Human Behavior and Communication in Legionella Risk Management

When people think about Legionella risk management, the focus often falls on engineering controls, water treatment protocols, and regulatory compliance. While these are essential, they’re only part of the equation. The human side of risk management, particularly behavior and communication, plays just as critical a role. Many outbreaks and compliance failures can be traced back not to technical shortcomings but to gaps in communication and human behavior. To truly understand and mitigate Legionella risk, healthcare facilities and large institutions must look at how their teams communicate, respond under pressure, and prioritize safety.

Why Behavior Matters as Much as Engineering

Every water management program depends on people. ASHRAE Standard 188 and CMS guidelines require facilities to have documented plans, but a binder on a shelf does not guarantee safety. Execution is everything, and execution depends on behavior.

Consider these questions:

• Do staff members know the water management plan?

• Do they understand why each element is in place?

• Do they feel empowered to act when something seems off?

Research on high-reliability organizations, like aviation and nuclear power, shows that safety culture stems not just from rules but from daily behaviors reinforced by communication and accountability. Legionella prevention is no different.

Communication Breakdowns: The Hidden Risk

A 2017 outbreak in a New York healthcare facility revealed the danger of poor communication. The CDC investigation found:

• Testing protocols existed, but frontline staff weren’t clear on reporting thresholds.

• Engineers assumed infection prevention staff would act on unusual results.

• Infection prevention staff assumed engineers would flag issues.

By the time the gap was recognized, patients were already exposed. The tools were sound, but communication was the weak link.

As the Journal of Water and Health (2022) noted, “Facilities with structured communication routines reported fewer compliance lapses than those relying on ad hoc conversations.” Regular cross-departmental reviews of water safety metrics, even just monthly, can prevent costly blind spots.

The Invisible Threat and Human Bias

Unlike a broken pipe or a flooding sink, Legionella bacteria can’t be seen. That invisibility means staff must rely on data, vigilance, and trust in the system. Here, human psychology comes into play:

• Normalcy bias: People underestimate risks during unusual events, assuming things will continue as they always have. A single high ATP or ORP reading gets dismissed as an anomaly instead of an early warning.

• Ownership gaps: Legionella prevention often falls into a gray zone between engineering, infection prevention, and environmental services. Without clear ownership, responsibility gets diluted.

Simulation exercises, similar to fire drills, can help staff recognize and respond to red flags before they escalate.

The Power of Psychological Safety

Assigning clear roles is critical, but accountability works best when paired with psychological safety. Dr. Amy Edmondson of Harvard Business School explains: “Psychological safety is not about being nice. It’s about giving people the confidence to speak up when they see a risk, without fear of blame or retaliation.”

In Legionella management, this means:

• A maintenance worker who notices a lukewarm hot water tank feels confident reporting it.

• An infection prevention specialist is supported in escalating concerns quickly.

• Leadership rewards vigilance instead of punishing questions.

Beyond Internal Communication

External partners—consultants, water treatment providers, regulators—are part of the communication ecosystem. Misalignment here often leads to confusion or noncompliance. For example, if a consultant recommends a treatment protocol but the engineering team doesn’t understand the rationale, consistency in execution suffers. Leaders must integrate external voices into the internal framework and translate recommendations into clear, actionable steps.

Lessons From Real-World Outbreaks

The consequences of poor communication can be devastating.

• Bronx, 2015: More than 120 people sickened and 12 deaths linked to Legionnaires’ disease. Investigations revealed not just technical failures in cooling tower maintenance but also lapses in communication between agencies, building owners, and the public.

• Midwestern hospital case study: Published in Infection Control & Hospital Epidemiology, this hospital faced unusual water test results. Because of clear and rapid communication between infection control, engineering, and leadership, they flushed systems and remediated risks before patients were exposed.

One shows the cost of fragmented communication, the other the power of coordinated behavior.

What Facilities Can Do Now

The most advanced treatment systems cannot compensate for poor communication. But even modest systems can be effective with a strong culture of safety, accountability, and collaboration. To strengthen the human side of Legionella prevention, facilities should:

1. Establish regular cross-department meetings to review water safety metrics.

2. Assign clear ownership of Legionella prevention tasks and responsibilities.

3. Invest in training and simulations that reinforce vigilance and rapid response.

4. Build psychological safety so staff can raise concerns without fear.

5. Align internal teams with external experts to ensure recommendations are understood and implemented.

As the Joint Commission’s 2024 water management standards highlight, surveyors are now looking not just for plans but for evidence that staff understand and live those plans.

Final Thought

Legionella prevention is about more than pipes, tanks, and chemical treatments. It is about people their choices, their communication, and their willingness to act. Facilities that invest as much in culture and communication as they do in technical controls will be best equipped to protect patients, residents, and staff.

As one facility manager put it after a successful response to a potential outbreak: “Our water treatment system didn’t save us. Our people did.”