Inside the VA Water Fix That Hospitals Need to See

A 2026 HSPA case study reveals how two VA facilities eliminated biofilm and conductivity failures through system mapping and team collaboration

19 Jun 2026

Two medical facilities within the Cheyenne VA Health Care System have resolved persistent sterile water contamination, according to findings presented at the HSPA 2026 conference. Bacteria, elevated conductivity, and biofilm had compromised critical water systems used in surgical instrument reprocessing, a failure with direct patient safety implications.

The remediation was led by Lisa Pawlowski, DNP, RN, CRMST, alongside Tyler Anderson and Danny Conrad. Their poster outlined a process applicable to hospitals across the country facing comparable water quality problems.

Complete infrastructure mapping formed the foundation of the fix. That mapping exposed multiple dead legs, stagnant pipe sections connected to hospital humidity systems where stationary water allowed biofilm to form and spread. Removing those sections broke a contamination cycle that earlier interventions had failed to interrupt.

Physical corrections alone were insufficient. Recirculation protocols and a restructured team brought together sterile processing specialists, infection control staff, and facilities engineers under a shared operational view. Cross-functional visibility allowed the team to identify root causes rather than manage recurring symptoms.

Healthcare operations leaders will find a sharper boundary drawn around water quality responsibility: it belongs to the whole institution, not to a single department. Aging infrastructure compounds the risk, as vulnerabilities in older facilities frequently go undetected until contamination has already reached reprocessing areas. Proactive mapping and coordinated response stand to reduce both remediation costs and regulatory exposure. The Cheyenne model offers an evidence-based framework for water quality management that can support both patient safety and operational continuity.