Don't let water quality hurt care quality: How healthcare organizations can maintain effective sterile processing


Poor water quality can have serious financial and clinical ramifications for healthcare organizations.

Water is used in many processes within a hospital's sterile processing department, ranging from the initial cleaning of devices to final rinses. If water quality does not meet appropriate standards, medical equipment and tools may not be fully decontaminated or sterilized, which poses a serious infection risk to patients and may cause surgical delays for the healthcare facility. Poor water quality can also damage or shorten the lifespan of expensive sterile processing equipment such as automatic endoscope reprocessors, washer disinfectors and sterilizers. 

To help mitigate these negative outcomes, sterile processing professionals must regularly monitor and maintain the water quality outlined in manufacturers' instructions for use, according to Seth Hendee, a clinical education coordinator at Healthmark Industries.

During a Sept. 5 webinar sponsored by Healthmark and hosted by Becker's Hospital Review, Seth Hendee discussed the importance of water quality in healthcare and shared how leaders can monitor compliance with recommended standards.

Water quality 101

To start the presentation, Mr. Hendee highlighted the four main types of water commonly used in sterile processing departments:

  • Potable — Water that has been treated and delivered in a manner deemed suitable for drinking by the Environmental Protection Agency.

  • Softened – Water in which ions such as calcium and magnesium have been removed.

  • Deionized – Water in which ionized salts have been removed using a specially manufactured ion-exchange resin.

  • Reverse osmosis — Water in which ions and some dissolved organic contaminants have been removed through a membrane separation process based on molecular sieving and ionic rejection.

Reprocessing protocols require different water to be used for different steps. For example, while potable water may be safe to drink, it's not always recommended for reprocessing use in manufacturing guidelines. Mr. Hendee said sterile processing professionals should know what type of water is needed for each stage of reprocessing and monitor it on a regular basis.

He also outlined the three major factors that affect water quality:

1. Hardness is defined as the concentration of calcium and magnesium ions in water, expressed in terms of calcium carbonate. These ions and other minerals can disrupt the cleaning process by binding with cleaning agents in detergents and preventing them from reacting with soils on instruments, according to Mr. Hendee. 

"We want those cleaning agents to work for us," he said. "If things in our water are binding with them and using them up, then we're not getting the effect we expect to get from our detergents."

Soap scum, the precipitate that forms when mineral salts react with the detergent, is difficult to rinse away and produces visible mineral spots or film on instruments. Some of the detergent is also used up by reacting with the minerals, which reduces the amount of soap available for cleaning. This effect can cause some sterile processing professionals to use more soap than typically needed, which is another way poor water quality can drive up costs.

2. pH level is the second factor that influences water quality. The pH scale measures how alkaline or acidic a liquid is based on a scale of one to 14, with 14 being the most acidic. Mr. Hendee said water should typically fall around seven on the pH scale, since highly acidic or alkaline water can also lead to instrument damage.

A related concept to pH is alkalinity, or water's capacity to resist changes in pH level. "At every given pH level, it's desired to have a high level of alkalinity," Mr. Hendee said, since the alkalinity can help stabilize pH levels.

3. Temperature can also influence water quality. "Many people think hotter is better when cleaning," Mr. Hendee said, but that's not always true in the medical industry. For example, blood can denature and adhere to instrument surfaces if the water used in the beginning of the cleaning process is too hot.

Proper water temperature varies based on the type and stage of cleaning, along with the type of cleaning agent used, according to Mr. Hendee. In most cases, healthcare organizations can maximize cleaning efficiency by using lower water temperatures in the beginning of the cleaning process and higher temperatures in later stages.  

Monitoring water quality

Healthcare organizations should regularly review all relevant standards and guidelines on water quality for device reprocessing, according to Mr. Hendee.

The following entities can provide valuable resources on water quality based on peer-reviewed literature and evidence-based practices:

  • Instrument, detergent and cleaning equipment manufacturers
  • Professional groups such as the Association for Professionals in Infection Control and Epidemiology
  • Federal agencies such as the EPA, CDC or FDA

Healthcare organizations can also use simple tools such as colorimetric dipsticks and digital thermometers to monitor water quality, Mr. Hendee said. If these tests point to potential water quality issues, organizations should follow-up with a more in-depth analysis. Mr. Hendee said detergent manufacturers can be a good first choice for this type of analysis, as they are often willing to conduct on-site water quality testing for free.


Water quality is a crucial component of safe and effective sterile reprocessing at healthcare organizations. Optimal water characteristics vary based on the type and stage of the cleaning process, meaning sterile processing professionals must stay up to date on recommended guidelines, while also regularly monitoring water quality.

"IFUs (instructions for use) and standards help you get and maintain best practices, but you still need more common sense, teamwork, certification, critical thinking and your tools of the trade to do the job right," Mr. Hendee concluded.

To access the full webinar, click here.

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