer (AE) or independent consultant is included and yet it is apparent that not all healthcare organisations understand the role of the AE or the need to have access to independent, impartial advice in relation to water systems management.
For other specialist systems – Medical Gas Pipeline Systems, HV Electrical systems, LV electrical Systems, Decontamination, and Ventilation systems – this need does appear to be well understood and established. So why not for water systems management?
The Institute of Healthcare Engineering and Estate Management (IHEEM) has established registers for AEs in all specialist areas and this can help in selecting an appropriately qualified, experienced and, most importantly, impartial independent specialist advisor to help the organisation comply with statutory and mandatory requirements, provide assurance to the duty holder and assess the suitability of individuals for appointment to designated roles. Seeking the advice of a qualified, experienced and knowledgeable specialist will be money well spent and in all cases provide an effective route to compliant and safe water systems.
Water – what’s the problem?
To many people water is not an issue – turn on the tap and there it is! However, as many Estates and Facilities Professionals know there is more to it than that. Establishing an appropriate management system for safe water systems is key to achieving a level of compliance that will not only make the systems safe for all service users, staff and visitors, but will provide assurance that safety is a priority.
Definitions
Duty Holder: Employers, those in control of premises and those with health and safety responsibilities for others.
Responsible Person: A competent person, appointed in writing by the duty holder to take day-to-day responsibilities for controlling any identified risk from legionella bacteria. A person with sufficient authority, competence, knowledge of the installation, suitably informed, instructed and trained and their suitability assessed.
Water Safety Group: A multi-disciplinary group formed to oversee the commissioning, development, implementation and review of the Water Safety Plan.
Water Safety Plan: A risk management approach to the safety of water. A living document to be kept under continual review.
