City of Fort Worth Consumer Health Division-2004 Crumbine Award winner.

Introduction

The city of Fort Worth Public Health Department (FWPHD) Consumer Health Division (CHD) was recently honored as the recipient of the 2004 Samuel J. Crumbine Consumer Safety Award. This prestigious award served as testimony to the city's goal of becoming the "safest city in America" and the dedication of the staff to their community. It is also a concrete example of the exemplary level of programming, performance, and protection sought by CHD.

Although the division has historically maintained a high level of service, a restrictive economic environment and subsequent constraints on resources and staffing have added to the challenge of developing creative and innovative activities that effectively increase coverage and ensure consumer safety.

With a total of 24 full-time employees, CHD is charged with regulating 3,200 facilities, inspecting 4,887 inventories, and providing consumer health services to a metropolitan community of more than 577,000 residents. CHD activities cover restaurants, mobile vendors, child care centers, hotels, and public pools, as well as the delivery of vector control and emergency response services.

Responding to a Growing Fort Worth Community

Fort Worth, Texas, affectionately referred to as "Cowtown," once known as "Panther City," and home to "Hell's Half Acre," has become one of America's most desirable places to live. The continuing rapid growth of Fort Worth has necessitated the development of innovative programs and interventions to adequately provide health and safety services to the burgeoning population. The Fort Worth CHD is responsible for developing and maintaining a safe consumer environment. It accomplishes this mission through a commitment to risk reduction, education, enforcement, and cultivation of interagency collaboration and community cooperation.

The development of innovative programming has been spurred by the brisk expansion of the city. Fort Worth encompasses 343 square miles and has an estimated 2004 population of 577,500--a remarkable increase of more than 9 percent since 2000. The population has grown because of proximity to the Mexican border, extensive academic and employment opportunities, the city's prominent place in the North Texas Metroplex, and overall environmental and residential appeal.

The growth also is attributable to ongoing annexation of much of the surrounding unincorporated areas (Tarrant County). Reflecting Texas's rich cultural heritage, the Fort Worth population is 3 percent Asian, 18 percent Hispanic, 20 percent African-American, and 59 percent Caucasian. Educational and consumer safety services have been designed to be concordant with the demographic and socioeconomic needs both of the food service industry and of the general citizenry.

Building a Foundation Through Strategic Planning 

To meet the demands of the growing and diverse population, a long-term plan was developed involving the integration of 10 strategic initiatives implemented over the past five years. This plan represents a data-driven perspective that incorporates strategic thinking, innovations in technology, customer education, personnel training, community partnerships, and staff commitment to an upstream approach to prevent rather than respond to undesirable consumer health issues.

FWPHD's vision is for Fort Worth to be the healthiest city in Texas. This vision was formally adopted in conjunction with the city's strategic goal of becoming the safest major city in the nation. CHD's mission statement is "to protect the public from foodborne, waterborne, and other communicable disease." Some goals related to this vision include promoting a safe consumer environment by ensuring the overall integrity and safety of food service, public swimming facilities, child care facilities, and hotels/motels: enforcing the tobacco-free ordinance; and protecting the citizenry from vectorborne diseases.

The objective is to integrate education with inspection and enforcement activities in order to enhance compliance by the professional community and ensure the safety of the general public. This objective has been accomplished through a strategic planning process that calls for mobilizing technology, providing training to staff and vendors, carefully managing resources, cultivating community and political support, establishing rapport with vendors, and assisting with the development of consumer-related entities from conception to fruition.

Moving to the Leading Edge of Technology

Prior to 2000, CHD used borrowed phones, pagers, and two-way radios to communicate. Each customer service representative (CSR) had a computer, but the consumer health specialists (CHSs) shared a handful of computers, all of which were antiquated. Inspections and violations were handwritten on a threepart form and entered into a database at least a month later. Bimetallic thermometers used at the time required time-consuming manual calibration and posed a risk of cross-contamination. Expensive paraffin strips were used to verify water temperatures in dishwashing machines. Furthermore, CHD experienced a chronic lack of transportation.

A meticulous strategic self-analysis of long-term needs was conducted, and the CHD budget was structured over the past five years to accommodate equipment acquisition. Extensive research into available technology enabled CHD to purchase digital stem-type thermometers, Barnant 115[R] thermocouple thermometers, Raytek[R] Raynger[R] ST[TM] infrared noncontact thermometers, and waterproof thermometers.

Negotiations with cellular providers resulted in a lease arrangement that enabled each CHS to have a cellular phone. This cellular lease plan was renegotiated in 2003, resulting in additional savings, and the two-way radios were completely eliminated.

Furthermore, the long-term CHD plan integrated newly leased Pentab[TM] tablet computers and expanded software to dramatically reduce paperwork, provide immediate data entry, and streamline the overall inspection process. The plan also allowed for the purchase of an additional CHD vehicle.

Innovations represented by the Pentab hardware and the associated software resulted in a time savings of 6.4 minutes per inspection and violation notice. When these results are extrapolated to, for example, the 4,731 routine food inspections completed in fiscal year 2003, a savings of 504 hours is realized. This figure represents a potential for 630 additional inspections, roughly equivalent to the annual field activity of one full-time CHS.

SWEEPS[c] is the centerpiece of the CHD data management system. The SWEEPS program offers the capability to retrieve reports and data immediately, greatly reducing response time in the field and improving overall efficiency. This system of data management has minimized the use of a paper-based filing system. The use of this system has resulted in a pervasive improvement in the manner that CHD conducted business by allowing instantaneous access to inspection histories, complaint data, and billing records. The main benefit of the change has been the ability to immediately enter data instead of having to key in a paper backlog of several months; staff are thus freed up to support other activities.

The corresponding decrease in CSR workload had the further impact of effectively compensating for some of the staff shortages. By acquiring the equipment over a period of several years, CHD was able to harness the technology needed to meet the objectives of risk reduction, improved communication, and increased field productivity, and to improve CSR efficiency.

Committed to Professional Training and Industry Education

Training CHD Personnel

In the past five years, CHD has made tremendous strides in upgrading professional training. To ensure consistency and uniformity in food inspections across the United States, the Food and Drug Administration (FDA) proposed nine standards through the Voluntary National Standards (VNS) guidelines. In an effort to meet these guidelines, the Texas Department of Health (TDH) revised the state food rules in 1998 for the first time in 22 years. These rules followed the 1997 FDA Food Code and changed the inspection form format from a 44-item all-inclusive list to a hazard analysis critical control point (HACCP)-based 27-item critical violation list.

In 1999, TDH instituted a program to standardize the activities of field CHSs with respect to the new regulations. During the same year, the Fort Worth food ordinance was revised and updated to reflect the changes in the state law; it adopted the new Texas Food Establishment Rules (TFER) as its core document. To help achieve compliance with the ordinance, CHD was required to have CHSs trained as registered sanitarians within six months of hire.

Needs were identified and training programs were developed for new and current CHSs. State standardization of TFER guidelines in 1999 redirected the development of the CHD food inspection program. The VNS guidelines and concurrent adoption of the TFER required that all CHSs obtain training on the new code. In addition, CHSs required training on the other services provided by CHD. The educational challenge was met while maintaining regular coverage and activity in the field.

The training program has improved field staff ability to recognize violations and provides a mechanism to promote CHSs who have demonstrated high proficiency to more responsible capacities. Furthermore, periodic quality assurance assessments maintain high levels of personnel competency and uniform enforcement of the TFER.

Educating Industry Workers

Following the contemporary public health model, CHD provides food, child care, and pool operator safety training and certification activities to prevent rather than respond to consumer safety problems.

All persons employed with a retail food operation are required to take an hour-long food handler course before being permitted to work. The resulting food handler card is valid for two years. Likewise, all daycare workers in Fort Worth are required to take a two-hour course before beginning work in a child care facility. The daycare worker permit is valid for two years. Many pool operators work in the city as well. Each pool operator must participate in an eight-hour class before receiving a permit, which is valid for three years.

To ensure participation and comprehension by audiences from broad educational and cultural backgrounds, classes are presented in a multimedia format, with classes and media available in Spanish. While the food handler and daycare courses are presented by CHSs, these programs also are supported via partnerships with local contractors and other FWPHD divisions.

Reaching Out as a Community Partner

CHD collaborates extensively with professional and educational organizations throughout the community. These affiliations include membership in numerous restaurant, food safety, environmental, hotel, child care, and regulatory associations. To further facilitate consumer interaction, CHD partners with local academic institutions, from elementary schools through college, as well as other organizations such as retirement communities and neighborhood associations.

Dieticians and other academically trained personnel are part of the foundation of safety in the food service industry. Therefore, CHD purposely has cultivated relationships with local academic institutions by providing presentations on food safety, offering opportunities to accompany staff during inspections ("ride-alongs"), and sponsoring internships. CHD also has pursued community contacts to promote consumer safety activities through numerous education events such as career day activities, holiday food safety seminars, health fairs, and community events designed to heighten visibility, build relationships, and engender trust. Collaborations with other city departments have been increased to optimize internal resources. Some notable examples include providing education, inspection, and enforcement services for parks and community services (PACS), development, code compliance, police, environmental management, and water departments.

CHD also works closely with mobile vendors and partners with the police department on late-night bar inspections. Moreover, CHD has coordinated emergency response with the fire department in support of any emergency affecting consumer safety 24 hours a day, seven days a week.

To foster relationships with industry organizations such as Child Care Associates of Fort Worth, Contract Care Management Services, the Hotel/Motel Association, and the Tarrant County Restaurant Association, CHD provides educational presentations designed to build support for and cooperation with CHD activities. CHD has instituted a customer satisfaction survey to ensure satisfaction and help guide the development of programs.

Remaining Vigilant Against Consumer Health Emergencies

The contemporary environment has introduced security issues that were not operative prior to the murders perpetrated by terrorists on September 11, 2001. Although emergency contingencies had been integrated into CHD's preplanned response protocols, CHD did not have a comprehensive plan or the personnel to respond in an organized manner to an intentional emergency event. This concern is especially acute since the food industry is an attractive vector for the intentional dissemination of illness (bioterrorism).

Maintaining consumer safety in response to an intentional, natural, or accidental emergency requires preplanning and the education both of the general public and of professional communities. Adequate personnel resources, however, were not available to educate the food service and related industries in prevention, identification, reaction, and recovery from acts of terrorism. Furthermore, traditional protocols for emergency response and foodborne-illness investigation did not address the considerations that would likely characterize an intentional exposure, or terrorist incident, involving the food service industry.

CHD worked with the FWPHD Bioterrorism and Health Emergency Preparedness (BHEP) team to include a staff position dedicated to food security issues. Grant funding was received from state and federal sources to support a consumer health safety officer (CHSO) position. This position developed a multimedia program to educate food service industry personnel on methods to enhance the security of their facilities, improve surveillance, and respond to suspected or actual terrorist events.

The CHSO aggressively investigates all foodborne illnesses to rule out intentional exposure. Arrangements have been made for follow-up response that includes epidemiological investigations by both the city and the county health departments in conjunction with the city's Emergency Operations Center.

The diverse training obtained by the current CHSO includes hazardous material response, emergency response protocols, incident management, security consulting certification, medical care, effects of weapons of mass destruction, field sanitation, fire prevention, and large-scale consumer safety issues. Along with a CHS background, the CHSO can serve as the focal point for interagency emergency response coordination of consumer health issues. The CHSO also interfaces with the medical community to monitor disease trends in order to detect unusual disease dispersion possibly indicative of intentional contamination.

In October 2001, CHD mailed an awareness document to all 3,200 permitted facilities regarding bioterrorism prevention and announcing the availability of a training program for food facility security. CHD also placed a warning on all computer-generated food inspection forms. All foodborne illnesses are logged into SWEEPS for tracking and are monitored to provide indication of coordinated intentional exposures.

CHD has adopted the policy of treating all suspected foodborne illnesses as potential bioterrorism incidents. The CHSO has produced brochures, handouts, and posters for distribution during the 63 security and safety presentations that have been made to the local food industry to date. Handling each foodborne illness as an intentional event prevents problems associated with "backtracking" if an attack is determined to have occurred.

Although CHD previously received no feedback on the final outcome of foodborne-illness investigations, systems are now in place to track all foodborne-illness inspections upon their conclusion. In addition, CHD has improved threat intervention and slashed response time to within one business day. The BHEP team won the 2003 award for "Best Presentation" at the Protect Texas Bioterrorism Contractors Meeting, and an article highlighting the program in the Fort Worth Star Telegram led to a request for security training for local store managers within the McDonald's Western Division. The new protocols also ensure preparedness for other consumer safety emergencies, including natural and accidental disaster events.

Summary

Historically, the Fort Worth CHD has striven to provide the highest level of service toward the assurance of consumer safety. The burgeoning growth of the city, however, combined with limited resources, has challenged this capability.

The response by CHD was to develop a long-term, orchestrated plan to not only maintain but also improve performance. To succeed, a multiyear, integrated plan to develop programming, personnel management, and budgeting was adopted. In accordance with this plan, the past five years have witnessed the cultivation and integration of strategic initiatives into a comprehensive and effective consumer safety program. The program has succeeded in improving inspections, lowering violation recidivism, maintaining compliance, and orchestrating activities to sustain improvements well into the future.

CHD is proud of these accomplishments and of its service to the citizens of Fort Worth. In this spirit, CHD is happy to accept the 2004 Crumbine Award, which recognizes the dedication to consumer safety underlying this program.

TABLE 1 Fort Worth Consumer Health Activity, FY 2003

Category                                        Quantity

Inspections                                      8,485
Food inspections                                 6,875
Child care facility inspections                    409
Pool inspections                                   906
Other inspections                                  295
Inspections per FTE                                652
Confirmed foodborne illnesses                        0
Complaint investigations                           883
Consultations                                   31,190
Plan reviews                                       197
Permit inspections (openings)                      752
Hours spent on vector control                      832
Food handler/child care trainees                14,484
Classes                                            613
Spanish classes                                    156
Percentage of classes offered in Spanish            25%
Percentage of customers satisfied with service      99%

Editor's Note: The Samuel J. Crumbine Consumer Protection Award for Excellence in Food Protection, named in honor of one of the most renowned U.S. public health sanitarians, is presented to a local public health agency by a jury of leading environmental health officials and public health sanitarians. The Crumbine Award is the most prestigious recognition that a public health agency can receive for excellence and improvement in food protection. Agencies that win the Crumbine serve as models for other public health and safety programs across the nation.

Below, readers will find a description of the division that won the 2004 award--the city of Fort Worth Consumer Health Division. The description is adapted from information the program submitted on its Crumbine application.

For more information about the Crumbine Award, please contact Lynn Rosseth, director of market development and programs at the Foodservice & Packaging Institute (FPI) at [phone]. A copy of Forth Worth's entire award-winning application is on the FPI Web site at www.fpi.org.

Jason Lamers, M.P.A.

Corresponding Author: Jason Lamers, Planning and Communications Coordinator, City of Fort Worth Public Health Department, 1800 University Drive, Fort Worth, TX 76107. E-mail: [e-mail].