Systemwide Implementation of Water and Steam Quality for Medical Device Reprocessing

Session Description: In response to the evolving requirements of the American National Standards Institute/Association for the Advancement of Medical Instrumentation Standard 108 (ANSI/AAMI ST108) , our health system initiated a multi-facility, multidisciplinary project to standardize and elevate water and steam quality in support of safe and compliant medical device processing. This session details our journey from gap assessment to systemwide implementation across six hospitals.
The project began with a comprehensive review to evaluate existing infrastructure, sampling practices, and data management processes against ANSI/AMMI ST108 standards. We then developed and deployed Facility Water and Steam Strategic Testing (FWSST) Plans, tailored to each site, that outlined precise sampling locations, parameters, frequencies, and procedures for utility water, critical water, and steam. Infrastructure upgrades, including installing new sampling points, modernizing key pieces of equipment, and enhancing some treatment processes, were executed in collaboration with sterile processing and engineering teams at each facility.
To ensure consistency, we implemented a system-wide contract for all ANSI/AMMI ST108-related water and steam testing. We also developed a robust data management system to store, analyze, and visualize water and steam test results from sampling points across the health system. Finally, we defined routine communication processes for reporting test results to a range of stakeholders, developed escalation plans for abnormal test results and other non-conformities identified by sterile processing stakeholders, and established corrective action plans for any issues identified.
The outcomes of this project included a documented systemwide approach to water and steam testing in alignment with ANSI/AAMI ST108 standards, full integration of FWSST Plans into infection prevention programs, and improved cross-functional collaboration between departments. This session will take attendees through our project, examine lessons learned, and provide a replicable framework for health systems aiming to improve patient safety and meet practice guidelines through proactive risk management and alignment with ANSI/AAMI ST108.

Maimuna Jatta

Senior Director of Infection Prevention & Control, Carilion

Maimuna Jatta is a certified infection preventionist and recognized leader with comprehensive experience in infection prevention, nursing leadership, and healthcare quality across the continuum of care. She currently serves as Director of Infection Prevention & Control at a not-for-profit healthcare organization, where she oversees system-wide programs aimed at advancing patient safety, minimizing healthcare-associated infections, and maintaining compliance with regulatory standards. Renowned for her expertise in quality improvement, mentorship, and interdisciplinary collaboration, Ms. Jatta has led numerous high-impact initiatives, including pandemic response strategies, data-driven infection control programs, and the development of innovative educational resources. Her dedication to excellence in infection prevention and patient safety is evident in every aspect of her work.

Mandy Swann

Clinical Project Manager, Carilion Clinic

Mandy Swann is a clinical project manager with Carilion Clinic's Infection Prevention and Control Department. For over 18 years she has led public health research and project implementation. With extensive experience in both domestic and international settings, her work focuses on innovative approaches to improve health capacity and mitigate the spread and impact of infectious diseases. At Carilion, Mandy leads a portfolio of evidence-based initiatives designed to reduce infectious disease transmission and combat emerging infectious diseases. She also oversees quality improvement, project, and research activities that reduce healthcare associated infections. Mandy has a Master of Public Health degree from Johns Hopkins Bloomberg School of Public Health.

Karen McGoldrick

Infection Preventionist, Sentara Leigh Hospital

Karen McGoldrick, MT (ASCP), CIC, CHOP, Infection Preventionist, Sentara Leigh Hospital in Norfolk, Virginia Karen has 18 years of experience in the field of Infection Prevention & Control with Sentara Healthcare, 14 of those years at Sentara Leigh Hospital and and the other four at Sentara Williamsburg Regional Medical Center. Karen has a BS degree in Microbiology from Texas A&M University and a BS in Medical Technology from the University of Texas at Tyler. She has been a member of the APIC Virginia Chapter Board for 16 years serving in multiple postions, incuding Chapter President in 2017, and is currently Awards chair. Karen is also a currently chair of Coastal Virginia Infection Preventionists and Epidemiologists and is serving a three year term on APIC's Annual Conference Committee. Her passion is partnering with healthcare workers to prevent healthcare associated infections and improving patient safety.

Caitlin Sharkey

Infection Preventionist, Carilion Clinic

Caitlin Sharkey is an Infection Preventionist with an MPH in Infectious Disease. Before joining Carilion Clinic as an Infection Preventionist in March 2025, Caitlin spent five years at the Bradley Free Clinic as Health Administrator. In her role as an Outpatient Infection Preventionist she works with Family Medicine, Velocity Care, and Outpatient Therapies to ensure infection control compliance and improve patient safety.