National Health Service (NHS) – Water Safety & Compliance Transformation

Achieved a 20% increase in technical compliance through a process redesign, introduction of electronic tracking and a new record management system to provide technical assurance.

How we helped...

An NHS Foundation Trust had a budget of £1.8 million over 2 years for the eradication of legionella and pseudomonas. They suffered from:

  • Unclear process and record management procedure to ensure adequate assurance of compliance
  • Lack of capacity amongst existing team to invest time in implementation whilst delivering business-as-usual activities
  • Insufficient Target Operating Model to ensure that remedials could be delivered in a timely manner whilst undertaking ongoing planned maintenance
  • Lack of data and in-house analytical skills to evaluate historic trends and forward-plan tasks

 An improvement was to be achieved by making improvements to the physical infrastructure and the water management processes. CI Projects were commissioned to analyse the current state and develop a solution for implementation with a target completion of one month. Within one month we delivered a Gap Analysis of the current state, designed a ‘To Be” process and a Water Management Tracker Tool.

With no administrative resource available to manage, track and record PPM Water Management activities and limited capacity within the existing team, CI Projects provided an interim Implementation team to embed the new water management process and maintain a record of all planned preventative maintenance (PPM) activities for onward assurance. The Implementation Manager supported the management team in ensuring that the designed process and tools worked practically and were fit-for-purpose. While the Implementation Coordinator supported in capturing and recording all activities relating to Water Management; reviewing the overall performance, ensuring process compliance and highlighting any gaps for resolution.

By working closely with the technicians, the Mechanical Lead and the Authorised Engineer, we were able to create a centralised asset list, verified by drawings and in person by technicians carrying out the PPMs. In the absence of historical electronic records of in-house PPM activities, it was not possible to measure compliance levels accurately and consistently. Our team archived the historic paper records and created a ‘Model Office’ setup for the records from 2020 onwards. We used weekly Water Hygiene Meetings to communicate and reinforce the new processes internally and with subcontractors. These regular meetings allow for accountability for performance and for the identification of any new risks and issues.

Within 3 months we were able to bring the water management process to a stable state which put us in a great position to keep on top of operational activities even with reduced staff during the COVID 19 outbreak. Throughout the project, we maintained engagement with all key stakeholders through progress reports on our activities and detailed reporting at the monthly Water Safety Board.

The benefits achieved include;

  • Improved Water Management compliance by 20%
  • Improved Water Management assurance
  • Improved record keeping and document management relating to Water Management using a newly designed Tracker tool and Model Office
  • Transitioned from a paper-based system which was cumbersome and prone to error, to an electronic database of statutory records
  • Standardisation of the Water Management process across two hospitals in the Trust to ensure data accuracy and consistency
  • Informed the evidence base for the Premises Assurance Model

 Here’s what the Executive Director of Estates and Facilities said: “Thank you for your assistance with the water management transformation, this has been a huge help to maintaining assurance against compliance.” 


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