A call for multidisciplinary competence in water safety

The UK government has announced that five hospitals constructed mostly using reinforced autoclaved aerated concrete (RAAC) will be rebuilt by 2030 as part of the New Hospital Programme, to ‘protect patients and staff safety’. The five hospitals are Airedale in West Yorkshire, Queen Elizabeth King’s Lynn in Norfolk, Hinchingbrooke in Cambridgeshire, Mid Cheshire Leighton, in Cheshire, and Frimley Park in Surrey. This is on top of two of the worst affected hospitals, West Suffolk Hospital in Bury St Edmunds, and James Paget Hospital in Norfolk.

The NHS has asked the government to prioritise the rebuilding of these hospitals given the risks they pose to patients and staff — the full extent of which has come to light since the New Hospital Programme was first announced in 2020. These new assets need to be designed and built with patient safety as the principal, immovable priority. Nowhere is this more pertinent than with systems and equipment utilising water, for which the design, construction, and operation of the healthcare built environment is a serious risk factor. Hot and cold water systems need to be planned, built, and maintained correctly to minimise opportunities for contamination, and staying on top of every stage of the project is a near-impossible task that Water Safety Groups (WSGs) will always struggle to have a complete overview of. This is why a focus on education and specific practical competencies that may affect water safety must flow right from the beginning of the project through every stage of its lifecycle if we are to prevent contamination of water systems from occurring.

Competence isn’t just about delivering more training; rather, all stakeholders involved in the design, build, and maintenance processes need to be competent for their duties. They also need to be able to demonstrate these competencies via good, well-kept records. It isn’t just about knowing the risks; it’s about understanding how they relate to a contractor, cleaner, or clinician’s specific job role, and applying best practices across a range of different scenarios. BS 8680:2020, Water quality — Water safety plans — Code of practice contains some very helpful advice for the design process, and for checking the competency of contractors and service-providers.

Need for a multidisciplinary approach

Another area where the need for this detail regarding competence has been expanded is in risk assessing for Pseudomonas aeruginosa, for which a new British Standard (BS 8580-2: 2022) was introduced. This standard, which was discussed at Armitage Shanks’ Water Safety Forum, makes clear the need for a multidisciplinary team approach to risk assessing the clinical environment, backed up by a living Water Safety Plan that operates and evolves based on continual feedback. The new standard is also intended to address risks to patient safety that may arise during the commissioning and procurement stages of building design and refurbishment.

Designing a new facility with sufficient handwash basins in the right place was highlighted as an illustrative example of the need for broad knowledge, excellent communication, and proven competence. New assets are often designed with too many handwash basins, meaning that some are left unused, thus increasing the risk of water stagnation and contamination. In this case, it’s about finding the right balance between the need to encourage hand hygiene compliance without over-provision. This question demonstrates that, for designers, specifiers, and contractors, the right decision often isn’t always the most intuitive, and establishing the competence and confidence to put patients first requires input from clinicians and healthcare staff at the earliest stage. It also requires challenging some of the old guidance, which has now been superseded by newer research.

Considering the breadth and complexity of these projects, this example is just one of a vast number of decisions that must be carefully examined from the perspective of water safety. Communicating with and educating stakeholders on this scale, and at the level of detail necessary, was another challenge that emerged during the Water Safety Forum — examples of tasks such as assembling pipework, the positioning of elbow-operated tap levers, and application of sealant to basins, all have serious implications for water safety risk.

It is not possible to have clinical staff or Water Safety Groups looking over the shoulder of every contractor at all times, and it’s here that targeted education and training can assist contractors in understanding how important their role is, and building the competence needed to identify and mitigate risks. There needs to be a ‘no job too small’ approach to every task, and some basic questions that everyone working on a project should be able to answer, e.g.

Can this task be performed incorrectly?
What are the consequences for patients?

The multidisciplinary approach should extend to manufacturers, who need to proactively add their expertise to help answer these questions. Installation instructions for relevant products must be created from a patient care perspective, according to both where and how they will be used. Again, there is an argument for introducing WSGs at an even earlier stage, ideally before a healthcare-focused product design is signed off for manufacture. If performed correctly, this is an opportunity for collaboration between manufacturers and WSGs, and allows both to add to their expertise, and ultimately their competence.

A work in progress

The vast majority of existing NHS assets aren’t brand new, and patient safety depends on their safe maintenance and operation, as well as engineering best practice being implemented and checked. Establishing competence in a working healthcare environment, rather than building on a static design, is an entirely different proposition, and there are opportunities as well as challenges.

Achieving a consistent level of competence across all the staff working in these facilities has become all the more difficult with job vacancies at record levels, and almost a third of staff coming from service delivery partners. There are anecdotal reports of hospital staff having to give contractors off-the-cuff lessons on best practice when their training hasn’t been adequate. Here, again, the value of the multidisciplinary approach is clear, but so is the difficulty of establishing the same level of competence and urgency across disciplines — what might be second nature to one job role will be challenging and new for another, so feedback has to flow in both directions.

Free on-site training offered

The Water Safety Forum was advised that to help combat these potential issues, and develop competencies, Armitage Shanks offers free on-site training to NHS Trusts, highlighting key information and best practice guidance for its Markwik range of thermostatic taps. An advantage of working closely with employees is that it’s possible to hear and respond to their feedback. Existing ways of working can be reviewed and improved faster, and new solutions tested and implemented, rather than having to wait for long periods before seeing the benefits of new approaches. For example, University Hospital Southampton NHS Foundation Trust has implemented a Water Action Group (WAG) (that reports to its WSG) to examine water sampling results and current hygiene procedures as they happen, and quickly trial and implement improvements.

The WAG’s latest focus has been the ‘one basin, two cloths’ protocol for cleaning basins in the hospital, with one cloth for the basin and another for the taps and drain; cleaning progresses from cleaner areas such as taps to dirtier ones, and finally the water outlet to the drain. The WAG is testing a ‘tweaked’ protocol in which every basin is cleaned with a dry cloth prior to wet cleaning to remove any water residues that dilute the chlorine solution used in the cleaning process. Staff are also being taught how to clean and manage point-of-use filters.

Testing the new method on one ward since January 2023 saw a 53% reduction in positive Pseudomonas aeruginosa samples over a two-week period. This process of trialling and improvement should be a constant in all healthcare settings, and demonstrates the value of a WAG that has the power to change things quickly based on consistent monitoring. One of the key ‘take-aways’ from the Water Safety Forum is that we are all still learning, and we shouldn’t be afraid to share knowledge.

Finding the right people

Water Safety Plans should require that potential contractors provide comprehensive evidence of training and competency, and this includes those involved in the commissioning process for new or refurbished facilities. This is often the task of Estates directors charged with handling water safety from an infrastructure perspective, who will employ Authorising Engineers (AEs) or independent advisers (IAs) to advise and audit systems of work. Some WSPs have particular suppliers and products listed, which have been tried and tested, and among the trusted suppliers to the NHS is Armitage Shanks, as it has proven delivery and installation of a dedicated and well-respected range of Part M-compliant sanitaryware products that many in the sector are familiar with.

The background of an IA or AE should also be scrutinised to determine how they define their role, and for evidence of their own Continuing Professional Development (CPD). What roles and projects have they been involved with? How have they kept up their CPD? Are they a registered member of a professional body? It’s a high bar, but a good AE should have a wide variety of competencies, and IHEEM has some helpful advice to assist those either thinking of employing, or those intending to become, AEs.

The ability and willingness to challenge what’s happening on worksites and on wards is a useful barometer of competence across a range of different job roles — it shows an awareness of best practice, and the ability to recognise it (or the lack of it) in situ. Contractors with this level of competence are worth their weight in gold, and that has led some Trusts to consider approaching them to work in their in-house teams. The rationale behind this isn’t just about reducing overheads and fees paid to third-party providers, but establishing that level of consistent competence on subsequent projects, and seizing opportunities for well-informed partners to raise standards across the board. WSGs have also recognised the power of bringing engineering teams ‘in house’ to help them deliver that consistency.

A safer future

The New Hospital Programme facilities will treat some of the NHS’s most vulnerable patients, who must be the focal point around which new and existing facilities are commissioned, designed, constructed, and operated. Achieving this change in focus means bringing everyone together right from the beginning of a project, and building their competence with regard to water safety, rather than just training, as the bar for entry into the project.

It’s time to challenge and be challenged at every stage — for architects, contractors, and installers, this can involve going against years of experience or just what feels natural. Competence checks need to be a routine task for supervisors and senior members of staff in order to maintain high standards. In the face of a water system’s infinite number of moving (and not-moving) parts, and countless opportunities for contamination, it can seem an unassailable task, but this is where a competence-based approach can be a WSG’s biggest asset. Establishing a multidisciplinary base of competence across all stakeholders in a project will ideally result in a safer and more easily managed water system, making it a crucial but manageable element of everyone’s role.