APPLYING QI TO FOOD SAFETY: INITIAL STORIES FROM THE NNPHI QI AWARD PROGRAMTed Talley, Northern Kentucky Health Department

Liz Mack, Webster County Health Department

Drew Downing, Toledo-Lucas County Health Department

Applying QI Techniques to Mobile Food Vending

Ted Talley

Environmental Health Manager

Northern KentuckyHealth Department

Combined district Boone, Kenton, Campbell, Grant

Population ~ 400K Approximately 160 employees

Environmental Services• 26 employees • 16 Registered Sanitarians • 3000 permitted establishments

Fixture RequirementsHand sink 3C sink Hot & cold running water under pressure Supply tank Waste tank

50% largerKY plumbing approval $120/year

Recognized throughout KY

Discovery

Affinity Diagram Need for improvement Impact on public health Increased interest in mobile food vending

Operation

By November 30, 2012, increase the percentage of properly licensed mobile food vendors providing lunch to employees of businesses located in the counties of Boone, Kenton, Campbell, and Grant from 25% to 100%

QI Tools

Affinity DiagramPDCA

Flow chart Fishbone diagramIndentifying improvements

Key Lessons

Embrace the process

Documentation & organization

Participation

Challenges

Challenges

Planned Outcomes

Improved process Communication channelsSustainable solutions Collaboration with local businesses

Properly licensed vendorsRequirementsEducated food handlers

Better protection of public health

Ted Talley Environmental Health Manager

Northern Kentucky Health Department610 Medical Village Dr Edgewood, KY 41017

859.363.2027

ted.talley@nkyhealth.org

Preserving and protecting public health within our community

Environmental HealthQuality Improvement Project:

Food Safety Liz Mack, EPHS/CEHS

Webster County Health Unit:Background

Webster County, MO is East of Springfield/Greene County, MO & Northeast of Branson, MO– Comprised of several small towns

Marshfield, Niangua, Elkland, Seymour, Fordland & Rogersville The Health Unit is located in Marshfield, the County Seat

– Stakeholders include tourists, entrepreneurs: including farmers market vendors and wineries, business owners, citizens, Mennonite and Amish communities

– Interstate I-44 and US Highway 60 run through the county

Webster County Health Unit: Background

In April of 2011, the Webster County Health Unit Board of Health & the County Commission adopted a Food Ordinance proposed by the Webster County Health Unit:– Effective June 18th, 2011– Requires all managerial staff plus two additional

employees on duty at all times to have food safety training documentation on-site at the food establishment

Webster County Health Unit:Background

Food Ordinance Requirements Continued:

– Food Establishment permit fees were based on priority risk assessments and categorized into: High, Medium or Low Priority Food Establishments

High Priority Establishments receive three annual inspections

Medium Priority Establishments receive two annual inspections

Low Priority Establishments receive one annual inspection

Webster County Health Unit:Background

How did we decide to focus on Food Safety?– After providing food safety classes and

training for one year, to over 500 trainees, a high priority food establishment was closed for several days due to several public health risk factors or critical code violations

Webster County Health Unit:Background

– This was a major concern and raised several questions for the Health Unit’s Environmental Staff:

Is the two-hour training we are providing sufficient?– No, the manager tied to the closed facility had attended the

training twice Are educational visits needed outside of the mandatory

two-hour training in order to communicate managerial responsibilities?

– Yes, at this point, only having had the Food Ordinance for one year, changes to the length of the course are not feasible

– Keeps the political climate calm, especially during election year, without creating a risk of losing the ordinance

Webster County Health Unit: AIM Statement

“Webster County Health Unit will increase the knowledge and skill of food managers and employees by 25% from pre to post-managerial course surveys and improve results on post-surveys or follow-up contact for education visits in 10% of medium and high priority establishments by December 31st, 2012. Improving these educational opportunities will help increase compliance with the Food Code and decrease public health risk factors or critical violations associated with foodborne illness.”

Webster County Health Unit: AIM Statement

Short term improvement outcomes:

1)      Percent of food manager and employees with improved scores on food manager and employee course results

2)      Percent of food managers with improved responses on post survey (from pre-visit surveys) for educational visits

Improvement Action to Test: Adding Active Managerial Control content in the managerial course and in the educational visits.

Webster County Health Unit:What work has been completed thus far?

A pre-test and post-test have been revised for the two hour manager/employee food safety class

Tests have been administered since April, 2012 Provides a measurable source of data Data gathered from the tests will help focus on the most needed

principles of Active Managerial Control Active Managerial Packets and training materials have been compiled Establishments for educational visits have been identified using a random

sampling method Educational pre and post-surveys have been developed Surveys and visits will commence at the start of the 2nd permitting year,

June 18th, 2012.– Great opportunity to show owners and operators that we are continually offering quality

improvement and that the Health Unit is vested in their training.

Webster County Health Unit:What key lessons have we learned thus far?

Ensure adequate staff is available to handle the project:

WCHU lost a full-time EPHS to military deployment shortly after receiving the QI award

For a small local public health agency, EPHS staff must delegate and pull from other Health Unit programs to complete work; we have created an Environmental Health Technician part time position as a result of the award.

Daily Environmental Health functions must carry on: food establishment inspections and food safety training; child care inspections (three counties); on-site sewage permitting, including complaints and new systems; and well water sampling

Webster County Health Unit:What key lessons have we learned thus far?

Focusing and narrowing down the topic is vital to prevent: Working on what you cannot control

– i.e. Our AIM statement was very broad initially: ‘reduce the number of critical violations’.

Selecting a sample size that is too large & unattainable Course tests had to be simple due to diversity in education levels

– Managers and employees receive the same level of training

Focusing on the most important area or key impact area first WCHU has several QI areas within Environmental Health to

improve upon; filtering through the issues and deciding was difficult

– Working with our operators directly will provide the biggest public health impact, collaborating to prevent foodborne illness in our community

Webster County Health Unit:What results do we hope to see?

Overall: our operators, managers and owners engaging in an Active Managerial role, using a food safety system that is proactive rather than reactive

Short term:– 1. an increase in improved scores on food manager

and employee test results– 2. percent of food managers with improved

responses on post-surveys, from pre-visit surveys Long term: Fewer public health risk factor violations

directly related to foodborne illness

Questions

Webster County Health Unit– Contact, Liz Mack:

(417) 859-2532 ext. 206– E-mail:

lmack@webstercohealth.com

Thank You!

Refining Foodborne Response

Applying CQI to the Foodborne Outbreak Investigation Process at the

Toledo-Lucas County Health Department

June 2012Portland, Oregon

A little background…• Previously

– Sanitarians were housed in Environmental

– Epidemiologists were housed in Disaster Preparedness, Response, & Community Services

• TLCHD recently merged divisions to form the Community Services and Environmental Health Division

A little background…

Introducing Team…

• Tanika Redmond – Epidemiologist• Patricia Fraker – Epidemiologist• Karim Baroudi – Supervisor of the Food

Protection Unit• Greg Moore – Toledo-APC Proj. Coordinator• Drew Downing – Toledo-APC Proj. Lead

Work CompletedGOAL CLARITY

Work Completed

AIM STATEMENT• “ “Between May 30 and November 30,

2012, the mean open-to-close time for foodborne response cases will decrease from average of 44 days to

37 days, a reduction of seven days (15%) when compared

to foodborne cases from January 2009 - October 2011.”

Work Completed

PROCESS MAP & FISHBONE

DRAFT

Work Completed

PROBLEMS IDENTIFIED Problems Identified

Inconsistent communication between Sanitarians and Epis

Incomplete data for Sanitarians and Epis

Work roles/assignments for investigations – not clear

Work Completed

BRAINSTORM & PRIORITIZE POSSIBLE SOLUTIONS

Prioritized Solutions – First Tierstandardize and update initial interview form

create “training” for Sanitarians and Epi’s based off the new initial interview sheet

incorporate Epis into Sanitarians’ weekly meetings to enhance communication

create shared folder for RS and Epi’s on shared computer drive

Work Completed

BRAINSTORM & PRIORITIZE POSSIBLE SOLUTIONS

Prioritized Solutions – Second Tier update and enhance the field report form to incorporate needed information from Epi’s grant

create an ICS format team that meets immediately after a case is suspected to be a foodborne to better launch the investigation

Prioritized Solutions – Third Tierclean and reorganize supply room used for field kits

Work Completed

TURNED SOLUTIONS INTO ACTION ITEMSAction Item Person Due Date

standardize and update initial interview form

Patti and RS June 5

create “training” for Sanitarians and Epis from the new interview sheet

Tanika June 12

incorporate Epis into Sanitarians’ weekly meetings to enhance communication

Karim June 5

create shared folder for RS and Epis on shared computer drive (HIPPA compliant)

Karim June 5

Expectations

• decrease in the mean open-to-close time and increase in efficiency for foodborne illness investigations

• enhanced communication between Epis and Sanitarians

• better standardized response procedure

Lessons Learned So Far…

• Select diverse team members

• Be flexible where necessary

• Dive deeper

Works Cited

NY Timeshttp://www.nytimes.com/2007/03/08/nyregion/08office.html

psdGraphicshttp://www.psdgraphics.com/psd-icons/psd-3d-business-graph-icon/