Paying Closer Attention To Your Water Quality and Reprocessing Can Decrease Harm To Patients And Many Long-Term Costs

Just because water is safe to drink, or use in consumable products doesn’t mean that it meets the strict standards for the sterilization of reusable surgical instruments, medical devices, and endoscopes across the country. 

In fact, you can actually drink certain chemicals within water which don’t do harm to your body, but those very same chemicals can muck up an entire sterilization process right off the jump. Yes, water purity really does matter and one of the biggest issues the medical community faces right now is the fact that water purity varies from not only state to state but town to town. 

This imbalance throughout the country makes water processing difficult on a macro level and it can lead to harmful results in patients. 


Many public water systems include additives such as chlorine, dissolved salts and naturally occurring mineral contents (hard water). In some cases, organic contaminants (bacteria and endotoxins), heavy metals, synthetic organic chemicals, biological parasites and other harmful contaminants can be found in water.

Depending on municipal water sources, untreated water can lead to the formation of hard water deposits (a layer of lime or scale) that can be difficult to dissolve, resulting in corrosion and other damage to medical devices. Untreated water also supports the growth of opportunistic pathogens such as Esherichia coli, Legionella, Pseudomonas (gram-negative) and non-tuberculous Mycobacterium (gram-positive) bacteria.

It’s critical that water be treated appropriately to ensure the removal of all such contaminants because they can impede critical aspects of reprocessing, and add increased workload and time to the process. Water treated appropriately provides better performance for cleaning and removing debris in addition to residual detergent impurities, from the instruments than untreated water.

Various minerals and contaminants commonly found in municipal water sources can adversely affect reprocessing medical equipment in several ways, and these issues can translate into costly recleaning, increased instrument and endoscope repair, and/or replacement.

The cost of poor water quality can add up quickly. The average instrument tray can have 100 instruments or more, and each set takes meticulous care and time to inventory, prepare, assemble and sterilize. A study by Rand Children’s Hospital, in San Diego, found that device reprocessing, including maintenance, packaging, labor and high-level disinfection, cost 51 to 77 cents per instrument (J Pediatr Urol 2019;15[2]:153.e1-153.e6). Other studies estimate the cost between 34 and 47 cents for one instrument in a tray and 81 to 84 cents in an individually wrapped instrument (peel pack). With hundreds of sets processed daily, the cost can skyrocket quickly

There are no new sources of water—our planet has a finite supply. Municipal water sources continuously recycle the same water over and over, but water treatment facilities are not designed to remove organic chemicals and toxic heavy metals, such as lead. These impurities can certainty have adverse effects on medical device reprocessing.

Potential effects on devices, processes, patients and staff include:

  • hard water deposits and scaling build-up;
  • increased microbial load and/or endotoxin content;
  • corrosion and pitting;
  • decreased effectiveness of cleaning chemicals and detergents;
  • increased workload and longer reprocessing times;
  • reduced life expectancy (equipment and devices);
  • delays in patient care and longer procedure times; and
  • exposure to toxins and infection.

Managing Your Water

On Jan. 1, 2022, the Joint Commission (TJC) released new water management standards (EC.02.05.02. Eps1-4). The new standard is designed to improve the quality and safety of care provided to immunocompromised patients and contains water management measures that affect medical device reprocessing (download at

Most organizations treat their water in some way. Knowing how water is treated (distilled, reverse osmosis or deionized) can only ultimately help the end user. Creating a comprehensive and defensible water management plan (WMP) that oversees all aspects of water within a healthcare organization (designed with the type of water treatment method being used in mind) is now part of TJC’s new standards.

It requires either individuals or teams to take responsibility for the implementation of water management. The expectation is that processes will include a risk assessment, WMP, testing protocols, and acceptable ranges to minimize pathogenic biological agents within cooling towers, domestic hot- and cold-water systems and other aerosolizing water systems (steam).

These responsibilities include, but are not limited to, the development, management and maintenance of all water activities and specifies required elements to be included, such as a basic diagram that maps all water supply sources, treatment systems in place, processing steps, control measures and end-use points. The plan should be based on the information in the diagram, and include an evaluation of the physical and chemical conditions for each step of the water flow diagram. In addition, a review of the WMP should be conducted annually and when any changes occur.


Because water quality is a multidisciplinary issue, it’s important to assemble a multidisciplinary team when forming a committee to oversee water management. Personnel who might be included on a water management team could be administrators, engineering, infection preventionists, risk management, state or local public health officials, certified industrial hygienists, environmental health specialists, and members of central sterile processing.

Once the team is assembled, its hierarchy should be determined through the delineation of responsibilities. To drive purpose and motivate the team, a mission statement should be developed early on. Without proper guidance, the water management team may take steps that are not required, steps that may be unnecessarily costly, or steps that are not helpful in reducing a threat to water quality.

7 Steps in a Management Plan

Creating a WMP can help healthcare organizations comply with TJC standards and mitigate risk as much as possible.

  • Create a team.
  • Map the water system.
  • Identify risks.
  • Develop strategies to mitigate the risks.
  • Monitor and respond.
  • Review periodically.
  • Document and keep accurate records.
  • Conclusion and Additional Resources

Water quality plays an important role in all stages of medical device reprocessing, with the primary objective of ensuring that surgical instruments, endoscopes and other medical equipment are properly cleaned, high-level disinfected and sterilized. If you have a WMP in place, review it regularly to ensure everyone knows what’s at stake and what their role is in mitigating risks. Reprocessing professionals must remain vigilant and report any signs of poor water quality quickly and to prevent negative effects on your organization.

The Association for the Advancement of Medical Instrumentation’s technical information report TIR34:2014/®2021 is a resource intended to provide guidelines for selecting the quality of water necessary for each stage of medical device reprocessing (clean, rinse, disinfect and sterilize) and for each category of medical devices. It also includes annexes that address technical aspects of water quality, such as water distribution and storage, quality control measures, bacterial control, and environmental and personnel considerations.