| Course | NUR 531 Interprofessional Leadership in Healthcare |
|---|---|
| Module | Module 9 |
| Paper type | Policy renewal with rationale (project) |
| Length | About 1,310 words, 7 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 531 Module 9
Project Three: Updating Wren Valley Medical Center's Water Management Policy to Prevent Healthcare-Associated Legionnaires' Disease
[Student Name]
Southern New Hampshire University
NUR 531: Interprofessional Leadership in Healthcare
Project Three
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Project Three: Updating Wren Valley Medical Center's Water Management Policy to Prevent Healthcare-Associated Legionnaires' Disease
Wren Valley Medical Center wrote its water management policy in 2018, a year after federal surveyors began expecting hospitals to manage the risk of Legionella in their water systems. The policy described a team, a plan and a monitoring schedule, and then sat unused for three years. When a patient on the oncology unit developed healthcare-associated Legionnaires' disease, the root cause analysis found that the policy had not failed on paper; it had failed because nothing in it made anyone act. This project updates the policy so that its most important steps are triggered automatically, assigned to named roles and checked monthly, and it adds the nursing responsibilities the 2018 version left out.
Why the Policy Needs Updating
Three problems with the 2018 policy emerged from the root cause analysis and the failure mode analysis. First, it relied on a team without requiring that the team meet or naming who would convene it, so when its chair retired, the program stopped. Second, it treated water management as a facilities function and gave nursing, construction and bed management no duties, although room closures, renovations and patient exposure all run through those departments. Third, it monitored temperatures only at the water heater and made no provision for rooms taken out of service or for construction, the two conditions that preceded the case.
These problems are typical. CDC's review of 27 outbreaks found that every one involved at least one water management deficiency, most often failures of process, and that changes nobody managed, including construction, contributed to about a third (Garrison et al., 2016).
Standards the Revision Meets
Federal guidance expects hospitals to assess where Legionella and other waterborne pathogens could grow and spread in their water systems, and to develop and carry out a water management program that considers the ASHRAE industry standard and CDC's toolkit (Centers for Medicare & Medicaid Services [CMS], 2018). The ASHRAE standard sets out risk management requirements for building water systems (ASHRAE, 2018). CDC's toolkit translates that approach into steps a hospital team can follow: describe the water system, identify where hazardous conditions could occur, decide on control measures with limits, monitor them, act when limits are not met and verify that the program works (Centers for Disease Control and Prevention [CDC], 2021). The revised policy is organized around those steps, and every requirement in it traces to one of them or to a finding from the hospital's own analyses.
How the Revision Was Developed
The water management team drafted the revision over four weeks, using the root cause analysis actions and the failure mode analysis as its starting point. Drafts went to the nursing practice council, the construction office, bed management and the medical executive committee for comment. Nursing staff on 4 East asked that the policy say plainly what a nurse should do when water restrictions are in place, which led to the procedure in section 6. The construction office asked for a single point of contact on the water team, which led to the named coordinator role.
Revised Policy
Title: Water Management Program for the Prevention of Legionella and Other Waterborne Pathogens. Policy number: EOC-114. Replaces: EOC-114 (2018). Approved by: Environment of Care Committee; Medical Executive Committee. Review: annually and after any healthcare-associated case.
1. Purpose
To prevent the growth and spread of Legionella and other waterborne pathogens in the hospital's water systems and to protect patients, especially those who are immunosuppressed, from healthcare-associated infection.
2. Scope
All buildings, water systems and water-using devices owned or operated by the hospital, and all staff, departments and contractors whose work affects them, including any room taken out of service for any length of time and any construction or maintenance involving plumbing.
3. Definitions
Closed room: any patient room or area removed from use for more than 72 hours, for any reason. Distal outlet: a faucet, shower or other point of use at the far end of a water distribution branch. Control limit: the acceptable range for a monitored condition, such as outlet temperature, set in the water management plan. Water restriction: a temporary order limiting use of tap water in an area, issued by infection prevention.
4. Policy Statements
4.1 The hospital maintains a water management team led jointly by its senior nursing and facilities executives, which meets at least monthly and keeps minutes. 4.2 The team maintains a written water management plan that describes the water systems, identifies hazardous conditions, sets control measures and limits, and specifies monitoring and corrective actions, consistent with the ASHRAE standard and CDC's toolkit. 4.3 Every closed room receives an automatic recurring flushing work order, and no closed room returns to patient use until a final flush and temperature check are documented. 4.4 No construction or maintenance involving plumbing, valves or water heaters begins without written sign-off by the water team coordinator, and this requirement is included in every contractor agreement. 4.5 Hospital-onset pneumonia is tested for Legionella as specified in the pneumonia order set. 4.6 Any healthcare-associated case triggers a full investigation and a review of this policy.
5. Responsibilities
Table 1 assigns responsibilities by role.
Table 1
Responsibilities Under the Revised Water Management Policy
| Role | Responsibilities |
|---|---|
| Water management team co-chairs | Convene monthly meetings; approve plan changes; report quarterly to the Environment of Care Committee |
| Water team coordinator (facilities) | Review and sign off on plumbing work; oversee flushing and monitoring; lead corrective actions |
| Infection prevention | Review hospital-onset pneumonia; issue and lift water restrictions; notify the health department of cases |
| Nurse managers and charge nurses | Record every room closure in the bed management system; report water concerns by work order; carry out water restrictions on their units |
| Bed management | Hold closed rooms from assignment until the final flush is documented |
| Construction office | Include water team sign-off in contracts; notify the coordinator before any plumbing work |
| Hospitalists and pharmacy | Maintain Legionella testing in the pneumonia order set |
6. Procedure During a Water Restriction
When infection prevention issues a water restriction for a unit, the charge nurse will: close showers and post signs; provide bottled water for drinking, tooth brushing and medication administration; remove ice from unit machines and supply bagged ice from an approved source; brief each shift at huddle until the restriction is lifted; and report any patient with new respiratory symptoms to the attending physician and infection prevention. Restrictions are lifted only by infection prevention in writing.
7. Monitoring
The water management team reviews a monthly dashboard that includes: closed rooms with a flushing order within 24 hours; flushing orders completed on schedule; distal outlet temperatures within control limits; plumbing permits with sign-off; rooms reopened with final flush documented; and hospital-onset pneumonias tested. A measure that misses its target in two successive months prompts a focused review. The team repeats its failure mode analysis before each major construction project.
Implementation and Evaluation
The revised policy will take effect on approval, with a thirty-day period for education. Nurse managers will review section 6 with staff at unit meetings, and the construction office will send the contract clause to all active contractors. Compliance will be evaluated through the monthly dashboard, which has already shown flushing and testing measures reaching their targets during the pilot period. The policy's real test will come during the second renovation phase, when eighteen rooms close under a new contractor.
Conclusion
The 2018 policy described a sound program and assumed people would carry it out. The revision assumes they will be busy, and so it triggers the critical steps automatically, names who is responsible for each one, gives nursing a defined role and checks itself every month. It meets federal expectations and CDC guidance, and it answers every cause found after the Legionnaires' case on 4 East. For a nurse leader, the lesson is that policy is a leadership tool only when it changes what happens on an ordinary day.
References
ASHRAE. (2018). ANSI/ASHRAE Standard 188-2018: Legionellosis: Risk management for building water systems.
Centers for Disease Control and Prevention. (2021). Developing a water management program to reduce Legionella growth and spread in buildings: A practical guide to implementing industry standards (Version 1.1). https://stacks.cdc.gov/view/cdc/114167
Centers for Medicare & Medicaid Services. (2018). Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD) (QSO-17-30, revised). https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/qso17-30-hospitalcah-nh-revised-.pdf
Garrison, L. E., Kunz, J. M., Cooley, L. A., Moore, M. R., Lucas, C., Schrag, S., Sarisky, J., & Whitney, C. G. (2016). Vital signs: Deficiencies in environmental control identified in outbreaks of Legionnaires' disease: North America, 2000-2014. Morbidity and Mortality Weekly Report, 65(22), 576-584. https://doi.org/10.15585/mmwr.mm6522e1
What the NUR 531 Module 9 instructions ask for
Project Three in NUR 531 typically asks you to renew or update a policy related to a hospital-acquired infection so that it reflects current best practice. Guidelines usually call for a rationale explaining why the policy needs to change, the evidence and standards behind the update, the revised policy itself with its standard sections, the roles of different disciplines, an implementation plan and a way to evaluate compliance. Some sections ask for the policy as an appendix to a paper; others want it in the body. The project commonly runs six to ten pages in APA 7, with the policy often formatted as it would appear in the hospital's policy manual. Start from a real policy format your organization uses, since graders reward documents that look ready for a policy committee.
How this NUR 531 Module 9 project three example is built
This sample updates a composite hospital's water management policy after a healthcare-associated Legionnaires' case. The rationale traces three weaknesses of the old policy to the root cause and failure mode analyses and to a CDC outbreak review. A section summarizes the federal requirement, the ASHRAE standard and CDC's toolkit, and another describes how the draft was reviewed and changed. The revised policy follows with a header, purpose, scope, definitions, numbered statements, a responsibilities table, a nursing procedure for water restrictions and monitoring requirements. An implementation section sets the rollout and names when the policy will be tested. Four real sources support it.
Where the NUR 531 Module 9 rubric puts the points
Policy projects are generally graded on the rationale for change, the use of current evidence and standards, the completeness and clarity of the policy, the definition of interprofessional roles, the implementation and evaluation plan and writing. The policy itself earns full credit when it has standard sections, uses clear directive language and assigns every duty to a role. Evidence credit depends on connecting policy statements to named standards or studies, not only listing sources. Evaluation should use measurable indicators with a review schedule. A revision that visibly answers the failures found earlier in the course shows the integration instructors look for at the end of this sequence.
NUR 531 Module 9 help: the mistakes that cost points
Policy updates often lose points by copying a template that has no link to the event or the evidence, by using soft language such as should consider, or by leaving roles vague. Others skip implementation, as though approval were the end. Explain what was wrong with the old policy, name the standards the new one meets, write numbered statements in directive language, assign every responsibility to a role and include a procedure frontline staff can follow. End with how compliance will be measured. If your infection or policy is different, we can prepare a policy update around your earlier projects, your organization's format and current guidance.
Get NUR 531 Module 9 written to your instructions
Send the Project Three guidelines and rubric, your earlier NUR 531 projects and any existing policy you are updating. A policy update with rationale, standards, a complete revised policy and an implementation plan is ready in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 531 Module 9 questions, answered
Where can I find a free NUR 531 Module 9 Project Three sample?
The complete project on this page is free to read: the rationale for updating a hospital water management policy after a Legionnaires' case, the standards behind it, the full revised policy with a roles table and an implementation plan.
What sections should a hospital policy include?
Usually a header, purpose, scope, definitions, policy statements, responsibilities, procedures, monitoring and references, with an approval and review date.
What do federal rules require for hospital water management?
CMS expects hospitals to assess where Legionella could grow in their water systems and to run a water management program that considers the ASHRAE standard and CDC's toolkit.
How do I show a policy reflects best practice?
Tie each policy statement to a named standard, guideline or study, and explain in the rationale what the old policy lacked.
What role does nursing play in water management?
Reporting room closures and water concerns, carrying out water restrictions, protecting high-risk patients and bringing the clinical perspective to the water management team.