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Food Safe Bullitt County

State: KY Type: Model Practice Year: 2017

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Bullitt County Health Department
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Food Safe Bullitt County
Located 15 miles south of Louisville, Kentucky, Bullitt County's population in 2015 was 78,702. Most residents identify as white (96.5%), followed by Hispanic/Latino (1.8%). The median household income in 2014 was $56,199 (U.S. Census Bureau). Most residents work in industry, manufacturing, transportation and distribution. The local health department provides many services and is best described by our mission, To promote healthy lifestyles in Bullitt County through prevention and protection.” According to the CDC, 59% of foodborne disease outbreaks involved foodservice establishments. Poor food handling practices are a leading cause of foodborne disease outbreaks and typically include cross contamination of raw and cooked food, inadequate cooking, and storage at inappropriate temperatures. Adequate training and behavior modification can limit improper practices and reduce the effects of contamination on consumer health (Adesokan et. al, 2015). Improper food handling was identified as a project by our Quality Improvement Team and the Environmental Department as early as June 2010. The 2005 FDA Food Code, 902 KAR 45:005 (Kentucky Food Code) and KRS 217.005 217.992 require the local health department to inspect and ensure the safety of local food establishments, including restaurants, schools, and other facilities. Food Safe Bullitt County began in October 2014 with two main objectives and encompasses the three core public health functions assessment, policy development, and assurance. Food Safe Bullitt County was developed with the following objectives: 1. Bullitt County will have an educated food service workforce through a required Food Handlers and Managers Training, leading to improved food safety and therefore inspection scores. 2. Consumers will have confidence in their choices with a trained food service workforce. Assessment The Environmental Department noticed decreasing restaurant inspection scores in late 2014 and a need for standardization to promote uniformity of food inspections. After discussions with our local Board of Health (BOH), the Environmental Department distributed a survey to area establishments to identify if there was a need for food safety training. Managers and employees of 40 establishments responded and 37 (92.5%) felt the trainings would be beneficial. Policy Development This led to the Food Handlers and Food Managers Regulation that was adopted by the BOH on August 12, 2015 and went into effect on October 1, 2015. Food handlers will take an online food safety course every three years and managers will attend an in-person training every three years. Each training has a certification fee that pays for administrative costs; $10 for food handlers and $25 for food managers. During routine inspections, certification cards are examined by inspectors to verify compliance. If an establishment is found to be in violation, they may be fined between $10 and $100 per day that the violation continues. Assurance As of November 1, 2016, 251 managers and 954 food handlers were trained. During these classes, a gap was identified. Study materials are provided for course attendees, and community members expressed concern as English was their second language. Translations into different languages were needed. A grant was received and course material was translated into Spanish and Chinese. Translated materials are maintained in paper and digital copy for distribution. In regards to our two objectives: 1. A mandatory Food Handlers and Food Managers Training regulation was approved by our BOH in August 2015 and went into effect on October 1, 2015. As of November 1, 2016, 954 food handlers and 251 food managers have been trained. We did observe a dip in inspection scores following the implementation of this regulation, due to the higher standards. This objective was successful because of stakeholder buy-in from our BOH and local establishments. 2. Consumers will have confidence in their restaurant choices since employees have been trained. Real-time inspection scores and specific violations for all establishments are now available on our website (www.bullittcountyhealthdept.org). Community members have expressed how beneficial online scores have been in helping them make informed decisions. Food safety should be the primary concern when preparing food commercially. Preventing serious foodborne illness by understanding and using safe food handling procedures is the main benefit as well as a well-trained staff and ongoing safe operation of commercial establishments. Promotion of food safety is an integral part of protecting the public's health.
The proper and safe handling of food products in our local establishments is a major concern for our health department and community. As stated by the CDC, 59% of food-borne disease outbreaks involved foodservice establishments and poor food safety practices are a leading cause (Adesokan et. al, 2015). In our county prior to this regulation, trainings were not required to work in food service. A lack of standardized training in the community was concerning, as we could not ensure that food handlers had a basic knowledge of safe practices or that any trainings they had received had provided accurate information. Other health departments in our state have mandatory food handlers and food managers' trainings available in their community that are sponsored by the health department. Occasionally, food handlers in our community would travel to other counties to participate in these trainings, if requested by their employer. Trainings are also available through commercial entities such as ServSafe and some establishments utilize this program. However, while some corporations require food safety trainings for their workers, we found this to be sporadic and not the case for all corporations as well as small, locally owned establishments. Some corporations only required food managers to be trained in food safety and expected these managers to train other employees. Evidence suggests that a trained workforce can limit improper handling practices and reduce the effects of contamination on health (Adesokan et. al, 2015). In terms of the population at risk, the entire population of the county (approximately 79,000), as well as visitors, are at risk for foodborne illnesses when visiting a food establishment without a trained workforce. Our county is bisected by a major interstate, bringing a large number of customers to food establishments along this corridor. Between 1998 and 2015, Kentucky had 25 outbreaks, 1,800 illnesses, 276 hospitalizations and 3 deaths from restaurant-associated outbreaks of foodborne illness (CDC Foodborne Outbreak Online Database). The most common etiological agents were Salmonella (52% of reported outbreaks), norovirus, E. coli, Hepatitis A and Staphylococcus aureus (CDC Foodborne Outbreak Online Database). In terms of our target population for the program, we currently have 207 establishments that prepare or serve food and are effected by the regulation. The Census Bureau estimated that in 2014 approximately 4,789 individuals (13.0% of the workforce) in our county were employed in the service industry. Using this estimate and the fact that we reached a total of 1,205 food workers by November 1, 2016, we believe we have reached approximately 25% of the workforce. The food service industry is highly transient, however, which creates a major barrier in reaching the entire workforce. The categorization of service industry also includes some establishments that are not required to attend food safety trainings, perhaps skewing our numbers. The training of food managers has been a major policy change in recent years. Other counties in our state have similar regulations, including Anderson County Health Department, Lincoln Trail District Health Department, and Louisville Metro Public Health and Wellness. Our Environmental Health Director participates in a statewide leadership group for Environmental Health officials, and learned about food safety regulations at a meeting of this group. Following this meeting, our Environmental Health Director reached out to other health departments to gather information about food safety programs. This was the beginning of a large collaborative effort between our health department, BOH, colleagues in public health, and our local establishments to create a food handlers and managers regulation to promote food safety in our community. In this way, our training is modeled off of those provided by surrounding health departments, the Kentucky Food Code, the FDA Food Code and additional information provided by the CDC. An Environmental Health Specialist Network (EHS-Net) study found that restaurants with kitchen managers certified in food safety are less likely to have foodborne outbreaks than restaurants without trained managers. A similar study by EHS-Net found that food handlers and managers who had been certified in food safety were more likely to pass a food safety knowledge test than those that were not certified. Those whose primary language was English were also more likely to pass a knowledge test than those whose primary language was not English. This finding strongly suggests that those whose primary language is not English likely have difficulty learning about food safety or taking tests on food safety in an English-only environment (EHS-Net, 2016). What makes Food Safe Bullitt County unique is our focus on improving the program from those who do not speak English as a first language. Previously, an instructor for the food managers' course would read the test questions and explain them to the English as a Second Language (ESL) participant. While this was an improvement over no assistance at all, we felt that ESL participants would greatly benefit from having course training material and the exams translated into additional languages. We convened a small focus group to determine which languages would be most beneficial for our community, and decided to translate our materials into Spanish and Mandarin Chinese (simplified and traditional) based on the feedback received from this group.
Food Safety
Food Safe Bullitt County was developed with the following objectives: 1. Bullitt County will have an educated food service workforce through a required Food Handlers and Managers Training, leading to improved food safety and therefore inspection scores. 2. Consumers will have confidence in their choices with a trained food service workforce. In our 2010 organizational Strategic Plan, a food handlers and food managers training was identified as a departmental goal. However, little movement was made on it until late 2014 when a new Environmental Health Director noticed a dip in restaurant inspection scores, with an average score of 97%. At this time, our Environmental department began to work to create a food handlers and food managers training for our county. In order to create an effective program, our Environmental Health Director reached out to other Environmental Health professionals across the state to see what was being done in their jurisdictions. In drafting our course materials and the regulation, we synthesized and modified information from multiple health departments across our state. When our BOH was approached about drafting a regulation requiring food handlers and food managers to participate in mandatory training courses, our Environmental Health department was asked to survey local establishments to determine a need for the trainings. A survey was distributed to area establishments in December 2014 and January 2015 during routine inspections. The managers and employees of 40 establishments responded (approximately 20% of our establishments), and 37 (92.5%) felt the trainings would benefit their establishment. One-third of the establishments surveyed had no formal training in food safety at that time. For those who had received training, the average costs of the trainings were $40. This information was compiled by our local Epidemiologist and the results were presented to our BOH in February 2015. At that time, a new Food Handlers and Food Managers Regulation was drafted. The regulation was officially passed by the BOH in August 2015. Prior to the regulation going into effect on October 1, 2015, course materials were created and reviewed by the entire Environmental department. Input was also sought from colleagues across the state. The course covers many food safety topics, including restriction and exclusionary requirements for ill workers, types of foodborne illnesses, hand hygiene, cross-contamination, food temperature danger zones, food storage, proper labeling, pest control, proper sanitizing of facility and equipment, personal hygiene and more. The regulation requires that all food handlers in the county complete the online course and that all food managers complete the in-person training. The food handlers training is an online module-based training hosted by TRAIN (ky.train.org). Course participants register through TRAIN and are required to pass an exam at the end. If they pass the exam, they can then print a certificate of completion to bring to the health department where they will pay the $10 certification fee and receive their certification card. The in-person food managers' training course lasts approximately four hours and covers similar, but more detailed, material from the food handlers training. The take-home message from the training is that the food manager is seen as the person in charge by the health department, and that they are responsible for all food safety in the establishment. At the end of the training, an exam is given over the course materials. If participants pass the exam at that time, they receive their certification card. The first food managers training took place on November 6th, 2015 with 19 participants. After a few food managers training sessions, environmental staff noticed participants for whom English was not their first language were struggling to understand course material and to pass the required exam. To immediately address these needs, the course instructor would work closely with the ESL participant to fully explain each question and answer any questions they may have had over the material to help them overcome the possible language barriers and to pass the exam. This, however, was not a perfect solution. In March of 2016, our state health department released a call for proposals for quality improvement projects with an environmental focus. The funding opportunity was sponsored by EnviroHealthLink and our health department applied for $14,291 of funding to cover translation of food handlers and food managers' course materials and to cover additional administrative costs. Up until this point, the only costs incurred during the project were staff time as well as general office supplies and print costs. Our health department was awarded the full amount to address this gap in culturally sensitive programming. A total of $7,900 was spent on translation services for Spanish and Mandarin Chinese including print materials. Additional grant dollars were spent on staff time and administrative costs. Multiple stakeholders played a role in the implementation and ongoing improvement of the Food Safe Bullitt County project. Our BOH was instrumental in the process by passing a regulation that made food safety training mandatory for food service employees in the county. Local establishments have also played a major role in shaping the trainings and the manner in which they were provided. Our local establishments have participated in the trainings as mandated and have provided beneficial feedback on how the trainings have benefited their establishments. We reached out to multiple corporations that would be effected by the regulation, but did not have much interaction with them. The same can be said for our hospitality board and Chamber of Commerce. We would like to see more interaction with these stakeholders in the future.
The objectives of our project guided our evaluation process. Food Safe Bullitt County was developed with the following objectives: 1. Bullitt County will have an educated food service workforce through a required Food Handlers and Managers Training, leading to improved food safety and therefore inspection scores. 2. Consumers will have confidence in their choices with a trained food service workforce. Food Safe Bullitt County implemented the food handlers and food managers' trainings in October 2015. As of November 1, 2016, we have trained 954 food handlers and 251 food managers, many of whom had no previous training in food safety. Throughout the implementation of these training programs, we have collected information from participant satisfaction surveys and collected inspection scores to see if the trainings have made an impact in improving inspection scores. Data from the trainings were collected by the Environmental Health department staff and analyzed by the Epidemiologist. Inspection scores were acquired and maintained by Environmental Health staff and also analyzed by the Epidemiologist. These are all primary sources. Minimal secondary sources were used in the evaluation of Food Safe Bullitt County. Average inspection scores for two reporting areas over two six month time periods were compared. The first inspection area was 605 Food Service Establishments, which includes general restaurants, childcare, school cafeterias, camps, and food trucks. The second inspection area was 607 Retail/Food Establishment which includes stand-alone stores that have a deli or other food prep (such as a gas station or grocery store). The time period of May to October 2014 was used as baseline data and May to October 2016 was used for comparison, a period beginning approximately six months after the implementation of the food safety regulation and the start of the food managers' training courses. In the baseline period, 148 inspections were completed for inspection area 605 Food Service Establishments, with an average score of 98%. During this same period, 38 inspections were completed for inspection area 607 Retail/Food Establishments, with an average score of 96%. The post-intervention period saw 142 inspections in area 605 Food Service Establishments, for an average score of 95%. The same period saw 34 inspections in area 607 Retail/Food Establishments, with an average score of 93%. Participant surveys were analyzed to garner feedback from course participants. Of the 954 food handlers who completed the course, 1033 surveys were completed (includes participants who did not pass the course). When asked to rate the quality of the course material on a likert scale from 1-5 with one representing poor and five representing excellent, 73% rated the course as a four or five. The most frequently cited concern was about registration and navigation of the online TRAIN system. Of the 251 food managers trained thus far, 235 completed a course evaluation. When asked if they will be able to apply knowledge gained in the training to their current position, 98.7% of food managers either agreed or strongly agreed. When asked if they would recommend this training to others, 96.5% of food managers either agreed or strongly agreed. The most frequently cited concern was about the course being too long. In regards to our objectives: 1. In an attempt to assure an education food service workforce, a mandatory Food Handlers and Food Managers Training regulation was approved by our BOH and went into effect on October 1, 2015. As of November 1, 2016, 207 establishments were subject to this regulation. During October 1, 2015 to November 1, 2016, 954 food handlers and 251 food managers became certified in food safety. In terms of the impact on establishment inspection scores, there was a decrease in the average score based on the baseline measure from May October 2014 of about 2%. This dip was expected by our team, given that the 207 establishments would now be held to a higher standard following the trainings. 2. Real-time inspection scores and specific violations for all establishments are now available on our website (www.bullittcountyhealthdept.com). Attempts to place a counter for the number of visitors to this portion of the website have been unsuccessful due to the structural coding of the page provided by our state health department IT department. However, community members have expressed how beneficial online scores have been in helping them to make informed decisions. A few modification were made to the project following implementation. Two major areas of concern identified by participants were addressed. Food handlers were concerned about the ease of registration and accessing the TRAIN online system. In order to address this, detailed instructions on how to register for the course were posted to our website. Food managers were concerned about the length of the in-person training course. Some material was cut from the curriculum but time for questions was considered essential so the course length was not reduced by any significant amount. Perhaps the most important modification to the project was the identification of the need for the translation of materials into additional languages to assist our participants who did not speak English as a first language. Multiple individuals reached out to the course director regarding how they were struggling with understanding the material and passing the required exams. To address this need, course materials and exams were translated into Spanish and Chinese (simplified and traditional). Thus far, feedback from the participants who have used the translated materials has been positive.
At the onset of this project, our Environmental staff did not have a good picture of the knowledge base of our local food workers. During routine inspections, food establishments would frequently be marked for the same violations over and over and when questioned, workers could not explain the basics of food safety to the inspectors. It was suspected that the knowledge base was low and that any introductory training (by the restaurant or corporation if provided) was inadequate. Feedback from our participants confirmed this suspicion as many participants learned about basic food safety for the first time (as evidenced by course evaluations). Now, food handlers are trained using an online course in food safety and food managers are trained to become food safety experts in their establishments. The expectation of the Environmental Health staff is that these managers can bring best practices back to their establishments and be prepared for a detailed inspection. Bullitt County, Kentucky is not a very diverse county. Approximately 98.5% of our residents speak English as their primary language at home and 99% were born in the United States (U.S. Census Bureau). However, many individuals who speak another primary language are employed in the food industry. In order to address this need, the Environmental staff identified a grant opportunity to have course materials translated into additional languages. This grant provided funds to have materials translated into Spanish and Mandarin Chinese (simplified and traditional). In addition to printed translated copies, digital copies of the translated material are also available, allowing us to print additional copies as needed or to distribute the course material via email or flash drive. As a result of this project, our health department has gained a culturally sensitive program that will benefit all members of our community. Stakeholders have been involved in this project since the beginning. The design of the Food Safe Bullitt County trainings was heavily influenced by feedback from our local BOH and local establishments. Feedback provided by the course participants themselves led us to focus on translating materials into additional languages. As Food Safe Bullitt County is a county-wide regulation, we anticipate continued participation from our stakeholders. As a result of the courses, food handlers are trained in food safety and food managers are trained to become food safety experts in their establishments. The expectation of the Environmental Health staff is that these managers can bring best practices back to their establishments and be prepared for a detailed inspection. One large corporation (Franchise A) modified a policy based on our training. Prior to participation in the courses, food handlers were not wearing gloves when serving fries to customers. As a result of our training, this policy was modified and food handlers are now required to wear gloves when working with fries. Through our trainings we have also emphasized a new cleaning regiment, where establishments can focus on cleaning one section of the facility at a time. The importance of establishing and sticking to a deep cleaning schedule has also been emphasized in the trainings. Since participating in the courses, we have seen this implemented in many establishments and they tend to perform better during their inspections. The Food Handlers and Food Managers regulation passed in August 2015 assures that this practice will continue until our BOH deems otherwise. A cost/benefit analysis was not completed for this project. Certification fees help to cover administrative costs associated with the trainings and will be instrumental in sustaining the program over the next few years. The Food Handlers training is provided online via the TRAIN system, at no cost to the health department. The main cost associated with the Food Handlers training is the printing of the certification cards, including the cost of the printer, and the ongoing cost of the cards and ink. The $10 certification fee covers these costs. Minimal staff time is devoted to the printing of the certification cards. The Food Managers training is an in-person training that has a $25 certification fee. The $25 fee covers the cost of certification cards and the salary of those providing the in-person training. At this time, we have no plans to change the certification fees. The in-person trainings will continue but will now take place less frequently, as many local food managers have already been trained. Online classes will continue as is given there is no ongoing cost for maintenance or administration of the course through the TRAIN online system. Food safety should be the primary concern when preparing food commercially and is an integral part of protecting the public's health. Standardization plays a large role in this and ensures accurate and fair inspections from our staff members. Through quality assurance activities, including three inspectors evaluating the same establishment, we hope to ensure a standardized inspection process for all establishments in our community. References Hezekiah Kehinde Adesokan, Victor Oluwatoyin Akinseye, and Grace Abiodun Adesokan, Food Safety Training Is Associated with Improved Knowledge and Behaviours among Foodservice Establishments' Workers,” International Journal of Food Science, vol. 2015, Article ID 328761, 8 pages, 2015. doi:10.1155/2015/328761 Environmental Health Services (EHS-Net), 2016. Centers of Disease Control and Prevention. https://www.cdc.gov/nceh/ehs/ehsnet/index.htm accessed on November 28, 2016.
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